Globally, antimicrobial resistance has often been framed as either a problem of access or excess, with stewardship interventions and overall reductions the dominant intervention to ‘rationalise’ use. Insufficient attention has been paid to care relations beyond the binary of ‘too many’ or ‘too few’ – particularly in low-income contexts – and how these relations shape, and are shaped by, antibiotic prescribing. Addressing this gap, our ethnographic work provides an in-depth examination of the practices that comprise care in rural Chikwawa. In this context, we found that care was centred around provision of an antimicrobial. Amid chronic lack of essential medicines and other resources, clinic interactions were tightly scripted, providing patients little time to question or negotiate their treatment. Based on our empirical work we developed the concept of ‘antibiotic vulnerabilities’ to reveal multiple ways in which provision of antimicrobials in rural Malawi impacts care in conditions of extreme scarcity.
Implications of our work
Ensuring a stable drug supply is vital, but must be accompanied by wider changes that enable quality care to be performed and received beyond antibiotic-oriented case management. We propose programmes be designed not only to protect vulnerable antibiotics, and patients vulnerable to antibiotic resistance but also to protect patients from systems that have come to be organised around antibiotics which leave patients with insufficient care.
