Precarity in Chikwawa, Malawi

The concept of precarity can be conceptualised as an embodied state of vulnerability that reflects the interdependence of bodies on others for survival [26]. Precarity describes a politically induced condition where certain populations suffer from failing social and economic networks of support that creates differential exposure to injury, violence and death [27]. First used to theorise class relations and neoliberal capitalism, it has been extended to conceptualise a general, pervasive ontological condition of vulnerability [28]. In the Chikwawa District of Malawi, a district of Southern Malawi, where we based our study, precarity is a state experienced by many residents. As one of the poorest countries in the world, and ranked 174 out of 189 countries in the Human Development Index [29], urbanisation has been slower in Malawi than many other countries, and approximately eighty percent of population continue to reside in rural locations [30]. As a rural district in a post-colonial state, Chikwawa has historically been overlooked in economic and development policies. During colonial rule, which ended in 1964, land was appropriated by the colonial rulers and distributed to European settlers to grow crops for export creating extractive agricultural policies that continue to shape land ownership and use today [31,32].

Opportunities for formal or wage employment are rare and state welfare provision extremely limited. The district is considered semi-arid, and many households survive on rain-fed, low-input farming to meet the food needs of the household [33]. Those participating in this type of farming are often referred to as subsistence farmers. In Chikwawa, 72% of households are considered to have very low food security and subsistence farmers often struggle to ensure there is sufficient food for their households [34]. Joshua and colleagues’ (2016) study in Chikwawa found that climate change, including the failure of perennial rainfall was resulting in declining yields of subsistence farmers crops worsening living conditions [13].

Chikwawa district has a heavy burden of infectious diseases, and one of the highest rates of malaria in Malawi [35–37]. The government provides access to medical care without user fees, but accessing services can often place a high financial burden on households through out-of-pocket expenses such as transport [38]. Substantial geographical inequalities exist with uneven health care coverage leaving rural areas underserved particularly when accessing District and Tertiary level health services [39,40]. As described elsewhere, we have previously shown that in primary health care facilities in Chikwawa, care centred on the provision of an antimicrobial. Amid chronic lack of essential medicines and other resources, health workers relied on only a few medicines–with cotrimoxazole and lumefantrine/artemisinin (antimalarial) drugs provided by international donors being the most frequently prescribed and dispensed to patients. Clinical interactions were tightly scripted which provided patients with little time to ask questions or negotiate their treatment. Fever was conceptualised by participants as more than just a symptom of malaria, reflecting global health campaign messages that not all fever is malaria [41].

The regulatory framework governing access to antibiotics and antimalarials prohibits purchase without a prescription. In practice, antibiotics and antimalarials can be bought from private clinics, pharmacies, drug shops, grocery and from informal drug vendors without a prescription [42]. Crackdowns on community-based drug vendors are reported regularly in the national newspapers [43]. The aim of our study was to provide an in-depth understanding of the ways medicines were accessed and used by households dependent on subsistence farming in the Chikwawa District of Malawi. We selected subsistence farmers in a low-income context because they are a group often economically marginalised yet still targeted with images and messages of awareness raising campaigns developed in the Global North.

Being a responsible citizen

AN and ES were visiting households to conduct medicine interviews. As they arrived at one compound, they were greeted warmly met a lady who seemed to be in her mid-30s. Her house was a simple structure with mud walls and a grass thatched roof. The household’s main livelihood was subsistence farming growing maize, millet, and sorghum for food. Any extra grain they were able to grow was sold for cash, but this only happened in the years when rains were good. During the interview explained they were a household of eight and she had never attended school. She said that the family were frequently sick and needed medicines from the hospital. She explained that cotrimoxazole was the most frequently used drug in the household. She went on to say she only gets medicine from the hospital or buys what the doctor has prescribed. She used the example of her eleven-year-old son, who suffers from persistent stomach problems and had recently been given metronidazole at the hospital. When ES probed about whether drugs were ever stored in the house, she explained that they never store medicines in the house because the doctors always advised her not to. She also said that they never kept left over drugs because they always finished the full prescription. When asked where she would go next time, she said she would return to the hospital (Medicine interview ES and AN).

As can be seen in the fieldnote above, when discussing experiences of navigating illness and seeking care, participants often conveyed narratives of the ‘right’ thing to do in terms of accessing and taking medicines. Participants talked of the importance of accessing ‘expert’ care through public health facilities, presenting symptoms and illness in the appropriate way, and accessing and taking medicines according to formal prescriptions only.

