Paper short abstract:

Based on ethnographic research in two clinics and a hospital in Harare, Zimbabwe, this paper explores how antibiotic prescribing practices labelled ‘irrational’ are a consequence of competing imperatives layered into the biomedical scripts and architectures of global health.

Paper long abstract:

Rising concerns around antimicrobial resistance (AMR) have led to a renewed push to rationalise and ration the use of antibiotics. As ‘AMR’ has crystallised as a policy object and travelled, it has carried particular imaginings of ‘responsible’ antibiotic use that exalt frugality and restraint, with attempts to convert people into ‘stewards’ of these threatened commodities. However, these relatively recent concerns with antimicrobial stewardship enter a longer historical trajectory in which the scripts, systems and architectures of global health have progressively pharmaceuticalised care in LMICs and squeezed out modes of caring beyond the provision (or withholding) of medicines. Based on ethnographic research in two clinics and a hospital in Harare, Zimbabwe, this paper explores the significance of antibiotics in local care practices and what it means to use them ‘responsibly’ amidst severe resource constraints. We found clinicians were well aware of AMR and committed, in theory, to the need to use antibiotics sparingly. Yet being ‘responsible’ in practice often meant using antibiotics beyond indication to ‘cover’ for multiple uncertainties, expectations and gaps in the system, and as metaphorical ‘explosives’, ‘guns’ and ‘bleach’ to combat severe infection. That antibiotics have taken on such broad, anticipatory roles, we contend, highlights both the naivety of many stewardship interventions and how vulnerable and exposed they could leave clinicians and their patients. We consider in turn what it would take to build a fuller picture of patients and illness back into health systems such that alternative ways of caring beyond medicines become possible.