Antibiotic resistance is making some infections harder to fight than ever before. Some bacteria have become so resistant that even the strongest antibiotics are useless against them. With fewer options available, doctors are turning to phage therapy–an experimental treatment using viruses found in nature that target and destroy specific bacteria.

Phage therapy has only IND (Innovative New Drug) and compassionate treatment approval by medical regulators like FDA and EMA for individual cases and isn’t widely available. Only a few people around the world have received it. One of the first people in India to take this treatment was Pranav Johri. In 2016, at age 33, he faced a stubborn prostate infection that no antibiotics could cure. After exhausting all options, he turned to phage therapy at Eliava Institute, a century-old institute dedicated to bacteriophage research and application in Georgia.

Ten years ago, getting doctors and medical institutions to even accept the problem of AMR was a huge challenge. Since then, we’ve come to a point where everyone acknowledges the problem, and we’re working on ways to tackle it.

Johri’s experience speaks to the promise of phage therapy in fighting antibiotic-resistant infections, even as access remains limited. We spoke to him, now running Vitalis Phage Therapy which is the official Indian partner of the Eliava Phage Therapy Center, to understand how this treatment fits into the global fight against antimicrobial resistance.

Understanding phage

Q. How long have you been involved in the field of AMR?

My involvement in the field of AMR started from my own experience of going through an antibiotic resistant infection not being able to find answers from the medical community. I live in Delhi and was seeing the top doctors in the city. Unfortunately, they had nothing to offer to a patient suffering from an antibiotic-resistant infection. After multiple failed antibiotic treatments, my doctors declared my infection to be multi-drug resistant and prescribed me a buffet of medicines to ‘manage’ my infection and symptoms since it could not be treated with antibiotics. That led me to look for alternative treatments in cases where antibiotic treatments fail, and that led me to phage therapy. After the successful treatment of my multi-drug resistant infection with phage therapy, my wife and I founded Vitalis Phage Therapy.

We started the initiative with two goals. First, to raise awareness about AMR and its impact on the patient's quality of life, as well as on life itself. Second, to promote phage therapy as an effective way to combat antibiotic-resistant infections. That’s how I got involved in the field of AMR.

Today, we are working with medical institutions, across the country for phage therapy treatments for their patient suffering from antibiotic resistant infections. We’ve organised treatment for cases of urinary tract infections, lung infections, wound infections, and even sepsis.

Q. What is the procedure like? When and why does it fail? 

Phage therapy is not a standardised treatment but a customised approach to tackling bacterial infections using bacterial viruses (phages), the natural predators of bacteria. The specific phage used depends on factors such as the sensitivity of the bacterial strain to that specific phage, whether the infection is acute or chronic and the patient’s condition. The approach is different for each case but is very effective in fighting antibiotic resistance when other treatments no longer work.

Since we started six years ago, we have organised phage therapy treatments for over 250 people, with a success rate of 70–75%. However, success can vary. For example, if someone has a urinary or kidney infection caused by kidney stones, the stones must be removed. Otherwise, they provide a safe place for bacteria, causing the infection to come back.

In some cases, like advanced sepsis, treatment may fail if started too late. This often happens when the patient is already in a coma or the infection in the bloodstream has become too severe.

Q. Why is the treatment not yet popular in India? 

There are many reasons for this, including political, historical, and regulatory factors.

Phage therapy is currently available in India and 145 other countries as a compassionate treatment. Patients can use it as a personalised option because it’s not yet part of standard medical protocols due to regulatory issues.

Today, phage therapy is at least recognised by regulators as a real option for treating bacterial infections. Work is ongoing to research and create ways to make it more available and accessible.

Taking responsibility

Q. What can be done better in terms of creating awareness? 

The challenge in India is that we face two problems: access and excess. In big cities like Delhi, Bangalore, Mumbai, Hyderabad, or Chennai, we deal with excess, where people are overusing and misusing antibiotics. They take antibiotics for conditions where they are not needed, like viral infections, and they don’t follow the correct dosage guidelines.

But if you move 200 kilometres away from the big cities and into the countryside, the problem shifts to access. Most people in rural areas don’t even have pharmacies or drug stores where these medicines are available.

Also read: Inside Tamil Nadu's battle against AMR

Awareness is the biggest challenge and needs to be addressed. Whether it’s in agriculture, the food industry, or animal husbandry, there is so much overuse and misuse of antibiotics. These antibiotics enter our food chain and our bodies.

It's like inoculation: the bacteria gets exposed to antibiotics and develops resistance. When we actually need antibiotics for an infection, the bacteria may already be resistant.

When the season changes and viral infections increase, people start taking antibiotics without thinking. Most aren’t even aware of the risks they’re putting themselves and the community at. Antimicrobial resistance (AMR) is not an individual risk, it’s a community risk. We all share the same water, sewage, and food, so it’s all connected. There’s a concept called One Health, which means we need to address the issue from the perspective of the whole environment and ecosystem, not just in isolation, because that would not be effective.

The government, regulatory bodies, and other stakeholders must focus on raising awareness. We need awareness campaigns like those for smoking. For example, cigarette packages carry clear warnings about the risks of smoking and lung cancer.

We need similar mass campaigns for AMR. Only then will society as a whole recognise the problem. Today, AMR is mostly known only within the scientific and medical communities, and not widely understood by the general public.

Q. What can an individual do? 

There are many things we can do. Most people are taking antibiotics when they don’t need them. Why is this happening? We need to stop it. We need to address the issue at the level of both doctors and pharmacies. Why are they prescribing antibiotics so often?

People should be saying, don’t give me antibiotics. Today, you can even buy colistin at pharmacies, even though it’s a controlled medicine. These issues need to be addressed at the regulatory level. We’re still far behind. While many guidelines exist on paper, there’s a gap when it comes to real-world implementation.

Q. How focused are the stakeholders on the problem of AMR? 

There is growing focus on the issue. Ten years ago, getting doctors and medical institutions to even accept the problem of AMR was a huge challenge. Since then, we’ve come to a point where everyone acknowledges the problem, and we’re working on ways to tackle it.

During COVID, every country tracked the number of infections. If we did the same for AMR, we would see similar numbers. It needs that same level of focus.

We are making progress, but the pace needs to speed up because AMR is not slowing down. It’s growing exponentially.

The problem requires a focused approach, just like how the world responded to COVID, including regulators, medical institutions, and the scientific community. We need the same focus for AMR because it’s just as much of a pandemic. It’s silently killing people because it doesn’t get the same media attention COVID did.

During COVID, every country tracked the number of infections. If we did the same for AMR, we would see similar numbers. It needs that same level of focus.

Also read: What happens when you stop taking antibiotics midway

Mohammad, a 22-year-old son of doctor parents, is no stranger to the routine that comes with an antibiotics prescription. Following through on a course of medication is something he rarely gives a second thought to. But, if the illness is not severe, the Bengaluru resident finds himself forgetting about the need to take them—especially as he begins to recover.

