The antibiotic trap

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 single gut. They leave the body through faeces and enter environments where sanitation is uneven and sewage often untreated. Open defecation remains common in parts of India, adding to a constant swirl of microbial exposure. Nor should we presume that this microbial story is lived in uniform ways across caste, class and gender. Women and girls, for instance, often bear a disproportionate burden of infection, since access to sanitation, diagnosis and timely treatment remains deeply unequal and antibiotic effectiveness increasingly uncertain.

The story does not end with human bodies. Antibiotics have become a routine tool of intensive farming. By volume, around two-thirds of antimicrobials sold worldwide are used in animals rather than humans. In India, their use is especially common in shrimp farming and poultry, where they are used to promote growth, ward off disease in crowded conditions and protect yields. What looks like efficiency is often a form of pharmaceutical dependence.

These intensive farming systems spew antibiotic-laced waste into rivers, ponds, soils and into the air, contributing to a wider resistant ecology. Drug residues and resistant bacteria move through effluent, runoff, feed and manure, but also through dust and airborne particles stirred up from animal sheds and waste. Resistance does not stay in barns or clinics. It travels across bodies, species and landscapes. The environment itself becomes a reservoir.

And, once resistance is embedded in these wider environments, it becomes much harder to contain within any one place or population. Microbes travel through trade and tourism. A study of Swiss travellers returning from India found strikingly high rates of gut colonisation with antibiotic-resistant bacteria, an unwanted bug carried home without symptoms. Resistance does not respect borders. It moves with the infrastructures and ecologies we have built.

Trade carries it too. India’s shrimp industry has come under mounting criticism for labour violations and export compliance failures. In 2025-26, several shrimp consignments bound for the US and Europe were rejected after testing positive for banned antibiotic residues. In other words, what looks like a local problem thousands of miles away is already in circulation.

Villagers near industrial estates described foul-smelling effluents, often released under the cover of night

Another vast transnational trade is the production of pharmaceutical drugs in India. What is often presented as the competitive advantage of Global South countries has in fact meant concentrating manufacturing, waste and exposure in places like India, while dispersing the benefits of cheap antibiotics elsewhere. The Global North consumes these drugs en masse, even as much of the environmental damage is borne in India. Our collective antibiotic footprint, to borrow from the language of fossil fuels, is large. And like carbon, its costs accumulate slowly before returning with force.

This is where the circulation of microbes meets the global production of cheap antibiotics. Over recent decades, a significant share of antibiotic manufacturing has moved to the Global South in search of better profit margins and weaker regulation. India is at the heart of this pharmaceutical trade. It is among the world’s largest producers of generic medicines and a major exporter of generic antibiotics to Africa, Europe and the US, while supplying its own vast domestic market. Large volumes of finished drugs, along with key active pharmaceutical ingredients, pass through industrial corridors around Hyderabad before reaching clinics and farms across the globe.

The industry generates billions in revenue and underwrites affordable treatment worldwide. Yet, as the The BMJ recently put it in a headline, it also has ‘a waste problem’. In several manufacturing hubs, poorly treated industrial discharge has released a mix of bulk drug ingredients, antibiotic residues, and sometimes heavy metals into surrounding soils and waterways. When bacteria are exposed to these substances again and again, the most robust ones are more likely to survive, multiply, and share resistance with others. Studies have documented striking levels of resistant organisms in such settings. The boundary between factory, pharmacy and field begins to blur.

On the outskirts of Hyderabad, often called the Pharma Capital of India, villagers living near industrial estates described foul-smelling effluents, often released under the cover of night. Shanakar, a former village head with whom we spoke, has spent decades challenging the pharmaceutical companies. At a site near his village, he gestured toward a darkened canal. ‘You see,’ he said, pointing to the water, ‘because of the pollution, the fish have died. Migratory birds have stopped coming.’ Paddy fields now yield half as much as before. A buffalo that once gave eight to 10 litres of milk a day now produces only two. ‘This is what progress looks like for us,’ he said. While Hyderabad may be celebrated as an IT and pharmaceutical hub and hailed as an economic miracle, from the banks of the Musi River, the cost of that success appears disturbingly dire.

