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The diminishing effectiveness of antimicrobials raises serious concerns for\ud human health. While policy makers grapple to reduce the overuse of\ud antimicrobial medicines to stem the rise of antimicrobial resistance,\ud insufficient attention has been paid to how this applies to low-resource\ud contexts. We provide an in-depth portrayal of antimicrobial prescribing\ud at primary health care level in rural Chikwawa District, Malawi.\ud Ethnographic fieldwork took place over 18 months (2018–2020). We\ud surveyed 22 health facilities in the district, observed 1348 health\ud worker-patient consultations, and carried out 49 in-depth interviews\ud with staff and patients. Care was centred around provision of an\ud antimicrobial. Amid chronic lack of essential medicines and other\ud resources, clinic interactions were tightly scripted, providing patients\ud little time to question or negotiate their treatment. We develop the\ud concept of ‘antibiotic vulnerabilities’ to reveal multiple ways in which\ud provision of antimicrobials in rural Malawi impacts care in conditions of\ud extreme scarcity. Antibiotics are central and essential to primary care.\ud As targets for optimal antimicrobial prescribing take a more central role\ud in global policy, close attention is required of the ramifications for the\ud delivery of care to ensure that efforts to stem resistance do not\ud undermine the goal of improved health for all.

The advent of antibiotics transformed the global public health landscape, dramatically improving health outcomes. Drawing on historical and ethnographic research on sex work in Zimbabwe, we examine the role of antibiotics in the management of sexually transmitted infections among sex workers, from punitive colonial approaches to "empowerment"-based discourses. We illustrate how programs for sex workers, while valued by these women, are narrow, exclusionary, and enact a pharmaceuticalized form of governance that hangs on the efficacy of antibiotics. With antibiotics' efficacy under threat, we consider how latent colonial logics are in danger of being reactivated to control both infections and women.

Rising concerns around antimicrobial resistance (AMR) have led to a renewed push to rationalise antibiotic prescribing in low- and middle-income countries (LMICs). There is increasing unease in conceptualising antibiotic use as individuals behaving '(ir)rationally' and recognition that rising use is emergent of and contributing to wider economic and political challenges. But in between these individual and societal 'drivers' of antibiotic use is an everyday articulation of care through these substances, written-in to the scripts, delivery chains and pedagogics of global healthcare. This article focuses on this everyday 'architecture' that over time and across spaces has knitted-in antibiotics and rhetorics of control that inform current responses to AMR. Based on historically informed ethnographic research in Zimbabwe, we examine points of continuity and change between 20th Century rational drug use (RDU) discourses and contemporary socio-political formations around AMR and antimicrobial stewardship (AMS), paying particular attention to their co-evolution with the process of pharmaceuticalisation. We illustrate how the framework and techniques of RDU were embedded within programmes to increase access to essential medicines and as such complemented the building of one of Africa's strongest postcolonial health systems in Zimbabwe. Whilst 20th Century RDU was focused on securing the health and safety of patients and affordability for systems, AMS programmes aim to secure medicines. Continuous through both RDU and AMS programmes is the persistent rhetoric of 'irrational use'. Health workers in Harare, attuned to the values and language of these programmes, enact in their everyday practice an architecture in which antibiotics have been designed-in. This research illustrates the struggle to optimise antibiotic use within current framings for action. We propose a reconfiguring of the architecture of global health such that frontline prescribers are able to provide 'good' care without necessarily turning to antibiotics. To design-out antibiotic reliance would require attention beyond '(ir)rationality', to the redrafting of blueprints that inscribe practice.

BackgroundAs concerns about the prevalence of infections that are resistant to available antibiotics increase, attention has turned toward the use of these medicines both within and outside of formal healthcare settings. Much of what is known about use beyond formal settings is informed by survey-based research. Few studies to date have used comparative, mixed-methods approaches to render visible patterns of use within and between settings as well as wider points of context shaping these patterns.DesignThis article analyses findings from mixed-methods anthropological studies of antibiotic use in a range of rural and urban settings in Zimbabwe, Malawi and Uganda between 2018 and 2020. All used a ‘drug bag’ survey tool to capture the frequency and types of antibiotics used among 1811 households. We then undertook observations and interviews in residential settings, with health providers and key stakeholders to better understand the stories behind the most-used antibiotics.ResultsThe most self-reported ‘frequently used’ antibiotics across settings were amoxicillin, cotrimoxazole and metronidazole. The stories behind their use varied between settings, reflecting differences in the configuration of health systems and antibiotic supplies. At the same time, these stories reveal cross-cutting features and omissions of contemporary global health programming that shape the contours of antibiotic (over)use at national and local levels.ConclusionsOur findings challenge the predominant focus of stewardship frameworks on the practices of antibiotic end users. We suggest future interventions could consider systems—rather than individuals—as stewards of antibiotics, reducing the need to rely on these medicines to fix other issues of inequity, productivity and security.

Understanding the prevalence and types of antibiotics used in a given human and/or animal population is important for informing stewardship strategies. Methods used to capture such data often rely on verbal elicitation of reported use that tend to assume shared medical terminology. Studies have shown the category ‘antibiotic’ does not translate well linguistically or conceptually, which limits the accuracy of these reports. This article presents a ‘Drug Bag’ method to study antibiotic use (ABU) in households and on farms, which involves using physical samples of all the antibiotics available within a given study site. We present the conceptual underpinnings of the method, and our experiences of using this method to produce data about antibiotic recognition, use and accessibility in the context of anthropological research in Africa and South-East Asia. We illustrate the kinds of qualitative and quantitative data the method can produce, comparing and contrasting our experiences in different settings. The Drug Bag method can produce accurate antibiotic use data as well as provide a talking point for participants to discuss antibiotic experiences. We propose it can help improve our understanding of antibiotic use in peoples’ everyday lives across different contexts, and our reflections add to a growing conversation around methods to study ABU beyond prescriber settings, where data gaps are currently substantial.

During ethnographic research at a tuberculosis vaccine trial site in South Africa, trial participants often evoked the idiom of "clean blood." In this article, we illustrate how the trials enacted a form of moral triage in which "objective" bioscientific knowledge and moral subjectivity were coproduced. Participation created possibilities to demonstrate healthiness, respectability, and godliness in a context where positive self-imaginings were hard won, but could also lead to dejection and shame. We suggest that struggles to be recognized as virtuous are often overlooked in anthropological critiques of clinical trials and bioethics, but are important for understanding how trials meld with local moral worlds.

Understanding memory performance under different operational conditions is critical in many occupational settings. To examine the effect of physical exertion on memory for a witnessed event, we placed two groups of law-enforcement officers in a live, occupationally relevant scenario. One group had previously completed a high-intensity physical-assault exercise, and the other had not. Participants who completed the assault exercise showed impaired recall and recognition performance compared with the control group. Specifically, they provided significantly less accurate information concerning critical and incidental target individuals encountered during the scenario, recalled less briefing information, and provided fewer briefing updates than control participants did. Exertion was also associated with reduced accuracy in identifying the critical target from a lineup. These results support arousal-based competition accounts proposing differential allocation of resources under physiological arousal. These novel findings relating to eyewitness memory performance have important implications for victims, ordinary citizens who become witnesses, and witnesses in policing, military, and related operational contexts.