Abstract: 

This presentation, which forms a part of my PhD thesis, discusses the push to “rationalise” the practices prevalent in modern medicine and how it comes to inflect the ways in which Infectious Diseases (ID) physicians are trying to rescript the relationship we have with antibiotics/antimicrobials in the contemporary—a time marked by the global crisis of antibiotic/antimicrobial resistance (ABR/AMR). ABR/AMR and the anxiety that a seeming “post-antibiotic” future provokes has led to a situation in which the “irrational” usage of these pharmaceuticals has been identified as the primary culprit and focus of intervention in policy prescriptions. Drawing on my ethnographic engagement with ID physicians working at a corporate tertiary care facility in Southern India, this chapter tries to show how the dichotomy between irrational and rational ways of relating to these pharmaceuticals is fraught in practice. All too often, and all too easily, the dichotomy between the rational and irrational use of these pharmaceuticals is mapped onto the dichotomy between expert and lay ways of relating to antibiotics—irrational consumption of these molecules is seen to either result from self-medication or from the illicit prescription of these drugs by “quacks” or those lacking the requisite expertise. However, following extensive ethnographic engagement with ID physicians in the hospital makes it evident that this picture is more complicated. What complicates this picture is that 1) the hospital itself produces and perpetuates the conditions under which infections, often resistant, proliferate. This demands increasingly extensive therapeutic care in the form of antimicrobials. 2) the critical condition in which patients in hospitals often are demands the disbursal of “empirical” antimicrobial therapy which is based on diagnostic guesswork which has not been/cannot be ascertained through laboratory tests. In the hospital, then, the dichotomy between irrational and rational ways of relating to antimicrobials contends with the dichotomy between empirical and definitive (where the aetiology of the infection has been established beyond doubt) forms of therapy. Empirical therapy has, more generally, received a bad rap in modern medicine and in its pejorative sense refers to what quacks engage in i.e. practices of therapeutic or curative modalities which lack a rationale (according to the dictates of biomedicine). Modern medicine is haunted by this pejorative sense of the “empirical”. In the hospital, however, many a time “empirical” therapy needs to be provided because the patients are in far too critical a state to await the results of cultures and tests, or the cultures don’t return usable results, or the patient is too weak for the procurement of samples. The fact that the clinical encounter between the physician and the patient often demands this mode of therapeutic care makes it difficult to a priori distinguish between irrational and rational ways of prescribing antibiotics in the hospital. 3) The implementation of stewardship programs—which aim to rationalise the use to antibiotics/ antimicrobials—in the hospital often involve feats of persuasion that exceed the domain of “rationality”; it involves what my interlocutors describe as “diplomatic” orchestrations— forging relationships, engaging affect and strategic thinking.