Now, with leftover antibiotics at hand, Mohammad does something that is not unusual for patients—he puts them away in a medicine cabinet for future use. “People have a tendency to save everything. I know many who keep medications for later. It’s the Indian stereotype of hoarding things… my grandmother keeps medications from two to three years ago, and buys them in bulk,” he says.

The growing overuse and misuse of antibiotics in India, and the resultant antimicrobial resistance, is further compounded by issues of personal misuse, from self-medication and overconsumption to patients ending their antibiotic courses prematurely. Though seemingly minor, these habits accelerate the spread of resistant bacteria, making infections harder to treat.

Quick fix much?

For young corporate employees like Bengaluru-based Apoorva, a long antibiotic course can seem like an inconvenience, pushing them to ask doctors for shorter courses when they are afflicted with common infections. “I don’t have the patience for a week-long course,” Apoorva rues, “I often forget to finish it anyway. With work and my personal commitments, I would rather have something stronger and be done with it.”

Dr Mohsin Bawkar, a physician specialising in occupational medicine for over three decades, attests to the prevalence of this sentiment. “Patients worry and ask for an antibiotic when they’re travelling, regardless of whether they need it or not. Working professionals ask for stronger courses because they can’t afford to take leaves at work,” Dr Bawkar says, asserting that the unnecessary use of stronger third-generation drugs worsens resistance.

Those on the other side of the examination table, too, are responsible for furthering this questionable habit. “Some practitioners, especially in smaller cities, skip established guidelines. Instead of starting with penicillin—the most basic antibiotic—they may prescribe stronger options like Augmentin or Cephalosporins, which are third-generation drugs,” the physician says. (Third-generation drugs are a class of medication that are typically more concentrated and effective, but known to pose severe long-term risks in cases where they are prescribed for common infections.)

There have been cases where even infants have been administered potent medications, with the belief that they will recover speedily. “However, a quick recovery doesn’t always mean a complete recovery,” Dr Bawkar warns.

ALSO READ: Why common infections could become killers again

Doubt and discomfort

One among many consequences of Big Pharma’s aggressive promotion of antibiotics is a growing mistrust, or even outright refusal, to take antibiotics. Sanjana, a 22-year-old legal analyst in Bengaluru, has observed such a tendency in her extended family. “More than anything, they’re worried they’re using more than what is necessary—even if the doctor has assured them it’s not the case. They’re petrified of suspected side effects, too. There’s a real reluctance to even take antibiotics sometimes, let alone finish them,” Sanjana says. She has observed older relatives switching to “natural” remedies, such as soups, spice mixes, and fruit and veggie-based concoctions, once they begin to feel slightly better.

Sanjana’s family isn’t alone in this hesitation. Satya Sivaraman, a coordinator at ReAct Asia Pacific, an organisation advocating and working to mobilise policymakers and the public on the issue of antibiotic resistance, highlights the two extremes he has seen —overt scepticism, like the rise of vaccine denial, or flippant overuse of antibiotics, fueled by a lack of curiosity about one’s health and the tendency to outsource bodily well-being to medical practitioners.

What science tells us

“In hospital settings, it makes sense to discontinue a dose before an operation when we administer antibiotics to patients who could face the possibility of being at risk,” says Dr Sonal Asthana, a lead consultant in transplant surgery at Aster Hospital, drawing from his first-hand experiences in dealing with the complexities of antibiotic misuse.

Discontinuation turns problematic in non-clinical set-ups, in cases of bacterial culture or infection, where stopping medication is dangerously counterproductive. “This does not kill all the bacteria; it singles out the bacteria that are going to be resistant to the antibiotic. It’s only killing selective bacteria while the resistant bacteria will thrive and gradually grow immune to the antibiotic,” Dr Asthana cautions. This process, which accelerates the evolution of antibiotic-resistant strains, is termed selective pressure.

Dr. Baliwanth, a paediatrician at Manipal Hospital with a specialised interest in infectious diseases, emphasises the risk of not differentiating between viral infections and bacterial infections. Antibiotics are ineffective against viral infections; thus misdiagnosing a bacterial infection often results in the prescription of antibiotics even when they’re not necessary. The judicious use of antibiotics lies in the right prescription, he crucially points out. “When bacteria are exposed to antibiotics but not fully eradicated, they evolve, developing special enzymes to neutralise and destabilise the drugs,” says Dr Baliwanth. This leads to therapeutic failure, wherein the prescribed treatment no longer achieves its desired recovery and the pathogens survive. 

Sanjana and Satya’s observations bring to light a common underlying hazardous assumption: that one might be ‘over-medicating’ if they complete their antibiotic course even after their symptoms subside.

Through genetic replication, the surviving bacteria reproduce, propagate, and transmit resistance genes within their population, leading to the proliferation of strains that the antibiotic can no longer effectively target. This fosters the spread of multidrug-resistant organisms (MDROs). Not only do incomplete antibiotic regimens reduce their efficacy over time but also contribute significantly to a reservoir of resistant pathogens that compromise infection control and treatment in the future.

ALSO READ: The looming crisis of post-antibiotic era

Where the buck stops

Dr Asthana brings to our attention hospital antibiotic stewardship programs, typically led by infectious disease specialists and microbiologists. “These teams collaborate to recommend appropriate antibiotic treatments and minimise antibiotic use whenever possible. Sure, this is definitely a more personalised approach than a systemic one, but it’s needed in a situation like ours. Both practitioners and the public need to exercise caution,” he says.

Personal responsibility is a crucial piece of this puzzle. When antibiotics are discontinued prematurely, there is the possibility of developing a recurring infection. Your doctor may then prescribe a full course of antibiotics again that needs to be finished in its entirety.

Completing an antibiotic regimen at an individual level is a small yet significant step in ensuring these medications remain effective for everyone.

It has repercussions for the bigger picture of public health and literacy. These informed choices, when made together, can help protect the potency of antibiotics across generations.

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Hyderabad’s origin story begins in the 1590s, when Mohammad Quli Qutub Shah, the fifth sultan of Golconda, dreamed of a city by the Musi river to escape drought and recurring outbreaks of plague and cholera. Over the centuries, the Musi, which originates in Vikarabad and flows into the Krishna River in Nalgonda, nurtured green spaces, sustained communities, and also stood witness to Hyderabad transforming into a bustling IT hub.

Today, however, the river tells a different story. Once clean and vibrant, it is now polluted and frothing, tainted by pharmaceutical waste and superbugs that pose significant threats to public health.

A study by the Indian Institute of Chemical Technology (CSIR-IICT) and Australia’s Commonwealth Scientific and Industrial Research Organisation has uncovered alarming levels of pollutants in the Musi such as commonly used antibiotics like Ciprofloxacin, antidepressants, anti-inflammatory drugs such as Naproxen and Diclofenac, and antifungal medications like Fluconazole.

While the river’s water is no longer used for drinking, it remains a lifeline for irrigation and cattle farming in Nalgonda and other Telangana districts. However, the toxins in the water risk contaminating groundwater, which directly impacts nearby communities.