Expressing the importance of seeking formal health care was a common feature of interviews about experiences of illness and treatment-seeking. When asked what they would do next time they get ill, many interview participants stated that they would “rush to the hospital” to seek care. This common narrative often referenced the availability of testing at formal facilities, leading to the prescription of “appropriate treatment for the illness” medicines. This reflects and reproduces official health messages about the role of tests in ‘rationalising’ the use of medicines [49].

Talk of doing the right thing ‘next time’ can be seen as a public performance of citizenship, recognising what is required to be deserving of care and recovery. It also reveals the disconnect between this normative intention and the contextual reality of navigating illness, [50] described in detail below, where the idea of ‘rushing’ to the hospital is an extremely challenging prospect for many, and neglects other, important temporalities of care-seeking in this context.

A second narrative of doing the ‘right’ thing as a citizen and patient centres on the importance of taking medicines in the ‘right’ way, specifically taking medicines only as prescribed and not accessing medicines privately unless instructed. While descriptions of saving and sharing medicines were common, these practices were often presented as something ‘others’ do: “it isn’t supposed to be happening” (female farmer, residential interview, Njeleza). It was also framed by some in terms of the collective impact, reflecting a civic responsibility towards taking medicines in the ‘right’ way, to avoid potential harm to others:

“I think this behaviour contributes greatly to persistent cases of malaria amongst people in this community. This is because the dosage is stopped before malaria is completely treated” (ES in-depth interview; residential ethnography, Mfera).

Furthermore, formal narratives around purchasing medicines privately, outside instruction by clinicians, involved criticisms of others, again setting apart those who recognise the importance of accessing medicines appropriately and those who do not. In the quote below a male participant during an informal group discussion narrated:

‘people in the area have a tendency of buying antibiotics from local groceries… some people are just lazy and reluctant to take patients to the hospital’ [The statement was met with a general nodding and agreement from the group of men and women] (AN fieldnotes; male farmer, residential ethnography, Njeleza).

Here, within a group setting there is an implication of a weak morality in the accusation of ‘lazy’ people who purchase medicines privately rather than seeking formal care. Verheijen’s work (2018) highlighting conditionalities around networks of reciprocity among women in Malawi, whereby being perceived to be ‘lazy’ or wasteful of resources which may render someone undeserving of support, such as the sharing of medicines [51]. This suggests the importance of being seen to be doing the ‘right’ thing within local social networks. These enactments of moral personhood are required for being positioned favourably within networks of relations that are vital support systems in a context of extreme poverty and frequent ill-health.

The narratives can be seen as normative accounts, through which participants conveyed the ‘right thing to do’ around care-seeking, and thus constructed themselves as good citizens, often in contrast with others. These normative accounts resonate with the focus of global health campaigns around AMR, such as the WHO co-ordinated World Antibiotic Awareness Week (WAAW) [52]. People living in Chikwawa could articulate the ‘rational’ behaviours expected and promoted through such messaging, which seeks to educate lay publics and correct ‘irrational’ behaviours of overusing or misusing antibiotics, assuming they are rooted in a deficit of knowledge [53]. However, as we go on to illustrate, these public narratives do not reflect the reality of how decisions are made about accessing care in contexts of precarity, amid local financial, social, and moral economies, and in relation to personalised knowledge and experience of illness.

Frequently accessed antibiotics and the local economies of accessing medicines

Across Chikwawa District, we found cotrimoxazole and amoxicillin to be the most frequently accessed and used antibiotics in all households we included (see Fig 1). Both antibiotics are on the access list according to the WHO AWaRe Classification, which means they should be easily accessible to patients when clinically needed [54].

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 1. Most frequently used antibiotics.

https://doi.org/10.1371/journal.pgph.0000314.g001

We found that it was commonplace for residents in Chikwawa District to seek medicines beyond the formal public health sector. For many, this was an economic decision: accessing the ‘free’ state-provided health care was more costly than purchasing medicines from local providers, such as private pharmacies, grocery shops, market sellers or mobile drug vendors. Subsistence farming left households with few opportunities to access cash. Thus, decisions about forgoing income generation and other basic activities for survival, such as seeking food, by spending time seeking care were presented as challenging, in addition to the difficulties of finding money for transport to the clinic. This can be seen during a conversation AN held with a mother who had recently visited the clinic with her daughter. She described her decision to go to the hospital in the following way:

“I went to the hospital because she [my daughter] wasn’t getting better, so I decided to take her to the hospital [the primary health care facility]. I borrowed MK 600 [approximately $0.74] from my neighbours. I spent some of the money on a bicycle taxi and the rest on a snack and drink because the wait at the hospital is so long.” (Female resident and primary caregiver, AN; residential ethnography, Mfera)