The local story of antibiotics points to a wider pattern. It is as much about a political economy of extraction and outsourced pollution as it is about poverty or precarity. The same drugs that circulate through global supply chains and seep into industrial effluent also pass through factory farms, street-side pharmacies, community health workers and household medicine cabinets. What begins behind the fortified walls of drug-manufacturing plants reappears in everyday acts of care, shaped by inequality, a lagging infrastructure and the normalisation of pharmaceutical quick fixes.

In rural India, too, antibiotics are made to compensate for what the health system cannot reliably provide. For people with limited access to formal medical care, they may be the only recourse, obtained from rural medical practitioners or grocery stores. A pill is cheap; a clinic visit may mean travel, lost wages and hours of waiting. In these settings, antibiotics stand in for diagnosis, continuity of care and the costs that proper treatment imposes. Yet the systems built around their reliability are beginning to strain.

Drugs once trusted to protect the most vulnerable – newborns with sepsis, surgical patients, people undergoing chemotherapy – no longer perform as they once did. In India, resistant bacterial infections are estimated to contribute to around 60,000 newborn deaths a year, while their effects are increasingly visible well beyond the poor.

Antibiotics as everyday solutions are not just the province of the poor. In India’s urban centres, a different dynamic takes hold: higher health-awareness coexists with an almost consumerist certainty, as relatively affluent patients arrive at pay-per-consult clinics already persuaded they know which drug they need. As Manish Yadav, a community physician in Chennai, told us: ‘It’s two Indias within one India.’ Even within the same city, he sees a sharp divide – affluent neighbourhoods where the overinformed put their faith in the speed and potency of antibiotics, and poorer settlements where knowledge of the drugs and their long-term consequences remains thin. Yet one similarity persists: from gated communities to urban slums, there is a shared belief in antibiotics as the most reliable path back to health.

In a busy public hospital, the physician Priya Patil moves quickly from bed to bed, overwhelmed by her patient load. Pollution and crowded housing fuel infections of every kind – bacterial, viral, fungal, parasitic. The same question shadows each consultation: is this fever bacterial, viral or something else entirely? ‘To start antibiotics, to stop antibiotics, which antibiotics?’ There is rarely time, money or equipment for proper diagnostics. Treatment becomes empirical, guided by symptoms and probability rather than lab confirmation – a shotgun approach where precision is needed. Broad-spectrum and last-resort drugs are deployed to cover as many possibilities as possible, disrupting entire microbial communities in order to hit the likely culprit.

Patil understands antimicrobial resistance and has watched once-dependable medicines falter. Yet patients frequently expect, and even insist on, a prescription. Leaving without one can be read as neglect; doctor-shopping often follows. In a system where many clinics operate as small businesses and reputation travels by word of mouth, withholding antibiotics carries real professional risk. The clinician stands in a bind: prescribe and risk contributing to resistance, withhold and risk losing the patient’s trust.

Patients seek security, doctors seek certainty, institutions seek efficiency, and industries seek profit

Private hospitals operate under different pressures but arrive at similar outcomes. Antibiotics satisfy patient expectations, protect revenue and ensure the fastest short-term result. Prescribing early and broadly moves patients through the system faster; higher turnover improves the bottom line. Prophylactic antibiotics for day surgery reduce bed days and cut costs. Here, antibiotic treatment functions less as targeted therapy than as a management tool in a competitive healthcare market. The irony is pointed: the drugs that made modern hospital care possible are losing their power precisely in the institutions built around them.

To call this misuse is to misread it. That word implies individual failure – the doctor who prescribes too readily, the patient who demands too much – and obscures the conditions that make such decisions not just understandable but rational. Responsibility is dispersed across patients seeking security, doctors seeking certainty, institutions seeking efficiency, and industries seeking profit. Antibiotics circulate not despite these systems but because of them.