Misdirected priorities

Despite the immediate and long-term risks, governments seem to be focusing on the wrong priorities. Successive administrations have focused on the river's beautification. But these efforts won't stop the health disaster brewing in the waters of the Musi: antimicrobial resistance (AMR) from consistent exposure to antimicrobials.

Pollution has to be stopped at the source; until then, no amount of cleaning will solve the issue.

Telangana, known for its pharmaceutical industry around Hyderabad, has a poor track record of managing pharma waste. Instead of addressing the main cause of pollution, the state is focusing on beautifying the river to boost tourism. The new Congress government announced a Rs 1.5 lakh crore Musi Riverfront Development Project to improve the river and attract tourists over the next five years. But there’s no clear plan yet. According to Municipal Administration and Urban Development principal secretary Dana Kishore, only Rs 3,800 crore (just 2.53% of the total budget) will go towards cleaning the river, leaving the main issue largely unaddressed.

Clearly, the Musi river needs more than a facelift; it requires urgent measures to curb pharmaceutical pollution and safeguard public health.

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“Pollution has to be stopped at the source; until then, no amount of cleaning will solve the issue,” said Shilpa Krishna, who has researched antimicrobial resistance (AMR) in Hyderabad. “Restoration and beautification will serve the purpose only when the state government takes an initiative to curb pollutants entering water bodies,” she added.

In the 1990s, a public movement against pollution started in response to the release of highly toxic and untreated waste from pharmaceutical and chemical companies near Patancheru and Bollaram in Medak district, close to Hyderabad. To manage the industrial waste in the Patancheru industrial area, a private company called Patancheru EnviroTech Limited (PETL) was set up to collect, treat, and dispose of the waste according to the required standards.

However, public policy expert Narasimha Reddy Donthi said PETL functions mainly as a secondary treatment facility. Industries are supposed to pre-treat wastewater on-site, but the company has been accepting untreated effluents from multiple industries to remain commercially viable. By not properly treating this extra waste to meet the required standards, PETL has made the pollution problem worse.

Also read: Inside Tamil Nadu's battle against AMR

Regulation and enforcement

This brings us to a crucial question: what actions has the Telangana State Pollution Control Board (TSPCB) taken? Tasked with enforcing compliance under the Water (Prevention and Control of Pollution) Act, 1974, TSPCB mandates pollution control measures like Zero Liquid Discharge (ZLD) systems.

“We held a meeting with industry associations in the first week of November and warned them of closures if untreated effluents are discharged into the common treatment plant, which eventually contaminates the Musi River,” said WG Prasanna Kumar, senior social scientist at TSPCB.

The pharma companies even have underground pipelines linked to Musi river to let their toxic waste into the water body.

Pharmaceutical companies in Hyderabad, many of which are US-based, reportedly continue to flout regulations. “It is disappointing that the United States Food and Drug Administration (USFDA) is only concerned about the quality of the medicines but is not bothered if local laws are violated. These companies should not claim to follow good manufacturing practices when disease is being created outside their premises, and the health index of communities living near Musi is at stake,” said environmentalist Lubna Sarwath. She has filed multiple cases with the National Green Tribunal (NGT) about the industrial pollution in Hyderabad’s water bodies.

During her visit to pharmaceutical companies in Hyderabad, she noticed colourful, toxic waste being dumped outside their premises, sparking concerns about pollution. “The pharma companies even have underground pipelines linked to Musi river to let their toxic waste into the water body,” she said.

Looming crisis

Antimicrobial resistance in water bodies is a public health disaster in the making. “Antibiotic effluent released into the rivers and rivulets can leach into the surrounding soil and contaminate the groundwater over time. This creates an environment conducive to the growth of antibiotic-resistant bacteria, which can spread through various water sources and agricultural products,” said Dr Ranga Reddy, president, Infection Control Academy of India. “For humans, exposure to these resistant bacteria can result in infections that are increasingly difficult to treat, posing serious public health risks and contributing to the broader challenge of AMR containment.”

Resistant bacteria lead to infections that are harder to treat, driving up healthcare costs and placing economic strain on affected communities.The situation poses a significant risk of a human health crisis in Telangana. With antibiotic-resistant bacteria on the rise and no new antibiotics being developed, the threat intensifies. Lack of ongoing research means that as resistance builds, patients will require higher doses to achieve the same effect, leading to increased healthcare costs and further economic strain on communities,” said Shilpa.

One Health approach

Studies suggest that adopting the One Health approach and involving local populations can help mitigate the spread of AMR. “Involving local populations in the responsible use and appropriate disposal of antimicrobials constitutes a comprehensive and impactful strategy for promoting awareness of the dangers of antibiotic resistance,” according to a recent study.

Investing in the Musi without addressing its root causes and risks will yield limited results. Sabarmati Riverfront Project is a good case in point. Launched in 2005, the project prioritised urban beautification and a revenue-driven approach. But Sabarmati remains India’s second most polluted river (CPCB 2023). Hence, the budget must prioritise eco-friendly restoration alongside beautification. Such an approach benefits the environment, aligns with international conventions, and protects the health and livelihoods of communities dependent on the Musi river.

The unchecked pollution of the Musi River highlights the urgent need for stronger enforcement, corporate accountability, and systemic change to protect public health and restore the river to its former glory.

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Antibiotic resistance genes (ARGs) are causing a major headache in the healthcare world, helping bacteria become immune to the drugs we use to fight them.

There are two primary ways bacteria become resistant:

Mutation: Bacteria can develop small changes in their DNA, called mutations, which allow them to survive when exposed to antibiotics. These changes can be due to small alterations in their genetic material, like substitutions or deletions.

Horizontal Gene Transfer (HGT): Bacteria can exchange genetic material with other organisms through three main processes: transformation, transduction, and conjugation.

ARGs are particularly problematic for physicians treating infectious diseases because they make bacteria harder, sometimes impossible, to eliminate. In medical terms, ARGs can be housed in plasmids, transposons, and integrons, which act as vehicles for spreading resistance. Tragically, this rise in antimicrobial resistance (AMR) hits children the hardest, especially those under five.

In India, one in five children under five succumb to drug-resistant infections, with nearly 190,000 of these cases linked to sepsis, a severe bloodstream infection.

The maternal-infant resistome

Pregnant women and infants are among the most vulnerable groups affected by ARGs. The maternal-infant resistome is the collection of antibiotic resistance genes shared between mother and child. While resistance genes naturally occur within bacterial populations, the misuse and overuse of antibiotics–both in medical and agricultural contexts–have accelerated their spread.

Did You Know?

Newborns are at heightened risk because their immune systems are still developing, making them more susceptible to infections and resistant bacteria, with potential lifelong health impacts.

“Infants typically acquire (bacteria with) resistance genes as they pass through the birth canal,” said Dr Ramya S R, a professor and microbiologist. "At birth, the infant’s gut microbiome is not yet well-established, and its development depends on various factors, including the type of delivery, feeding methods, and other influences."

