Postcolonial Global Health, Post-Colony Microbes, and Antimicrobial Resistance

Rather than ‘superbugs’ signifying recalcitrant forms of life that withstand biomedical treatment, drug resistant infections emerge within and are intricate with the exercise of social and medical power. The distinction is important, as it provides a means to understand and critique current methods employed to confront the threat of widespread antimicrobial resistance. A global health regime that seeks to extend social and medical power, through technical and market integration, risks reproducing a form of triumphalism and exceptionalism that resistance itself should have us pause to question. An alternative approach, based on a postcolonial as well as a ‘post-colony’ approach to health and microbes, provides impetus to challenge the assumptions and norms of global health. It highlights the potential contribution that vernacular approaches to human and animal health can play in altering the milieu of resistance.

Antibiotics, Rational Drug Use and the Architecture of Global Health in Zimbabwe

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 level ‘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 these everyday ‘architectures’ that over time and across spaces have 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 Zimbabwe’s building of one of Africa’s strongest postcolonial health systems. Whilst RDU was focused on securing health and safety of patients and affordability for systems, AMS programmes aim to secure medicines. Continuous across both RDU and AMS programmes is the persistent rhetoric of ‘irrational use’ by frontline prescribers. Health workers in Harare are attuned to the values and language of these programmes, but their everyday practice follows 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 rationality, to the redrafting of blueprints that inscribe practice.

Air Care: an ‘aerography’ of breath, buildings and bugs in the cystic fibrosis clinic

With significant relevance to the Covid-19 pandemic, this paper contributes to emerging ‘aerographic’ research on the socio-materialities of air and breath, based on an in-depth empirical study of three hospital-based lung infection clinics treating people with cystic fibrosis. We begin by outlining the changing place of atmosphere in hospital design from the pre-antibiotic period and into the present. We then turn to the first of three aerographic themes where air becomes a matter of grasping and visualising otherwise invisible airborne infections. This includes imagining patients located within bodily spheres or ‘cloud bodies’, conceptually anchored in Irigaray’s thoughts on the ‘forgetting of the air’ and Sloterdijk’s immunitary ‘spherology’ of the body. Our second theme explores the material politics of air, air conditioning, window design, and the way competing ‘air regimes’ come into conflict with each other at the interface of buildings, bodies and the biotic. Our final theme attends to the ‘cost of air’, the aero-economic problem of atmospheric scarcity within modern high-rise, deep-density healthcare architectures.

Negotiating Relevance

What is the relationship between knowledge and practice in research on health, disease and illness? Yoder explains how the majority of public health intervention and communication projects we encounter today are based on social psychology models of behaviour change that assume that changes in beliefs and knowledge precede behavioural changes. This has been the dominant model in health research and intervention in the developing world, informing our approach to almost all critical issues in public health for over fifty years, including HIV/AIDS prevention, improving vaccination rates, breastfeeding, the use of oral rehydration salts, and bed nets to prevent malaria, and today antimicrobial resistance (AMR), among others. Yoder explains that this model of behaviour change is attractive because of the promises they make: “they claim the ability to predict behaviour change from cognitive elements, and scales have been developed to measure these cognitive elements, and they offer ways to intervene through health education” (134).

But does it work? What Yoder explains – based on extensive research and review – is that projects that take this behaviour change model often do not see relevant behaviour changes within the populations intervened upon because 1) This model overemphasizes the role of the individual in maintaining good health; 2) The model claims universality but is mainly based on behavioural models of middle-class Americans; and 3) While the role of social and ecological determinants of health are seen as barriers to ‘good behaviours’, these factors receive comparatively little consideration in behavioural explanation and modelling.

The Opacity of Reduction

This article explores the process of consolidating technical and historically contingent ideas about nourishment into seemingly straightforward terms such as vitamins and minerals. I study the adoption of scientific principles of abstraction and reduction as a strategy of nutrition education in three Guatemalan highland sites: an elementary school classroom, a rural clinic, and the obesity outpatient center of Guatemala’s third-largest public hospital. I show that despite its pretense of simplicity, the reductionism of nutritional black-boxing produces confusion. Moreover, dietary education not dependent upon simplified and fixed rules and standards may be more intelligible to people seeking nourishment in their lives.