We first saw this dynamic at a public hospital in Hyderabad, where staff initially tried to remove us – they had mistaken us for pharmaceutical representatives. The reflex was telling. Years of aggressive marketing, commissions and promotional visits had made the institution wary. Drug promotion was not an occasional intrusion but a routine presence.

Across the country, from city hospitals to rural clinics, we encountered the same pattern. Medical representatives moved through waiting rooms and consulting offices carrying sample packs, glossy brochures and digital presentations, pitching newer, more potent antibiotics as solutions to germs already showing resistance to older drugs. The pitch was polished and deferential, stressing faster recovery and better patient satisfaction – precisely the currency that matters in overcrowded, time-pressured settings.

Clinicians understood these visits were commercially driven, yet they also filled a real gap. Few doctors had time to keep up with trials, new drugs and shifting treatment guidelines. Representatives offered quick summaries and simplified updates shaped to fit a crowded schedule, sometimes sweetened with conference invitations and professional perks. In rural areas especially, where practitioners often had limited formal training, the line between instruction and salesmanship was hard to find. Information and promotion had become, for practical purposes, the same thing.

What this points to is a system in which the conditions pushing antibiotic use and those undermining its effectiveness are not in tension – they are the same conditions. Overcrowded wards, insecure livelihoods, commercial healthcare, aggressive marketing, weak diagnostics and fragile governance do not each contribute a separate share of the problem. They form a single ecology in which resistance is not an accident or a failure of individual behaviour but a predictable outcome. AMR is, in this sense, not a disease the system has failed to prevent. It is one the system keeps producing.

The deeper we explored the story of antibiotics in India, the clearer it became that these drugs are inseparable from the country’s post-independence vision of progress: a vision built on self-reliance, scientific capacity and the promise that technology can secure health and prosperity.

Jawaharlal Nehru, the country’s first prime minister, was adamant that political freedom had to be matched by industrial and scientific capacity. Just as India would build its own steel plants and dams, it could also manufacture its own medicines. Antibiotics in India were championed and celebrated as symbols of modernity, progress and improved life expectancies.

Antibiotics helped build modern systems of scale. Not only in hospitals, but in the intensive farms and aquaculture operations that now supply cheap protein to Indian consumers and foreign markets. Yet this entanglement rarely features in the triumphant language of trade. Recent free trade agreements with Europe and the US have been presented as mutual gains, expected to boost pharmaceutical exports and agricultural productivity. But the reality on the ground looks rather different.

Contact with antibiotics and resistant bacteria is not an exceptional event. It is part of the texture of daily life

On poultry farms outside Hyderabad, workers tear open sacks of powdered additives and empty them into water tanks serving thousands of birds. The contents include antibiotics, though few on site can name the compounds. Rapid expansion has made chicken and eggs widely accessible, but crowded sheds and tight production cycles encourage routine antimicrobial use. In the absence of reliable official data, much of the scrutiny has come from India’s nongovernmental sector and international investigations. Civil society groups have published a series of hard-hitting reports on industrial farming, documenting the routine use of antibiotics in poultry production. Investigations such as ‘A Game of Chicken: How Indian Poultry Farming Is Creating Global Superbugs’ (2018) and reports such as ‘Poultry’s Pill Problem: Antibiotics and its Environmental Concerns’ (2024) have framed antibiotic use in farming not simply as an agricultural issue, but as a matter of environmental degradation and risk to public health.

Economic pressures push farmers toward higher yields and thinner margins, leaving little room to scrutinise what goes into feed, water or growth promoters. Many remain only vaguely aware of the antibiotics moving through their operations. The consequences extend well beyond the occasional failed export consignment flagged for residues. At home, the exposure is quieter but constant – in the food on the table, the water in the ground, the manure spread across fields. For animals, farm workers and the communities living closest to intensive agriculture, contact with antibiotics and resistant bacteria is not an exceptional event. It is part of the texture of daily life.

