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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.

Rising concerns about antimicrobial resistance have sparked a renewed push to rationalise and ration the use of medicines. This article explores the case of the Integrated Management of Childhood Illness (IMCI) guideline, a periodically updated ‘global’ algorithm that shapes and normalises the centrality of medicines to care in low- and middle-income countries and, increasingly, the imperative to ration them. Using ‘classification work’ as analytic frame, we firstly consider the IMCI algorithm as a blueprint for global health that classifies illnesses, patients, and care in particular ways relative to available medicines. Zooming in on this blueprint, we then offer a classificatory reading of ‘fever’ over time, tracing ‘nonmalarial fever’ from being malaria’s residual ‘other’ category to becoming increasingly legible through attention to diagnostics and antibiotic (over)use. Our reading suggests that an apparent refinement of the ‘fever’ category may concurrently entail the closing down of medicine options. This raises the possibility that an increasingly high-tech but ‘empty’ form of pharmaceuticalised care is being incidentally worked into the infrastructure of weak health systems.

Background Overuse of antibiotics is one of the main drivers for antimicrobial resistance (AMR). Globally, most antibiotics are prescribed in the outpatient setting. This survey aimed to explore attitudes and practices with regards to microbiology tests, AMR and antibiotic prescribing among healthcare providers at public primary health clinics in Harare, Zimbabwe. Methods This cross-sectional survey was conducted in nine primary health clinics located in low-income suburbs of Harare between October and December 2020. In Zimbabwe, primary health clinics provide nurse-led outpatient care for acute and chronic illnesses. Healthcare providers who independently prescribe antibiotics and order diagnostic tests were invited to participate. The survey used self-administered questionnaires. A five-point Likert scale was used to determined attitudes and beliefs. Results A total of 91 healthcare providers agreed to participate in the survey. The majority of participants (62/91, 68%) had more than 10 years of work experience. Most participants reported that they consider AMR as a global (75/91, 82%) and/or national (81/91, 89%) problem, while 52/91 (57%) considered AMR to be a problem in their healthcare facilities. A fifth of participants (20/91, 22%) were unsure if AMR was a problem in their clinics. Participants felt that availability of national guidelines (89/89, 100%), training sessions on antibiotic prescribing (89/89, 100%) and regular audit and feedback on prescribing (82/88, 93%) were helpful interventions to improve prescribing. Conclusions These findings support the need for increased availability of data on AMR and antibiotic use in primary care. Educational interventions, regular audit and feedback, and access to practice guidelines may be useful to limit overuse of antibiotics.

Although access to healthcare has improved since South Africa’s democratic transition, neoliberal reforms have had detrimental effects on clinic-community and nurse-patient relationships, undermining efforts to control tuberculosis (TB). This article focuses upon the work of nurses in three public health clinics in the Western Cape, South Africa. We explore how they experienced, made sense of and grappled with the challenges of TB control, especially patients “defaulting” on medication. Paying particular attention to confrontations between nurses and patients, we build upon previous qualitative studies that have contested popular constructions of nurses as “rude” and “uncaring.” We argue that patient blaming and scolding need to be understood in light of nurses having to tread a fine line between compassion and assertiveness, individual and public good against the backdrop of a dissonance between the theory and reality of TB control. Nurses’ confrontational approaches are responses to the messy reality of TB control on the ground, solutions to which require attention to the socioeconomic and historical context of nursing and primary healthcare. In the absence of such attention, animosities between clinics and communities could continue being cyclically reproduced.

Much of the current social science literature on the clinical trials industry focuses on the profit-seeking practices adopted by pharmaceutical companies and the contract research organisations they employ to enable the mass production and distribution of their products. However, what the current literature demands is further ethnographic engagement with the particularities of the diseases being investigated, the local contexts and histories in which they are entwined, and how these impact the affective relationships between clinical research organisations and their participants. On the basis of ethnographic research with a nonprofit clinical research organisation specialising in TB vaccinations in South Africa, I argue that the complexities of TB mean that research into it necessitates frequent and often intimate interactions with research participants. These were perceived by researchers to yield opportunities to take an interest in the physical and psychosocial wellbeing of research participants which went beyond and sometimes ran into conflict with the requirements of protocol. The aim of this paper is to advocate more finely tuned attention to the challenges posed by the clinical trials industry today, an attention sensitive to the particularities of the contexts of clinical trials.

Despite a steady global decline in the incidence of tuberculosis (TB), progress towards health targets has been slow and a crisis of drug-resistant strains of TB continues unabated. The United Nations high-level meeting on TB in September 2018 resulted in a renewed push to invest in drugs, diagnostics and vaccines to “reach” those most vulnerable to the disease. Yet, an overriding focus on biomedical technologies to manage TB at the expense of meaningful engagement with the social threatens to further consolidate its reputation as a “silent killer.” Drawing on anthropological contributions from South Africa and one from neighbouring Zimbabwe, this special issue explores how human action produces, shapes, names, experiences and resists the disease in its fullest breadth within local conditions. The articles recognise TB as a “global” object of biomedical knowledge and intervention, on the one hand, and as intricately tied to a legacy of colonial and apartheid governance, on the other. Each article deals with different aspects of understanding the interface between global and national policies and their unintended effects in local worlds.