Fast Relief

The experience of time famine in contemporary U.S. culture affects household decisions about self‐care and the use of pharmaceuticals for selfmedication. This article examines the manner in which time demands shape lay interpretations of medicine efficacy and drive increases in medication use for adults as well as children. Medicines, like other time‐saving commodities, appear to shift the time‐power differential in favor of individuals, placing them in control of how time is spent. When there is “no time to be sick,”allopathic medicines become time‐saving devices that enable women to fulfill responsibilities at work or home while they attend to sick children or to being ill themselves. Medicines are used to beat the clock by increasing one’s own capacity to be productive, [self‐medication, domestic health care, United States, time]

Self-care and the informal sale of drugs in south Cameroon

Self-care, though the most common of all forms of therapeutic action, has been little studied. This paper describes the context of self-medication with western pharmaceuticals in an area of South Cameroon (in 1980). The identity and appropriateness of these pharmaceuticals are briefly discussed. The paradoxical character of self-medication is emphasised: improvement in the quality of self-medication implies both growth and loss of self reliance, increase and decrease of medicalisation. People in Cameroon, or indeed anywhere in the Third World, find themselves in a ‘double-bind’.

The efficiency of inefficiency

An attempt is made to explain why public health services in South Cameroon function inefficiently. Special attention is given to the distribution of medicines. The root cause of inefficiency is believed to be ‘corruption’, the private use of public goods. It is suggested that some degree of commercialization may solve the present problems and replace the ‘expensive free distribution’ of medicines by a paid distribution of cheap medicines. The research for this article was carried out in 1980 in South Cameroon.

The Charm of Medicines

Even amongst biomedical scientists, medicines have an enigmatic air, for example in the way they are often referenced as ‘magic’ bullets. In reference to antimicrobials, ‘magic’ evokes both the power and potential super-power of such substances and their relations to our material and social realities. Moving this further, anthropologists Sjaak van der Geest and Susan Reynolds Whyte describe medicines as having ‘charm’, providing a concrete solution to ill- health, and an effect that can be separated from a therapeutic encounter. This distinguishes medicines from other forms of healing such as surgery, which cannot be separated from a surgeon.

Medicines are democratic and exoteric, they are ‘widely believed to contain the power of healing in themselves. Anyone who gains access to them can apply their power’ (Van der Geest & Whyte, 1989 p346). The authors extended this perspective to incorporate a wide range of places and spaces where medicines flow, are exchanged as commodities, are prescribed and consumed. They invoke an analytical framework of the ‘Social Lives of Medicines’, proposing that as things, medicines have biographies (S.R. Whyte et al., 2002). The authors trace the careers of medicines, often antimicrobial, and provide useful context for the ways in which these substances travel beyond the enclave of professional control and are made common. In drawing together a range of anthropological works, through which they illustrate how people in different settings, roles and industries, employ these substances for various endeavours, this volume is compelling in arguing that medicines should be understood beyond their capacity to cure (or poison).

The charm of pharmaceuticals, as concrete entities with wider symbolic, economic and political value, is a useful lens through which to consider how antimicrobial resistance may arise as well as how it may be tackled, especially in relation to the drivers of antimicrobial use. We can look at the value of antimicrobials for different actors in order to gain insights into the status quo, important to consider if intervention is to be undertaken, both to design effective interventions and to anticipate potential consequences beyond impact on AMR.

The Politics and Anti-Politics of the Global Fund Experiment

After a decade of operations, the Global Fund is an institutional form in flux. Forced to cancel its eleventh round of funding due to a shortfall in donor pledges, the Fund is currently in firefighting mode, overhauling its leadership, governance structures, and operations. Drawing on a case study of Uganda, we look at how the original Global Fund vision to be a simple financial instrument has played out at the country level. Even prior to the cancellation of round 11, the proliferation of partners required to sustain the Global Fund to Fight AIDS, Tuberculosis and Malaria experiment led to increasing bureaucratization and an undermining of the Fund’s own intentions to award life-saving grants according to need. Understanding these effects through the ethnographic material presented here may be one way of reflecting on the Fund’s structure and practices as it struggles to reinvent itself in the face of criticism that it has impeded resource distribution.