This agricultural exposure needs to be seen within a wider lens of illness and dependency. Compounding these cumulative exposures, India carries an increasingly heavy and shifting disease burden. Tuberculosis (TB) remains widespread, and the country has one of the world’s largest burdens of multidrug-resistant TB: strains that no longer respond to first-line treatment and require longer, more toxic and far more expensive regimens. Diarrhoeal illnesses persist, alongside chronic conditions now common worldwide, including diabetes, cancer, hypertension and kidney disease. Many patients depend on reliable antibiotics to protect those undergoing chemotherapy, to prevent post-surgical infections, and to manage the many complications of chronic illness on the rise in the subcontinent. At the same time, hospital-acquired infections resistant to multiple drugs are becoming more common. Dependence is deepening just as efficacy is being diminished.

The pandemic exposed just how entrenched that dependence had become. When COVID-19 hit and no definitive treatments were available, antibiotics were widely used as precaution, reassurance and habit, sometimes with backing from authorities. Recent studies have found that such practices contributed to a dramatic rise in antibiotic use during the pandemic, even though only a small fraction of hospitalised COVID-19 patients had bacterial co-infections. Experts have linked this to worsening antimicrobial resistance in India and beyond.

This is not a distant abstraction. The imagined ‘post-antibiotic era’ tends to conjure dramatic headlines – travel bans, collapsed supply chains, a world visibly coming apart. But the reality would be both quieter and more pervasive than that. Unlike COVID-19, whose acute phase passed, a world where antibiotics fail would not resolve. It would simply become the new condition of medicine. The threat is not only that resistant infections would be harder to treat. It is that the entire scaffolding of modern healthcare depends on antibiotics working. Hip replacements, chemotherapy, caesarean sections, organ transplants – none of these are exotic procedures. They are the everyday traffic of hospitals everywhere. Each carries an infection risk that antibiotics currently make manageable. Without that assurance, much of what contemporary medicine takes for granted would become difficult, or impossible, to safely perform.

Nor is this dire outcome confined to India. Globally, antibiotic resistance continues to rise. The World Health Organization reports steady annual increases across common bacterial infections, with a significant proportion now resistant to first-line treatments. India is frequently described as an epicentre, but the forces at work are not uniquely Indian. They are intensified there, and visible at scale, yet they are rapidly infiltrating biological and environmental ecosystems around the world.

The rise of so-called superbugs is not only a medical development or problem. It reflects decisions about trade, regulation, food systems and industrial growth. Antibiotics have enabled extraordinary gains. They have also become load-bearing pillars in systems that struggle without them. The question is no longer whether they transformed modern life. It is how much of that life now depends on them.

If the threat of superbugs still feels abstract, the economic damage may yet force attention

None of this means new antibiotics are irrelevant. They matter because they can treat infections that are no longer sensitive to older drugs. But they should be used sparingly to preserve their effectiveness, and they are, at best, a short-term fix. Bacteria will adapt, as they always have, under pressure. Durable solutions have to cut across clinics, farms, factories and environments, because each of these settings amplifies the others.

India’s crisis is our collective crisis. Offshored production, export markets and cost-driven procurement shape what enters global supply chains and what then circulates through waterways, food systems, hospitals and bodies far beyond India. Industry cannot be a bystander. Civil society has long called for effective wastewater treatment and transparent disclosure of antibiotic use and discharge. What’s needed now is a global response with enforceable supply chain rules, alongside technology transfer that builds regional capacity and fits local realities while confronting the global forces driving misuse and pollution.

The update to the Global Action Plan released in January 2026 puts hard numbers on what is at stake. The costs will be paid not only in lives, but in higher treatment expenses, lost productivity, and major hits to livestock production and wider welfare. If the threat of superbugs still feels abstract, the economic damage may yet force attention. Unless the global community assumes shared responsibility for the rise of resistance in India – and the Global South more broadly – it will end up paying for the consequences everywhere.

Superbugs care little for national borders or bodily boundaries. They move through healthcare systems, infrastructures and industries that reward short-term gain while dispersing long-term harm. India is not the source of this crisis, but one of the places where those pressures converge most intensely and at scale. Until those arrangements change, superbugs will remain not an aberration, but a predictable outcome of the world we have made.

Note: where necessary, the authors use pseudonyms to protect the identities of people and places.

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