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The likelihood of the infant inheriting resistant genes increases if the mother possesses them. “If a mother already carries antibiotic-resistant genes, there's currently no vaccine or direct preventive measure for controlling it,” said Dr Olivia Marie Jacob, a gynaecologist at AIIMS Andhra Pradesh.

In India, the challenge lies in over-the-counter access to antibiotics, allowing people to purchase and consume them without prescriptions. Antibiotics come with specific courses–some for three days, others for five or seven. Once an antibiotic course begins it must be completed, stopping midway after just one or two doses creates selective pressure allowing resistant genes to develop in the gut. Overuse of antibiotics also builds this antibiotic pressure. 

In contrast, in Western countries, a baby may receive antibiotics once or twice in their first year. In India however, a child might be exposed to antibiotics up to 12 times by the age of two. 

“The constant antibiotic exposure creates selective pressure, leading to mutations in the gut microbiota of the child. The most effective prevention strategy is to avoid unnecessary antibiotic use. Most upper respiratory infections in kids such as sore throats, colds and coughs are viral infections with only occasional bacterial involvement. However, we often don’t wait for confirmation and start taking antibiotics, which only adds to the resistance problem,” she added.

Escalating resistance

In recent years, antimicrobial resistance has become a critical public health issue, with links to the poultry and livestock industries. Current projections warn of 10 million AMR-related deaths annually by 2050.

Routine antibiotic use in healthy animals has led to a dangerous buildup of resistance genes in their gut bacteria. When these resistant genes enter the food chain, they pose a potential threat to human health. In India, stronger policies to regulate over-the-counter antibiotic sales for animal husbandry could be key in slowing the spread of AMR.

Detecting AMR

To identify the presence and prevalence of antimicrobial-resistant genes, researchers rely on two primary sampling methods: clinical and environmental.

“Clinical sampling involves collecting stool samples from individuals in the general population, which are then cultured to identify bacteria types and the resistant genes they carry.” Among the commonly detected gut bacteria are Escherichia coli, Klebsiella pneumoniae, Pseudomonas, and Proteus, which can reveal the extent of antibiotic resistance, said Dr Pooja Rao, a microbiologist and expert with the National Action Plan for AMR at KMC Karnataka.

In contrast, environmental sampling focuses on hospital environments, where swabs from various surfaces are cultured to identify resistant genes. Following sample collection, polymerase chain reaction (PCR) techniques help pinpoint specific resistance genes. Both methods provide essential data on how antimicrobial resistance spreads across communities and healthcare facilities. Hospitals record and report this information to the Indian Council of Medical Research (ICMR), which tracks emerging resistant bacterial strains and related fatalities.

National Action Plan

The government, along with the National Medical Council (NMC), has initiated a National Action Plan to combat antimicrobial resistance. This plan involves comprehensive research to determine resistance levels in various bacteria, analysing the prevalence of resistant genes within both gram-positive and gram-negative bacterial groups. By evaluating the percentage of resistance across bacterial species, the initiative aims to inform more effective antimicrobial and diagnostic stewardship practices. It also has a manual for clinical approach for prescribing antimicrobials which can only be used for treatment.

Diagnostic stewardship emphasises collecting the correct sample at the appropriate time, ensuring accurate and timely diagnosis. Antimicrobial stewardship, meanwhile, focuses on administering the right antibiotic to the right patient at the right time, avoiding unnecessary use across the population. 

The government is working with the Indian Council of Medical Research (ICMR) and the NMC to advocate and implement these measures. However, there remains uncertainty regarding the implementation of similar practices within the poultry and animal industries.

A One Health approach, integrating human, animal, and environmental health, is key for combating resistance. Effective stewardship, supported by national initiatives, and stricter regulation in sectors like poultry and animal husbandry, are crucial to safeguarding public health and ecosystems to fight against antimicrobial resistance.

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Last January, Kerala launched AMRITH (Antimicrobial Resistance Intervention for Total Health), an initiative to curb the rampant use of antibiotics. The initiative builds on Kerala’s longstanding commitment to AMR prevention. Back in October 2018, the state collaborated with the Ministry of Health and Family Welfare and the WHO to launch the Kerala Antimicrobial Resistance Strategic Action Plan (KARSAP). A year later, Kerala Antimicrobial Resistance Surveillance Network (KARS-NET) came about. The network aimed to standardise AMR surveillance, track emerging resistance patterns, and provide critical data to the state government and the National Centre for Disease Control (NCDC). By restricting antibiotic sales without a doctor's prescription, such programs have led to a remarkable Rs 1,400 crore reduction in antibiotic sales, according to state health minister Veena George.

"We have adopted a scientific, strategic approach to fight AMR," George said in a statement, highlighting the state's all-round efforts, including public awareness campaigns at educational institutions and public spaces.

The All Kerala Chemist and Druggist Association reported a sharp decline in antibiotic sales as early as August 2023. "As per our assessment, there is an annual drugs turnover of Rs 15,000 crore, of which antibiotics account for around 25 to 30%. After the government increased awareness, there was a 30% reduction in the 2023-24 fiscal year from the previous year, including sales from private hospital pharmacies," said association state president and national vice-president AN Mohanan.

State action plans

In November 2023, the Family Health Centre (FHC) at Kakkodi in Kozhikode district became the country's first antibiotic-smart hospital. Just two months later, the Ozhalapathi Family Health Care Centre in Palakkad followed suit, becoming the second such facility. Such health centres are recognised for meeting ten key criteria to monitor and control antibiotic use.

While India introduced the H1 rule in 2011 to curb over-the-counter antibiotic sales, it wasn’t until 2013 that the regulation was modified to restrict sales of more powerful antibiotics while allowing the sale of first-line options without a prescription. Kerala is the only state rigorously enforcing the original H1 rule.

Expanding community efforts

In May 2023, Kerala’s Health Department issued a directive to all District Medical Officers to implement Standard Operating Procedures (SOPs) for block-level AMR committees. The committees focus on raising awareness about infection prevention, proper antibiotic use, access to antibiotic-free food and water, and the safe disposal of expired antibiotics. "It was IEC (Information, Education, and Communication) in the first phase of the KARSPA activities. We reached as many people as possible for awareness, conducting workshops and speaking on all platforms. In the second phase, we resorted to punitive action under the Drugs and Cosmetics Act by conducting inspections and taking swift action against unchecked sales. Both measures resulted in a considerable reduction in sales and consumption,” said Shaji M Varghese, state coordinator of One Health and AMR and Assistant Drugs Controller, Kozhikode. The state has over 25,000 wholesale and retail medical shops, he added.

A model for the nation

Kerala’s AMR strategy exemplifies a comprehensive, multi-faceted approach to public health. From community-based initiatives to pioneering healthcare facilities, the state is leading the way in the fight against antimicrobial resistance. By focusing on education, regulation, and innovation, Kerala offers a clear blueprint for other states looking to safeguard the future of antibiotics and preserve their life-saving power.

