Easy access to desperately needed drugs has made India the global accelerant of our antimicrobial resistance crisis

by Assa Doron & Alex Broom  BIO

Photo by Ian Teh/Panos Pictures

is professor of anthropology and South Asia at the Australian National University in Canberra. He is the author of Life on the Ganga: Boatmen and the Ritual Economy of Banaras (2013), and the co-author of The Great Indian Phone Book: How the Cheap Cell Phone Changes Business, Politics, and Daily Life (2013), Waste of a Nation: Garbage and Growth in India (2018) and A World of Resistance: India and the Global Antibiotic Crisis (2026).

is academic director for Social, Behavioural and Economic Sciences at the Australian Research Council. He is also professor of sociology and director of the Sydney Centre for Healthy Societies at the University of Sydney. His books include Dying: A Social Perspective on the End of Life (2015), Survivorship: A Sociology of Cancer in Everyday Life (2021) and A World of Resistance: India and the Global Antibiotic Crisis (2026).

Edited byPam Weintraub

In a streetside pharmacy in Hyderabad, Sushil, 48, hands out antibiotics one strip at a time. He holds a bachelor’s degree in commerce but learned the trade from his father, a trained pharmacist. He takes pride in serving his community, where many cannot afford to miss even a single day of work. Few have the means for a full course of antibiotics, so he cuts a strip of tablets in half.

Across India, antibiotics are regarded as ‘strong medicine’: a fast and familiar solution when there is neither time nor money for a proper diagnosis and medically supervised treatment. Decades of routine use by millions of Indians – rich and poor alike – have reinforced the sense that antibiotics work and are just part of day-to-day life. They are cheap, widely available through thousands of streetside pharmacies and, for most people, seemingly free of immediate side effects.

When we asked Sushil why he dispenses antibiotics so readily, his answer was direct: ‘I cannot risk a person’s life. If someone comes from the village and doesn’t have money, what will I do? I’ll give them antibiotics for three days. I cannot just let go of their life.’

Consider the daily wage labourer with a family to feed, moving from job to job with no contract, and many others ready to replace him if a shift is missed. A bout of diarrhoea or a respiratory infection can mean losing his job altogether. A visit to a nearby pharmacy, a short course of antibiotics, a day or two of rest, and it’s back to work. For people at the lower rungs of Indian society, there are no medical certificates and no paid leave to protect either their health or their jobs. With lack of regular access to clean water and sanitation, health, like income, is managed day by day. For many, a single missed wage is enough to push basic needs out of reach.

The costs, however, accumulate elsewhere. The side effects are not immediate, overt or dramatic, but delayed, concealed and pervasive. Bacteria adapt. Previously potent drugs lose their power. What once seemed like the perfect answer to human vulnerability to bacterial infection is now revealing its limits in the form of antimicrobial resistance: a slow-moving consequence of antibiotic overuse.

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India is the accelerant of the global antimicrobial resistance crisis. Weak governance of pharmaceuticals, easy access to antibiotics, a high burden of infection driven by gaps in sanitation and health infrastructure, prolific antibiotic use in agriculture, and industrial pollution from pharmaceutical and other waste streams have combined to speed the rise and spread of resistant bacteria.

In a connected world, those microbes and resistant genes will not remain local.

They may travel in the gut of an unwitting tourist or circulate through the body of a worker in India. But resistance is not contained within individual bodies. It moves through wider systems, from sewage and waste to farms, food chains and global trade. Superbugs emerge in densely packed farms outside India’s megacities and in shrimp ponds supplying supermarkets in the United States. There, antibiotics do more than treat disease. They help sustain intensive production, deliver cheap protein, protect farmers’ incomes and secure corporate profit.

Resistant bacteria also gather around pharmaceutical manufacturing plants in South India. Wastewater from some of these facilities has repeatedly been found to contain antibiotic residues and resistance genes. At the same time, some manufacturers produce substandard or spurious antibiotics for both foreign and domestic markets. These are two distinct routes into the same problem. Environmental contamination exposes bacteria to a mixture of chemicals and low levels of antibiotic residues, helping the hardiest survive and multiply. Poor-quality drugs allow bacteria to persist, making treatment less effective next time. Either way, the phenomenon is the fuel behind MRSA bacteria, drug-resistant tuberculosis, and the highly resistant strains of E coli, Klebsiella and Acinetobacter. Then, such microbes and their resistance genes cross borders through travel, trade, food systems, displacement, conflict and global supply chains.

It is not a purely biomedical problem but a political, economic and social crisis with global reach

Countries in the Global North are hardly immune. Many of them have been relatively more successful in slowing the spread of drug-resistant bacteria through tighter controls on prescribing, farming and waste management. But such measures will hardly shield them from a problem carried by an interconnected world. Resistance, in other words, will not be India’s burden alone.

Our interest in antimicrobial resistance (AMR) emerged from different directions – for Assa Doron, through anthropological fieldwork near pharmaceutical plants in Hyderabad, a manufacturing hub long linked to antibiotic-laden waste; and for Alex Broom, through sociological study of AMR as a product of structural vulnerability, everyday self-care, and weak governance. Years of joint research across pharmaceutical zones, clinics, farms and everyday sites of medicine use in India led us to understand AMR not as a purely biomedical problem but as a political, economic and social crisis with global reach. What we found is that resistance takes shape at the intersection of governance failures, global supply chains, labour, poverty and agriculture – the same inequalities that determine who gets antibiotics, under what conditions, and to what ends.

These inequalities do not operate only at the level of policy or markets; they are ultimately inscribed in the microbial life of the body itself. Inside the gut of a daily wage worker, an antibiotic kills many of the bacteria causing illness, but not all. Some survive because they already possess traits that make them less susceptible to the drug. The next time infection strikes, those microbial survivors are better equipped to endure antibiotic treatment.

Drug-resistant bacteria survive, thrive and spread. These microbes do not remain confined to a........

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