A World of Resistance: What's driving India's antibiotic overdose crisis

The very drugs that transformed India's health, agriculture, and development now threaten to undermine all three

A World of Resistance: India and the Global Antibiotic Crisis

By Assa Doron and Alex Broom

Published by Harper Collins India

245 pages  ₹699

  The “wicked problem” of drug-resistant microbes has long alarmed doctors in India and beyond. Antimicrobial resistance (AMR) is recognised as one of the world’s critical public health threats. It was directly responsible for an estimated 1.27 million deaths globally and contributed to a further 4.95 million deaths in 2019. In the same year, antibiotic-resistant infections accounted for 300,000 deaths in India, including tens of thousands of new-born babies.

 

The Covid-19 pandemic, and the vulnerabilities it exposed, offered critical lessons in how we can respond to AMR. In A World of Resistance, Australian academics and authors Assa Doron and Alex Broom place themselves at “ground zero” of the crisis — India, one of the world’s largest consumers of antibiotics and a pharmaceutical powerhouse — to investigate the global antibiotic emergency. The paradox of antibiotics in India is striking, as the very drugs that transformed the country’s health, agriculture and development now threaten to undermine them all.

 

The story begins in 2008, when a Swedish man returned from a trip to India with an infection that was resolutely resistant to antibiotics. The resistance mechanism was identified as NDM-1 (New Delhi metallo-beta-lactamase-1), quickly dubbed India’s first “superbug”.

 

Taking a long view, layered with extensive fieldwork, the authors trace the social and economic forces that have fuelled the rise of antibiotic resistance.

 

It’s a well-oiled nexus: Medicine wholesalers, salesmen and medical representatives have fostered an epidemic of self-medication and the widespread sale of prescription-only drugs over the counter. “…The antibiotic trade isn’t just influenced by retailers, customers and the government. The vested interests of the developers and producers are a dominant force. The lobby, propelled by Big Pharma’s quest for profit, permeates every layer of the market, from airports and organised chain stores to street stalls and public clinics,” the book observes.

 

The crisis is deeply tied to India’s growing private health care sector, which is prone to prioritising “volume over drug discretion.” Over decades, the culture of over-prescription has cultivated patient expectations for immediate relief. Similar patterns have been noted across Europe.

 

What complicates the situation in India is the scale and diversity of the population and frequent movement, with minimal state border control and surveillance to track health-related behaviours. If one doctor refuses to prescribe antibiotics, it is common for a patient to go to another doctor who will.

 

Compounding the issue is the vast network of informal rural medical practitioners, many of whom lack formal medical training and operate in a murky zone. While they play an important role in delivering health care to underserved regions, the common practice of prescribing and dispensing antibiotics for every ailment forms a worrying link in the chain of AMR.

 

The book unfolds in three sections. The first provides historical context, tracing the arrival of antibiotics in India as it emerged from World War II and colonial rule, and the country’s rise as the pharmacy of the world. With government support to produce antibiotics for the domestic and then the foreign market, antibiotics took over every layer of Indian society. From a salve to treat India’s high burden of bacterial disease, it became an all-purpose pill.

 

The second section explores how antibiotic use became embedded in communities and medical institutions, creating a dependence that has deepened over decades, with antibiotics ridiculously easy to access and widely abused. The final section turns to agriculture, the proliferation of factory farming and the widespread use of antibiotics for growth promotion. Despite global warnings, there is great silence in certain quarters — antibiotics do not find mention in policy documents or national action plans for the poultry or dairy industries, for instance. With growing demand for antibiotic-free products, particularly in overseas markets, the industry has largely responded with lip service, making lofty marketing claims even as systemic problems continue to prevail.

 

The authors argue that the solution to mitigate the risks of AMR is not to simply restrict access to antibiotics, but to improve culturally relevant health education, redesign policies, and build solidarity.  As an introduction to the subject,  A World of Resistance serves as a useful primer. Readers new to the topic will find it comprehensive and well-researched. Those who have followed developments in AMR, however, may find little that is new. Even so, it is a timely warning about a worsening global crisis.

 

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The reviewer is a journalist and author