In the battle against antimicrobial resistance (AMR), Kerala stands out for its innovative and thorough strategy. Dr Divya PK, an ENT specialist, played a pivotal role in transforming the Kakkodi Family Health Centre into an antibiotic-free facility. “I used every opportunity whenever I got a microphone; whether it was a festival at an Anganwadi, a Kudumbashree (State Kudumbashree Mission for Women Empowerment) gathering, or an elderly people’s meeting. Wherever I could get ten people together, I would talk about this. People initially had a reluctance to stop using antibiotics; they had an idea that only antibiotics could cure their disease. Later, people got used to the idea that doctors would prescribe them if needed."

She also reached out to resident associations, Kudumbashree units, and private medical shops, promoting the Go Blue Campaign, which raises awareness about AMR. “Most importantly, the focus was on preventing infection by promoting handwashing, stressing hand hygiene, vaccinating, etc. We distributed pamphlets to all households and informed private medical shops to raise awareness about the Go Blue Campaign (which aims to increase awareness of global AMR and encourage best practices), asking them to sell antibiotics in blue covers. Information was shared with doctors in the private sector through a WhatsApp group. I also spoke at Grama Sabha meetings and to veterinarians,” she added. Divya is now the MO of Koodaranji FHC in the district. 

I used every opportunity whenever I got a microphone; whether it was a festival at an Anganwadi, a Kudumbashree (State Kudumbashree Mission for Women Empowerment) gathering, or an elderly people’s meeting. Wherever I could get ten people together, I would talk about this [AMR].

Antibiotic classification

In 2017, the WHO introduced the AWaRe classification (later revised in 2019 and 2021) to group antibiotics into three categories: Access, Watch, and Reserve. Access antibiotics have a narrow spectrum, fewer side effects, lower resistance risk, and are cost-effective. They are recommended for common infections and should be widely available. Watch antibiotics carry a higher risk of resistance and need careful monitoring to avoid overuse. Reserve antibiotics are the last resort for severe infections caused by multidrug-resistant pathogens.

“Kerala had developed resistance even to the Reserve group–for example, linezolid (used to treat bacterial infections), which resulted in deaths. Ninety-five percent of the total antibiotic usage should be from the Access group, with only 5% from the Watch group. Data from April 2022 to March 2023 showed that Kakkodi hospital used only 5% from the Watch group, despite the usage of antibiotics during the Shigella outbreak in Kozhikode,” Divya said.

Kakkodi FHC and sub-centers set up collection points for unused and expired antibiotics, as discarded medicines can contaminate plants. The PROUD program was launched for safe disposal, training hospital staff and ASHA workers. Monitoring ensured that Kakkodi remained an antibiotic-smart centre, with the entire panchayat also becoming antibiotic-literate.

“As a first step in antibiotic literacy, dairy, poultry, and honeybee farmers were identified with the help of veterinary doctors. We also collected data on the use of antibiotics in animals and found Reserve and Watch antibiotics used among them. The use of antibiotics in animals like cows and poultry transfers to human beings through milk and poultry meat. Antibiotics are even mixed into cattle feed and poultry feed,” she further said adding that veterinarians wholeheartedly supported the campaign.

One Health approach

Kerala’s approach to AMR is rooted in the One Health concept, which encourages collaboration across sectors–public health, veterinary, environmental, and agriculture. This holistic approach recognises that human, animal, and environmental health are interconnected, making it essential to address AMR on all fronts.

In 2023, Kerala made history as the first state in India to establish AMR committees at both district and block levels, covering all 191 health blocks. The committees are composed of representatives from health, animal husbandry, agriculture, and environmental departments. “AMRITH was launched after the formation of the committees, followed by ROAR (Rage on Antimicrobial Resistance by the Drugs Control Department in September 2024). We began groundwork even before 2017; it’s just that coordinated meetings started in 2017, and the declaration came in 2018,” said Dr Aravind, state convener of the KARSAP Working Committee. He is also head of the department of Infectious Diseases Medical College Hospital, Thiruvananthapuram.

The state’s approach also involved creating awareness among doctors, pharmacists, students, and the general public, in that order. “It does not mean that we have achieved 100% success. We have engaged all One Health stakeholders in the process. The most visible example of our success is the increase in media coverage of AMR from 2018 to 2024. The OTC (Over-the-counter) sale of antibiotics can’t be curbed by awareness alone; that’s why AMRITH was launched to provide legislative backup. We’ve also provided a toll-free number for the public to report if antibiotics are dispensed without a prescription, making the public part of enforcement as well,” he said.

A toll-free number lets the public report medical shops selling antibiotics without prescriptions. Complaints lead to licence cancellations after verification. "Kerala’s initiative parallels Sweden’s only. Their motto is 'Antibiotic-aware Sweden,' and ours is 'Antibiotic-literate Kerala.' We can't claim that we have become an antibiotic-literate state, but all process indicators have been instituted. The decentralised, people-centred approach to make each panchayat literate is carried out through block-level AMR committees and antibiotic-smart hospitals. Customised action plans are required for each panchayat based on local AMR challenges. Gap analysis is done, and AMR hotspots in each panchayat are identified before preparing an action plan," he added.

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Direct action

The health minister released the first district-level antibiogram (helps track changes in antimicrobial resistance and guide empirical antimicrobial therapy) to prevent the misuse of antibiotics in Ernakulam district under KARSAP in February 2024.

Kerala’s commitment to AMR awareness also extends to migrant workers, with outreach efforts delivered in their native languages to ensure effective communication. In November, health workers began house-to-house visits as part of a campaign to spread awareness. By then, they had already reached 200,000 homes in Ernakulam, further solidifying the community’s role in combating AMR.

By focusing on education, regulation, and community engagement, the state is taking bold steps to protect the future of antibiotics and ensure their effectiveness for generations to come.

The once under-appreciated, delicate lotus seeds, commonly known as makhanas or fox nuts, have recently gained traction as a healthy, low-calorie snack among the health-conscious community. No longer relegated to traditional wedding gifts or prayer assortments, these airy, nutty delights are now being consumed by a wider audience, signalling a shift towards healthier snacking habits.

Makhana has a rich history, being cultivated in India for over 3,000 years. Bihar takes the lead in Makhana production, contributing over 85% of the total production in the country. On the e-commerce platform Swiggy Instamart, Makhana became the most ordered snack last year.

Makhana seeds come from a water lily species, Euryale ferox, found across Asia. The seeds undergo a lengthy, labour-intensive process, where black seeds are popped and polished until they transform into their white, edible form.

Nutritional powerhouse

The seeds are packed with essential macronutrients like calcium and magnesium, along with numerous micronutrients. Not only are they nutritious, but they’re also easy to digest.

Makhanas are low in saturated fats, calories, sodium, and cholesterol, while being mineral-rich, especially in magnesium. Their low glycemic index makes them particularly supportive for heart health and diabetes management. Plus, they’re powerful antioxidants and have a long history of use in addressing various health concerns, such as chronic diarrhoea, diabetes, gonorrhoea, kidney disorders, constipation, stomach pain and beri-beri.

