India is the world’s pharmacy. How did it become a superbug hotspot?

As a young nation carved from an old civilisation, India made the choice to assert its independence not by rejecting modern medicine, but by mastering it. This decision kicked off the country's legacy as a pharmaceutical powerhouse. As the supplier of over 20% of generic drugs globally, India has firmly established itself as the 'Pharmacy of the World'.

But this distinction comes at a steep price: Hyderabad, home to most of India's pharmaceutical factories, suffers from extensive antibiotic and heavy metal contamination in its water—affecting fish, cattle, crops, and the health of locals.

Concurrently, unregulated access to antibiotics across the country—in hospitals, clinics, and roadside pharmacies, as well as in the dairy and poultry industries—expose citizens to low levels of exposure constantly, thus feeding antimicrobial resistance (AMR), the stage when disease-causing bacteria stop responding to antibiotics.

Two academics from Australia, who have studied India extensively, found that the country’s  AMR crisis has largely been studied from the scientific perspective. They decided to take a more holistic approach, one that accounts for the historical context (like the rise of India's pharmaceutical industry), and the people at the heart of the crisis.

The result of this exploration is the book, 'A World of Resistance', by authors Assa Doron and Alex Broom. Doron is an anthropology professor at the Australian National University, and has studied Indian society for over two decades. Broom is a Professor of Sociology at the University of Sydney, who studies how systems shape people's experience of illness and care.

In this conversation with the Good Food Movement, author Assa Doron reflects on the systems, rather than people, that contribute to antimicrobial resistance in India.

Drawing from your study of healthcare systems in other South Asian countries, Prof. Broom and you observe that India’s neighbours, such as Sri Lanka or Nepal, perform better than it in some aspects of healthcare and sanitation. What are the specific vulnerabilities that the Indian healthcare system is plagued by, that fuel improper antibiotic consumption? How does this compare to other countries in the subcontinent?

I wouldn't say that they perform better, but I think they are useful comparisons. The picture is mixed: the vulnerabilities are tied to different gaps or questions of surveillance, informal sales, and so on. Nepal is a different story because of its smaller scale with different patterns of access. I guess in a smaller, more centralised health system, there may be more room for control. In India, that scale, that fragmentation, makes antibiotics extraordinarily available, but also extraordinarily hard to govern.

India becomes more vulnerable because of scale and intensity—the antibiotic system is much larger.

India becomes more vulnerable because of scale and intensity—the antibiotic system is much larger. The public health system is fragmented and commercially dense. You've got millions of informal and semi-formal points of access. Just think of all those stores that double up as pharmacies. Similarly with infrastructure gaps—the magnitude of sanitation and infection prevention gaps is heavily concentrated in India.

It's not like India is uniquely irresponsible, but it's an outlier insofar as antibiotics sit at the intersections of so many systems at once.

Also read: Why India’s wastewater is a haven for superbugs that outdo medicines

Intriguingly, you write that people are more aware about the harms of antibiotic usage in poultry production than they are about AMR through improper antibiotic intake. But why are people more wary of a medicated chicken than they are of what will happen if they take a strip of azithromycin without a prescription?

In some ways, it's about seeing what you're eating. Often, food, or rather ingredients, can feel ‘hidden’, and this makes people worry. Antibiotics in chicken are invisible and beyond their control, whereas when you take azithromycin, it's a decision you actively make, sometimes with the advice of the pharmacist, sometimes with the advice of the doctor. Industrial food producers are seen as being far away, more distant. There is less distrust in the pharmacist or the doctor. It's an immediate risk versus an abstract risk.

While the book acknowledges that there are many imperfections within the healthcare system, a majority of antibiotic usage in India is attributed to the livestock and animal husbandry sectors. Do you think that streamlining and reducing antibiotic usage in food production is a more urgent need than regulating how medicines are prescribed?

Animal agriculture is perhaps the most urgent sector structurally speaking, because antibiotics are used at scale, often sub-therapeutically, or preventatively, and they're tied to food production at large. But it's not unique to India. It is estimated that between 60% to 70% of antibiotics used worldwide is in the animal sector, not human consumption.

The animal husbandry sector is a major driver of antibiotic use globally, so it deserves serious attention, but I wouldn’t want to exclude the human aspect.

But I think human medicine remains a critical site for regulating antibiotics, and the failure of life-and-death treatments. The question is, can we really separate the two? I'm not sure. The animal husbandry sector is a major driver of antibiotic use globally, so it deserves serious attention, but I wouldn’t want to exclude the human aspect.

What was the most challenging part about reporting for the book?

Resisting a simple ‘villain story’. It would have been really easy to say, patients misuse antibiotics, doctors overprescribe, pharmacists sell too freely and the farmers behave irresponsibly, right? Add to that the regulators who constantly fail to provide oversight.

Now some of this is true, but I don't think it’s enough to understand the story. And for us the task was to show how each of these actors is making decisions inside conditions that they didn't create. So we looked at overcrowded hospitals, weak primary care, and work under conditions of job insecurity, especially for people at the lower echelons of society.

For us the task was to show how each of these actors is making decisions inside conditions that they didn't create

Poor sanitation and access to water persist alongside intense market competition and the pressures to produce cheap food and cheap medicines for India. The challenge before us was both analytical and ethical. How to describe these harmful practices without blaming the people who are often trapped inside them?

A recurring refrain through the book is to not blame any single actor—patient, pharmacy or poultry farmer—for what has been a systemic failure. While systemic fixes are most urgent, does this argument not risk undoing progress on AMR awareness and generating a citizen-led demand for responsible antibiotic usage?

Individual responsibility does not disappear. Antibiotics must be used more carefully in hospitals, in pharmacies, in farms and households. But blame is often a poor way to explain what is going on.

If we simply blame patients, we ignore why people need a quick cure—because they can't miss work. If we start blaming the doctor, we might ignore the overcrowded clinics and diagnostic uncertainty. If we start blaming the pharmacist, then we ignore the absence of access to primary care. If you go to the farmers, again, we risk ignoring the economic pressures to produce cheap meat, shrimp and fish for exports.

Blame is often a poor way to explain what is going on.

Our argument is not against responsible antibiotic use. It's against a narrow moral story where the problem is reduced to the ignorance of careless individuals.

Responsible use will only work if people have real alternatives, whether it's fair farming or better access to vaccination, or better systems of sanitation, infection control and primary care. All of these together will coalesce to provide a far more robust bedrock for the  highlighting of individual responsibilities and antibiotic use.

Also read: Typhoid lurks in India’s water. Why are antibiotics failing to stop it?