Taking opportunities, taking medicines:Antibiotic use in rural Eastern Uganda

The ways in which dimensions of health and healthcare intersect with economics and politics in particular contexts requires close attention. In this article we connect concerns about antibiotic overuse in Uganda to the social milieu created through policies that follow President Museveni's vision for a population who kulembeka, "tap wealth." Ethnographic fieldwork in rural Eastern Uganda illustrates how taking medicines in rural households reflects a wider landscape of everyday imperatives to "tap" opportunities in a context of acute precarity. We argue for a closer connection between medical and economic anthropology to push forward understanding of health, medicines and wellbeing in Africa

City of clones: Facsimiles and governance in Sao Paulo, Brazil

São Paulo is a megacity defined by formal and informal patterns of urbanization. Informally urbanized spaces are not absent of state intent, despite appearances. Grassroots-led social and spatial practices for survival, agency and self-governance contribute to the reproduction of urban political order in surprisingly unoriginal and routinely recognizable ways. This article argues that these unexceptional informal practices can be understood as ‘facsimiles’ of their formal institutional originals. Using the example of cloned cars the article shows that the facsimile and the original are the same in form and function. Facsimiles do not exist outside of political authority, but are a byproduct and a component of it. They are indistinguishable in their bureaucratic deployment, recognition and acceptance as part of social and spatial order. This is the author accepted manuscript. The final version is available from Sage via https://doi.org/10.1177/001139211665729

Use of antibiotics to treat humans and animals in Uganda: a cross-sectional survey of households and farmers in rural, urban and peri-urban settings.

BACKGROUND: Use of antibiotics to treat humans and animals is increasing worldwide, but evidence from low- and middle-income countries (LMICs) is limited. We conducted cross-sectional surveys in households and farms in Uganda to assess patterns of antibiotic use among humans and animals. METHODS: Between May and December 2018, a convenience sample of 100 households in Nagongera (rural), 174 households in Namuwongo (urban) and 115 poultry and piggery farms in Wakiso (peri-urban) were selected and enrolled. Using the 'drug bag' method, participants identified antibiotics they used frequently and the sources of these medicines. Prevalence outcomes were compared between different sites using prevalence ratios (PRs) and chi-squared tests. RESULTS: Nearly all respondents in Nagongera and Namuwongo reported using antibiotics to treat household members, most within the past month (74.7% Nagongera versus 68.8% Namuwongo, P = 0.33). Use of metronidazole was significantly more common in Namuwongo than in Nagongera (73.6% versus 40.0%, PR 0.54, 95% CI: 0.42-0.70, P < 0.001), while the opposite was true for amoxicillin (33.3% versus 58.0%, PR 1.74, 95% CI: 1.33-2.28, P < 0.001).Veterinary use of antibiotics within the past month was much higher in Wakiso than in Nagongera (71.3% versus 15.0%, P < 0.001). At both sites, oxytetracycline hydrochloride was the most frequently used veterinary antibiotic, but it was used more commonly in Wakiso than in Nagongera (76.5% versus 31.0%, PR 0.41, 95% CI: 0.30-0.55, P < 0.001). CONCLUSIONS: Antibiotics are used differently across Uganda. Further research is needed to understand why antibiotics are relied upon in different ways in different contexts. Efforts to optimize antibiotic use should be tailored to specific settings

Antibiotic ‘entanglements’:Health, labour and everyday life in an urban informal settlement in Kampala, Uganda

Antibiotics are a routine part of everyday life in many contexts, contributing to the development of antimicrobial resistance (AMR). Our ethnographic research documents the ways that antibiotics have become a key part of everyday life for precariously employed urban day-wage workers living in a large informal settlement in Kampala, Uganda. We found that for many people, their daily work and ongoing health was entangled with antibiotic use; that is, people showed us how their antibiotic use cannot be separated from the realities of living in a politically, economically and environmentally degraded ‘informal’ landscape. Thinking through entanglement as itself a politics, we show how limited political power, inability to demand change, and inequitable access to good health care, are associated with high rates of infection and disease, precarious work, and polluted environments. Antibiotics, we argue, have become a way to negotiate the inequalities written into these informal urban landscapes; their use entangled with ongoing relations with labour, environment and bodily suffering. Through this approach, we show how antimicrobials are used in society, with an attention to how vulnerabilities, risks, and forms of abandonment and exclusion shape their everyday use. Antibiotic use is entangled with everyday life in informal settlements, and the politics that produce ‘informality’. In Kampala today, the entanglement of antibiotics with life in informal settlements reveals how forms of urban segregation, life in ‘slums’ and their everyday acceptance, shape the pathways and uses of antimicrobials