In traditional Ayurvedic and Unani practices, fox nuts are valued for their potential aphrodisiac qualities. The alkaloid ‘drummine’ in the leaves is thought to contribute to the plant's anti-rheumatic effects, while all parts of the plant are known for their tonic, astringent, and de-obstruent properties.

Makhana gained significant popularity during the COVID-19 pandemic. “During COVID, doctors started advising that every day in the morning, one should consume 10 or 20 raw or roasted makhanas so that it can fulfil the protein requirement, some vitamins and other minerals nutrients,” said Dr Indu Shekhar Singh, principal scientist at the Research Centre for Makhana in Darbhanga.

“From 2020-2021 onwards we have seen that it is now marketed and sold at medical shops also. Many farmers have been given the training to become entrepreneurs, particularly in the North Bihar region. They are now selling snacks, seeds and even Makana cookies,” he added.

GI tag

To unlock makhana’s potential, a regional centre was set up in Darbhanga under the ICAR Research Complex for the Eastern Region. The centre leads a range of research and development initiatives, including the creation of 'Swarna Vaidehi,' the first variety tailored to thrive in Bihar’s wetlands.

According to estimates from the National Research Center for Makhana, Darbhanga (ICAR), India’s makhana cultivation covers about 15,000 hectares, producing 120,000 metric tons of makhana seeds. After processing, this yields around 40,000 metric tons of makhana pop, with an estimated farm-level value of Rs 250 crore and trader-level revenue reaching Rs 550 crore.

Makhana is a high-value crop primarily grown in Bihar and parts of eastern India, and naturally found in states like Madhya Pradesh, Rajasthan, Jammu & Kashmir, Tripura, and Manipur. Darbhanga city’s Gullobara Bazar serves as a key trading hub, handling about 2,000 metric tons annually, while Madhubani sees 3,500 metric tons traded each year. In Katihar, roughly 3,000 metric tons are traded, with Katihar town and Kada Gola as major markets. Meanwhile, Purnia district’s markets (Harda, Sapni, Khushkibagh, Belauri, and Gulabbagh) handle about 3,500 metric tons yearly.

Despite Bihar’s lead in makhana production, the largest wholesale markets are outside the state, located in Khari Bowli (New Delhi), Nayaganj (Kanpur), Gola Dinanath and Vishweshwarganj (Varanasi). Makhana also reaches international markets, including the USA and the Middle East.

In 2022, makhana received a geographical indication (GI) tag, protecting its unique identity against imitation.

High value

Compared to common weight-loss snacks like peanuts and popcorn, makhanas are more expensive, typically costing between Rs 600 and Rs 1,800 per kilogram. This premium price stems largely from the labour-intensive harvesting process.

“The price [of makhana] this year is higher than the other nuts, particularly cashew and almonds. It is being sold in the market at a rate of Rs 1200 to Rs 1400 rupees per kg. We can see how important it is being given to by all the entrepreneurs and purchasers,” said Singh.

Despite its economic value, makhana production remains one of the most labour-intensive processes. Skilled workers collect seeds from muddy pond beds using long bamboo poles between 9 am and 4 pm, navigating the thorny plants. After harvesting, the seeds are stored in a traditional container called a gaanja, cleaned through a two-step process, and sun-dried for several hours.

The seeds are then graded using ten different-sized sieves, heated in cast iron pans or earthen pitchers over an open flame, and left to cool at room temperature for three days in a process called tempering. Finally, the seeds are roasted until they pop and are packaged for sale.

It’s worth noting that despite the effort, only around 40% of the initial harvest reaches the market as edible makhana. The traditional techniques, passed down through generations, have remained largely unchanged for centuries.

Versatile profile

Though makhana is popular as a snack, it can also be enjoyed in various ways. Makhana’s neutral taste allows it to shine in both savoury and sweet dishes, making it a versatile ingredient for chefs and home cooks alike. Puffed makhana is often seasoned with oil and spices or used in curries, complementing green vegetables and pulses when powdered, flaked, or used whole.

Makhana is also widely used in desserts, such as kheer (a porridge-like dish) made by chefs like Avinash Kumar from the Novotel hotel chain. Healthier dessert options like makhana barfi, kalakand, and makhana chapati provide high calories with low sugar, appealing to health-conscious consumers. The sweets are also commonly offered as prasad after religious ceremonies.

Recently, makhana has found new life in fusion recipes, with caramelised makhana, chocolate-coated makhana, and makhana chocolate cookies gaining popularity among those with a taste for Western-style treats.

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Let’s imagine a scenario where you and your friends are talking about inventions that have changed the course of human life. And you, obviously, are thankful for hundreds of them. Mobile phones? yes. Electricity? Always. The internet? Every waking minute. But what are the chances of one of you bringing up antibiotics? Slim at best. An average person may not count antibiotics among the list of discoveries that they are grateful for. Call it apathy or ignorance, it's one of those things we take for granted. It is as if this miracle drug has been around all along. After all, every time you are down with flu, you are handed a generous dose– prescribed or not. 

But how did this discovery, which revolutionised modern medicine, become so easily accessible? Let’s take a look.

The first antibiotic, the mighty penicillin, was discovered in 1928 (by Scottish microbiologist Alexander Fleming). 

Fun story: While researching Staphylococcus bacteria in his laboratory, Alexander Fleming noticed that a petri dish containing the bacteria had become contaminated with mould. But the area around the mould was free of bacteria. On closer examination, he identified the mould as Penicillium notatum and realised it was producing a substance that killed the bacteria. He named this substance penicillin.

Before this breakthrough, routine surgeries carried life-threatening risks due to fatal infections, organ transplants were unthinkable, and even common infections like UTIs posed a serious risk of death. Everyday activities like gardening or shaving required caution, as a small cut could lead to serious health complications. Simply put, without antibiotics, modern medicine would have been at a standstill.

The magnitude of Fleming’s discovery wasn’t immediately clear even after he published his findings in 1929. At the time, extracting and purifying penicillin in large quantities was challenging, limiting its practical use. The turning point came during World War II, as the need to treat bacterial infections in wounded soldiers became a top priority. Scientists Howard Florey and Ernst Boris Chain developed a method for mass production, and by 1944, penicillin was being manufactured at scale, turning it into a viable antibiotic. As it saved thousands of lives, penicillin quickly gained widespread acclaim. 

Cornerstone of modern medicine

The miracle drug transformed healthcare as it became the standard treatment for various bacterial diseases. But we are not here to thank our stars for Fleming’s accidental discovery, which became one of the greatest breakthroughs in medical history. But to discuss a bigger problem. Antimicrobial Resistance (AMR)— a situation that the World Health Organization has recognised as one of the top 10 global public health threats.

For the uninitiated, AMR is when bacteria, viruses, fungi, and parasites evolve and develop the ability to resist the effects of antimicrobial drugs such as antibiotics, antivirals, and antifungals, which are intended to kill or inhibit them. Their ability to resist would mean that infections caused by these microorganisms become harder to treat, leading to prolonged illnesses, increased mortality, and higher medical costs.