This scenario was compounded by the frequency of medicines being out of stock at the health facility. A familiar feature of health care in low resource settings,[55] the unpredictable, and frequent stock outs of essential medicines in facilities in Malawi often leaves patients having to purchase prescribed medicines themselves [41]. In Chikwawa, there was a limited number of licenced pharmacies, and for most residents, local informal drug vendors or grocery stores were the most accessible to purchase medicines. Due to the limited number of medicines available in the Malawian health system, public facilities were considered to offer little more than informal providers. This can be seen in the quote below, during this conversation, AN was talking to a subsistence farmer about why people did not go to the hospital and the farmer narrated:

“the drugs we receive at the hospital are the same drugs, we can buy them from the local grocery, so people consider it a waste of time to go to the hospital.” (Male farmer, Ethnographic fieldnotes AN, Residential ethnography, Njeleza).

This reflects how ‘care’ is commonly reduced to the provision of medicines [41,49]. If the formal health facility provides scarcely more (if any) ‘care’ than the local drug vendor, strategies for accessing medicines locally are highly rational when the costs of ‘free’ care are so high for daily survival. This reality is therefore incompatible with the assumed ‘irrationality’ of the behaviour to be ‘corrected’ through WAAW and other public health education campaigns around antibiotic ‘misuse’.

The local circulation of medicines in Chikwawa District also involves anticipating future illness events, which prompts saving medicines for sharing and borrowing among friends, families, and neighbours. This reflects a temporality that is shaped by precarity, and the ongoing sense that misfortune will likely occur at any time [26,51]. Through the medicine interviews, participants narrated how frequently household members fell sick and the frequency with which they took antibiotics:

“we need this medicine [cotrimoxazole] almost every week” (female farmer, Medicine interview AN Mfera).

In this context, keeping medicines from drugs dispensed at the public health clinic once a patient has recovered was considered a necessary act for preparing for and mitigating against the challenges of inevitable illness both within the household and the wider community. In the quote below, the female farmer described the practice of stopping medicine early to ensure they have some spare medicine:

“most women stop giving medicine to their children the moment their children start feeling better, so they keep the remaining medicine which is shared amongst the communities” (Interview with female farmer, ES ethnographic fieldnotes Mfera).

While acknowledging that ‘not finishing a prescribed dose’ can be considered problematic regarding the recognised civic responsibility around antibiotics, the act of saving medicines is embedded in local networks of reciprocity that are often vital for people’s access to care at “crucial timings”[51]. This highlights two intersecting dimensions of temporality experienced in this context of precarity. The everyday reality of illness requires urgent decisions about care that are set against other decisions for daily subsistence, as well as imaginings of the future, necessitating contribution to wider social relations that offer potential for support going forwards.

Sharing saved medicines locally, between friends, family, and neighbours, is formally acknowledged as something that is “not supposed to” happen. Yet we heard multiple accounts of people sharing leftover medicines with others. This was sometimes framed as a necessary act, in terms of the timing of an illness episode, occurring, for example, when access to health facilities or medicine providers was not possible. A child falling ill late at night may be considered particularly time-critical in terms of accessing medicine.

AN arrived at a compound in the morning. He was visiting a family after he was told that the family were asking for medicines during the night. When he arrived at the compound, he met a lady whose daughter had been sick in the night. He asked her what had happened, and she explained that her daughter had a high fever and was breathing fast. She was alone in the compound as her husband was away and wanted to urgently get help for her daughter. She had no money for a taxi and no way of asking her husband for the money. She explained that she went to neighbours close by who she hoped would be able to give her medicines to help her daughter get better. She explained that one of the neighbours gave her Bactrim [cotrimoxazole] which she had then given the medicines to her child. In the morning, she felt her daughter was looking better because she had taken the medicines (Female farmer, Residential ethnography, AN, Njeleza).

This sense of urgency, necessitating the sharing of medicines, may also reflect wider global health messaging in malaria campaigns about the importance of early treatment-seeking for fever in children [56]. Talk of sharing medicines also revealed the contribution of the practice to established and ongoing social relations:

“I share the medicines with my family and with a neighbour who is my sister. We know each other well and we always sincerely tell each other if we have medicine available in our houses or not.” (female farmer in-depth interview AN during ethnographic fieldwork, Mfera).

This example suggests a temporality of continuing support over time, constructed around the likelihood of medicine being available to share in the future, if not right now.