Pharmaceuticalised livelihoods: antibiotics and the rise of 'Quick Farming' in peri-urban Uganda

The 'livestock revolution' has seen the lives and livelihoods of peri-urban peoples increasingly intertwine with pigs and poultry across Africa in response to a rising demand for meat protein. This 'revolution' heralds the potential to address both poverty and nutritional needs. However, the intensification of farming has sparked concern, including for antibiotic misuse and its consequences for antimicrobial resistance (AMR). These changes reflect a micro-biopolitical conundrum where the agendas of microbes, farmers, publics, authorities and transnational agencies are in tension. To understand this requires close attention to the practices, principles and potentials held between these actors. Ethnographic research took place in a peri-urban district, Wakiso, in Uganda between May 2018 and March 2021. This included a medicine survey at 115 small- and medium-scale pig and poultry farms, 18 weeks of participant observation at six farms, 34 in-depth interviews with farmers and others in the local livestock sector, four group discussions with 38 farmers and 7 veterinary officers, and analysis of archival, media and policy documents. Wide-scale adoption of quick farming was found, an entrepreneurial phenomenon that sees Ugandans raising 'exotic' livestock with imported methods and measures for production, including antibiotics for immediate therapy, prevention of infections and to promote production and protection of livelihoods. This assemblage - a promissory assemblage of the peri-urban - reinforced precarity against which antibiotics formed a potential layer of protection. The paper argues that to address antibiotic use as a driver of AMR is to address precarity as a driver of antibiotic use. Reduced reliance on antibiotics required a level of biosecurity and economies of scale in purchasing insurance that appeared affordable only by larger-scale commercial producers. This study illustrates the risks - to finances, development and health - of expanding an entrepreneurial model of protein production in populations vulnerable to climate, infection and market dynamics

Antibiotic stories:A mixed-methods, multi-country analysis of household antibiotic use in Malawi, Uganda and Zimbabwe

Background As 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. Design This 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. Results The 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. Conclusions Our 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

Reconciling imperatives: Clinical guidelines, antibiotic prescribing and the enactment of good care in lower-level health facilities in Tororo, Uganda.

Faced with the threat of antimicrobial resistance, health workers are urged to reduce unnecessary prescription of antimicrobials. Clinical guidelines are expected to form the basis of prescribing decisions in practice. Emerging through evaluations of best practice - bundling clinical, technological and economic dimensions - guidelines also create benchmarks through which practice can be assessed with metrics. To understand the relationships between guidelines and practice in the prescribing and dispensing of antibiotics, ethnographic fieldwork was undertaken in lower-level health care facilities in rural Eastern Uganda for 10 months between January and October 2020, involving direct observations during and outside of clinics and interviews with staff. In a context of scarcity, where 'care' is characterised by delivery of medicines, and is constituted beyond algorithmic outputs, we observed that clinical practice was shaped by availability of resources, and professional and patient expectations, as much as by the clinical guidelines. For stewardship to care for patients as well as for medicines, a better understanding of clinical practice and expectations of care is required in relation to and beyond clinical guidelines

Antimicrobials in Society: A film about anthropological approaches to antibiotic use in East Africa

The Antimicrobials in Society (AMIS) Project Uganda: A film about anthropological approaches to the study of antibiotic use for humans and animals in households and farms in rural, urban, and peri-urban settings in Uganda, East Africa. The film shows the AMIS Uganda research activities aimed at understanding the roles that antibiotics play in everyday life and the context within which antibiotics are used in rural Tororo, peri-urban Wakiso and urban Kampala. It portrays the way antibiotic use is shaped by economic concerns among commercial poultry and piggery farmers in peri urban Wakiso and challenges of limited access to clean water and inadequate toilet facilities in rural Tororo and urban Kampala. The Youtube video is available at https://youtu.be/KyToiiv-MJk

Antibiotics as Protection: A film about antibiotic use in pig and poultry production in Uganda

Antibiotics as Protection: A film about antibiotic use in pig and poultry production in Wakiso district, Uganda. The film depicts everyday life on peri-urban pig and poultry farms in Wakiso district in relation to the use of antibiotic medicines. It highlights the magnitude of finances invested in production versus threats that compromise profits. Irrespective of adoption of modern biosecurity measures, production is precarious. In this case, antibiotics have become a recipe, shifting connections away from treatment and prevention to economic concerns regarding profitability and protection of financial investments. The film is hosted on Youtube at https://youtu.be/TEFe_hz7qNQ