Such a scenario can be dangerous on so many levels. A common infection such as pneumonia, which is now easily treatable may no longer respond to it, leading to prolonged illness or even death. Surgeries could become riskier because of increased chances of untreatable infections. Moreover, resistant infections could mean longer hospital stays, more expensive medications, and multiple treatments.

We were warned

If you are wondering how a lifesaving invention went on to become a threat to mankind in a matter of decades, the answer is simple. Misuse and overuse. The key contributor to AMR development is believed to be the misuse of antibiotics in humans, animals, and even agriculture.

In his 1945 Nobel lecture, Fleming expressed concern about the improper use of penicillin. Specifically how low doses or incomplete treatments could give bacteria a chance to mutate and become resistant.  

He had famously said: "There is the danger that the ignorant man may easily underdose himself and, by exposing his microbes to non-lethal quantities of the drug, make them resistant."

And this is precisely what has been happening since.

Overprescription, failure to complete courses, and the use of antibiotics in livestock for growth promotion have contributed to the rapid development of AMR.

By the ‘60s and ‘70s, scientists began to notice that bacteria were evolving to resist antibiotics like penicillin, leading to the development of newer antibiotics. However, the misuse of these drugs continued, and the development of AMR accelerated.

But it’s hard to keep up with this mutation. Developing newer antibiotics is inherently difficult. As bacteria constantly evolve, finding new compounds that can kill or inhibit them without harming human cells is a complex process. Additionally, developing new antibiotics requires heavy financial investment in research and clinical trials. Besides, the process of bringing a new antibiotic to market involves stringent regulatory hurdles and testing phases, which can take up to a decade or more. This discourages many pharmaceutical companies from investing in antibiotic development. At the same time, antibiotics continue being prescribed for viral infections (where they are ineffective) and are widely used in agriculture to promote animal growth.

As a result of the widespread misuse, superbugs or multidrug resistance organisms (MDROs) have evolved to survive treatment with multiple antibiotics. A few notorious examples include MRSA (Methicillin-resistant Staphylococcus aureus): Resistant to several types of antibiotics, including methicillin; VRE (Vancomycin-resistant Enterococci): Bacteria that have become resistant to vancomycin, often causing infections in hospitals; CRE (Carbapenem-resistant Enterobacteriaceae): Resistant to carbapenems, one of the last lines of defence in treating bacterial infections and Multidrug-resistant Tuberculosis (MDR-TB): A form of tuberculosis resistant to first-line antibiotics like isoniazid and rifampin. These superbugs cause severe infections that are difficult to treat, leading to longer hospital stays, higher medical costs, and increased mortality rates.

Time to act is now

In the last few decades, very few new antibiotics have been approved, with many belonging to existing classes rather than entirely new types of drugs. In fact, between 1980 and 2000, no new major classes of antibiotics were discovered. While there have been a few new drugs approved recently, they are often met with rapid resistance from bacteria.

Efforts to boost antibiotic development have included government incentives, public-private partnerships, and global initiatives like the WHO’s Global Action Plan on AMR. Yet, the number of new antibiotics remains limited, falling short of what’s needed to tackle the AMR crisis.

In short, without new antibiotics, we are at risk of entering a post-antibiotic era where even minor infections or routine surgeries could become life-threatening. The race to develop new antibiotics and alternative treatments such as bacteriophage therapy (treatment for bacterial infections that uses viruses called bacteriophages to target and inactivate bacteria) is critical to avoid this scenario.

The slow pace of antibiotic development, the rapid evolution of resistant bacteria, and the prevalence of superbugs mean that we are running out of effective treatments for infections that were once easily cured. If no urgent action is taken, even routine medical procedures (think surgeries, childbirth, and cancer treatments) could become life-threatening. 

Tackling AMR requires coordinated global efforts—reducing the misuse of antibiotics, promoting responsible use in healthcare and agriculture, funding research for new treatments, and improving infection prevention measures. The cost of inaction is too high, as we risk entering a post-antibiotic era where modern medicine as we know it could be undone.

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Tears rolled down Rakshit’s* cheeks as he talked about losing his 75-year-old father six months ago. In April, his father was rushed to a top hospital after experiencing chest pain. An angiogram showed severe artery blockages, and doctors advised an urgent bypass surgery.

A week after being discharged, his father’s chest wound became infected. He was readmitted to the same hospital and treated with several antibiotics, but the wounds didn’t heal. Lab tests later showed the infection was from a bacteria resistant to most antibiotics, leaving only one or two options. The doctor suggested an expensive treatment plan but warned there were no guarantees.

"The doctor told me everything depended on my father’s response to the medicine," said Rakshit. Already deeply in debt from high-interest loans for his father’s care, Rakshit was conflicted.

Facing mounting hospital bills, Rakshit made the difficult decision to bring his father home against the doctor’s advice. “He passed away two days after we got him home. If I had enough money, I would have agreed to try the expensive medication,” he said.

Rakshit, an air conditioning mechanic, lives with his family of five on Bangalore’s outskirts. His story is not unique. Hospitals nationwide are seeing a rise in critically ill patients being discharged without medical consent, a practice known in medical terms as Discharge Against Medical Advice (DAMA) or Left Against Medical Advice (LAMA).

Experts point to antimicrobial resistance (AMR) as a key driver of this trend.

India is one of the world’s hotspots for antimicrobial resistance, primarily due to the uncontrolled use of antibiotics over the years. The AMR has disproportionately impacted healthcare access for economically and socially vulnerable populations. 

Data collection

Eight years ago, the Indian Council of Medical Research (ICMR) began efforts to collect antimicrobial resistance data from 20 major medical colleges across India. Meanwhile, the National Center for Disease Control (NCDC) collects antimicrobial resistance information from 35 labs across India. A key partner in this initiative is Kasturba Medical College, part of the Manipal Academy of Higher Education (MAHE) in Manipal.

Dr Vandana KE, professor and head of Microbiology at the college and coordinator of the Centre for Antimicrobial Resistance, and Manipal-bioMerieux Centre of Excellence in antimicrobial stewardship, said the soaring medical costs driven by antimicrobial resistance often compel patients' families to opt for discharge against medical advice. Even if they continue to receive hospital care, the health outcome is compromised. “The situation is grave, to say the least,” she said.

The centre of excellence is set up with the support of bioMerieux, a leading French firm focussing on in vitro diagnostics for more than six decades.

The recently released eighth annual antimicrobial resistance report from ICMR has shed light on rising antibiotic resistance and the decreasing effectiveness of standard treatments against common bacteria in India. The report focused on frequently used antibiotics for managing conditions such as upper respiratory infections, fever, diarrhoea, pneumonia, sepsis, community-acquired pneumonia and other bloodstream infections.

Dr Vandana said this data is invaluable for doctors to gauge the resistance levels of specific bacteria. "A few years ago, we had no comprehensive data on antimicrobial resistance. Now, things are slowly but surely improving," she said.

The report, compiled from nearly 10,000 culture-positive isolates across 21 partner hospitals, provides crucial insights. "Each of the partner hospitals collects bacterial samples, analyses their sensitivity patterns, and uploads the information to the national portal," she added.