These reciprocal exchanges of medicines are part of a broader system of circulation of basic commodities, a necessary strategy for survival in a context of extreme poverty [51]. When the expected reciprocity does not happen, this is potentially damaging to the social relations around which it is built. It highlights again the unique temporalities around accessing medicine, where past exchanges shape expectations for care-seeking in the moment:

“It felt painful to have been denied medicine because I usually help that friend with medicine anytime she asks me for help. It was like she took my help for granted” (female resident in Mfera, AN, IDI during residential ethnography).

These quotations also suggest a gendered nature to forms of local care through the sharing of medicines. This was acknowledged in some participants’ accounts of when and why sharing medicines happens locally, describing women as being “sympathetic” towards the needs of others, and therefore more likely to share. It may also reflect the dependency of women on local social relations for access to basic resources in Malawi, as described elsewhere [51]. These social and moral relations are situated within temporalities of access to medicines-as-care in the moment, and at any time. These tempos of antibiotic need are marginalised in AMR awareness campaigns, which rest on logics of acquired knowledge to be applied in a particular moment of deciding to access care.

Medicine practices informed by local, empirical knowledges

Individuals’ empirical understandings of their bodies, their illnesses and what medicines offer intersect with decisions around where and how to access medicines. This knowledge is established through multiple illness and care-seeking encounters and is applied in pragmatic ways to manage individual illness, and as part of local social and moral exchanges.

People’s understanding of their illnesses as distinct are brought to light particularly in accounts of the limitations of formal care, which were experienced as incompatible with their individual bodies. As well as the costs of accessing formal health care, tests and medicines offered at facilities could conflict with personal expectations for how to treat illness. This is evident in relation to testing for malaria through the malaria rapid diagnostic test (mRDT), and subsequent access (or otherwise) to lumefantrine/artemisinin (LA). Many participants’ accounts reflected past frustrations that mRDTs failed to detect ‘their’ malaria, and therefore restrict their access to LA which is experienced as effective in alleviating their symptoms:

“many people choose to buy LA from the shops at Dembo because they know that sometimes they are not diagnosed malaria positive due to their type of blood, so they simply choose to buy LA for them to get recovered.” (Male farmer, Residential ethnography, AN Mfera).

Experiences of this disparity led people to bypass formal care, applying their empirical knowledge of what works for their malaria and seeking medicines such as LA locally. This practice contributes to broader narratives of the failure of formal care to provide adequately for people’s health needs, resulting in the necessity of other strategies to access the right medicines for their bodies.

Yet, past experiences of attending health facilities and receiving prescribed medicines do play an important role in applying knowledge of medicines in local contexts. Participants conveyed how knowledge gained through clinical encounters, as well as empirical experiences of illness and recovery, can be recalled and employed in decision-making around medicines, both for themselves and others in their social networks. In the quote below, a mother explains why she asks for LA from the neighbours:

“Every time my child is sick, she is diagnosed with malaria and that is why I ask for LA from the neighbours, it always works and my child recovers very well” (mother and resident in Mfera, AN in-depth interview, Mfera).

Similarly, this knowledge of medicines can be transferred to purchasing medicines from private providers where information on medicines and dosage may not be provided:

AN was sat on the veranda chatting to a local male resident in his early thirties. AN was asking him about his experiences of buying medicines from an informal drug vendor. The man narrated that he often bought medicines locally as it was easier than visiting the clinic. He explained that the drug vendor didn’t tell him how to take the medicine, but he knew from his previous experiences of using antibiotics (amoxicillin, cotrimoxazole and pen V) that he should take two tablets in the morning and evening. (Male resident of Njeleza, AN ethnographic fieldnotes)

Knowledge acquired through multiple experiences of illness and recovery-seeking applied to fill the gaps in the form of care available through others reflects what Rodrigues (2020) describes as a form of ‘legitimacy’ in self-medication practices [57]. Previous formal prescriptions combine with empirical encounters of illness and recovery to contribute to “a more autonomous form of self-care” (ibid, p5) for (perceived) familiar conditions [57].

The building up and application of this knowledge also intersects networks of reciprocal relations around sharing medicines. Sharing often included description of the information about the recommended dosage. The passing on of advice about taking medicines, reflecting the transference of accumulated knowledge, is an important part of the exchange, and can be considered part of the act of care in itself. This practice highlights the social dimensions of rationales for seeking medicines. They are built not only on individualised “embodied experiences” of illness and recovery, but also on the experiences of others, and relations of trust and reciprocity within social networks [57].