Limited options

Rising antimicrobial resistance is making many once-common antibiotics less effective. A few decades ago, doctors prescribed antibiotics based on symptoms and physical exams. With the rise of microbiology labs and advanced tests, doctors now send patient samples to labs to identify the specific bacteria and effective antibiotics. This approach helps doctors choose the right treatment, but they’re facing a bigger problem: new antibiotics are scarce, while bacteria are becoming more resistant.

Dr Muralidhar Varma, professor and head of Infectious Diseases at the college and chairman of Antimicrobial Stewardship (AMS) programme, said the number of antibiotics that can be used for treatment has come down drastically. “For example, doctors had seven or eight drugs at their disposal some 25 years ago to treat the common E.coli (Escherichia coli) which causes urinary tract infection,” he said.

“Now, we have only one or two medicines available to treat the same urinary infection. E.coli bacteria has developed resistance to every other antibiotic. This is a huge challenge healthcare professionals are facing now,” he added.

According to experts, antimicrobial stewardship, which encourages the proper and judicious use of antibiotics, is essential in the fight against antimicrobial resistance. The focus is on educating healthcare providers to follow guidelines based on scientific evidence when prescribing and administering antibiotics. 

The Kasturba way

At Kasturba Medical College, a team of pharmacists, physicians, and microbiologists collaborates to ensure that AMS efforts are effective. Under the team’s guidelines, high-end antibiotics can only be administered to patients after receiving approval from the AMS team. “We are not about restricting antibiotic use altogether because patient safety is paramount. If healthcare professionals have a valid reason to prescribe a particular antibiotic, we authorise it,” said Dr Varma. “Similarly, hospital pharmacies must seek AMS team approval before dispensing any new antibiotic.”

We aim to have open conversations with doctors, explaining why certain antibiotics may not be ideal. They understand our reasoning, and we can move forward collaboratively.

The biggest challenge in implementing antimicrobial stewardship is gaining the trust of senior doctors who are accustomed to having autonomy in prescribing antibiotics.

Dr Vandana emphasised that strict mandates are unlikely to work with experienced doctors. “There are two global approaches to stewardship: restrictive and handshake. With a restrictive model, doctors must justify their rationale for using certain antibiotics, but this approach can feel intrusive and harm the programme’s success,” she said.

Dr Vandana’s team primarily relies on the handshake approach. “We aim to have open conversations with doctors, explaining why certain antibiotics may not be ideal. They understand our reasoning, and we can move forward collaboratively,” she said. “The handshake approach fosters shared responsibility.”

Diagnostics is key

“Without proper diagnosis, effective infection management is impossible. That’s why we also focus on diagnostic stewardship. Diagnostic stewardship means applying the right test for the right patient at the right time, along with accurate interpretation and effective communication between the diagnostician and prescriber,” said Dr Vandana. 

However, accurate diagnostics remain a distant dream for much of India’s population, as microbiology labs are scarce or nonexistent in rural areas.

“The lack of access deprives people in these regions of the benefits of both antimicrobial and diagnostic stewardship,” said Dr Varma. “Until we establish robust facilities, a vast majority will be left out of efforts to reduce antimicrobial resistance.”

(*Name changed to protect identity)

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If you ever visit Thanamir, a quiet village on the Indian side bordering Myanmar, you’re likely to be welcomed with a glass of freshly made apple juice or dried apples–a fitting choice for a community of fewer than 800 residents that has made a name for itself as the only apple-producing village in the entire Northeast. The small yet vibrant community is not only helping Nagaland become one of India’s six apple-producing states but also establishing itself as a destination known for both its fruits and natural beauty.

Thanamir sits at over 2,000 metres high and is known for two things: its apples and Saramati, one of Asia’s tallest peaks. Nearly every home has at least one apple tree in the yard. Visit between July and September, and you’ll see trees bursting with blossoms. “For me apple means sustenance. It has become the means of my survival”, says Somuli Kips, a longtime apple farmer in Thanamir. Many others share his sentiment, seeing the apple as both a livelihood and a community symbol.

Today, the village’s apples are so celebrated that a quick google search for Thanamir online brings up pages all about its produce. Yet, despite the visibility online, Thanamir itself remains largely isolated, perched on a quiet hill in Nagaland.

Community Apple Project

In the 1970s, India was seeing a rise in apple production, but in the village of Thanamir in Nagaland, apples were unheard of. That changed thanks to a surprising act of kindness during the Indo-Naga conflict. An Assam Rifles soldier gave three apple saplings to a Village Guard in Thanamir as a peace offering. The saplings, planted in the village’s fertile soil, grew well, and soon apples became a part of daily life in Thanamir.

By 2011, apple farming had become such a success that Thanamir held its first Apple Festival. The festival grew into a yearly tradition, putting Thanamir’s apples on the map and resulting in the Community Apple Project, a local initiative to support and grow the village’s apple industry.

Today, Thanamir produces 40-50 tonnes of apples each year. The village’s cool, moist climate is perfect for apple growing, helping the apples develop a rich flavour and firm texture. With 19 inches of rainfall a year, the apples need very little irrigation, making farming here both natural and sustainable. This climate advantage has earned Thanamir the nickname Nagaland’s Apple Capital.

But the village faces challenges. Poor roads and limited phone access make it hard to reach new markets. Even so, Thanamir dreams of becoming an apple export hub. With better infrastructure, the village could expand to reach nearby countries like Myanmar and Malaysia. The demand for apple saplings is also growing, offering another way for the village to share its success.

What began as a simple gift has grown into an important part of life in Thanamir, bringing pride and new opportunities to the community. 

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Call for support

In September, the village of Thanamir celebrated its 15th annual Apple Festival, themed "Apple for Health, Wealth, and Prosperity." The event drew locals and officials alike, with the Minister for Women Resource Development & Horticulture, Salhoutuonuo Kruse, making a huge announcement: plans for a new apple processing unit in Thanamir. The facility would enhance the value of the village’s apple production and support economic growth. She also encouraged farmers to explore other crops suited to the region’s unique climate, pledging departmental help in connecting them with markets and providing technical guidance.

Yet, despite the festival’s success and the enduring charm of Thanamir’s apples, challenges persist. Locals are grappling with poor road infrastructure, which severely limits their ability to fully capitalise on the apple harvest. Community members are urging the state for a more equitable distribution of funds and assistance in establishing better marketing channels to reach wider audiences.

The pandemic added to these difficulties. With the festival on hold, Thanamir’s farmers took matters into their own hands, bringing their apples directly to urban markets. This meant long, exhausting journeys–over 300 kilometres, often taking eight hours or more–to the state capital, Kohima, and beyond to Dimapur, Nagaland’s bustling commercial hub. The payoff, however, was evident: their apples sold out swiftly at a wholesale rate of Rs 1,000 per 7 kg carton. The demand was undeniable.

Thanamir’s farmers are ready and eager to increase their apple yields. All they need now is the right support to make it happen.

(Image Credits: Imtiakang Imsong)