India’s silent pandemic: Why antibiotics are failing and what it means for your health
Just last week, I had a throat infection, and did what many people in our country do when they have similar issues—bought some antibiotics from the nearest pharmacy, without consulting a doctor first, and chose to self-medicate. However, when I finally went to consult an ENT specialist after I was not getting better, the doctor, in no uncertain terms, cautioned me against using Azithromycin for throat infections (which I consumed without prescription). She even made me promise never to self-medicate.
The reason? Antimicrobial resistance (AMR) —a condition the World Health Organization (WHO) estimates was directly responsible for 1.27 million deaths in 2019 and contributed to nearly five million deaths globally.
Today, AMR has become one of the biggest public health crises and is often called a ‘silent pandemic’. “In 2023, approximately one in six laboratory-confirmed bacterial infections worldwide were caused by bacteria resistant to antibiotics,” according to the Global Antibiotic Resistance Surveillance Report 2025 released by WHO’s Global Antimicrobial Resistance and Use Surveillance System (GLASS).
AMR also carries deep social and economic costs, with the World Bank estimating that AMR could result in US$1 trillion additional healthcare costs by 2050, and US$1 trillion to US$3.4 trillion gross domestic product (GDP) losses per year by 2030.
With low- and middle-income countries, such as India, facing disproportionate consequences, where skewed regulation and high infectious disease prevalence create ideal conditions for resistance to emerge and spread, this World AMR Awareness Week, it is imperative to understand what AMR actually is, its significance and its public health costs.
What is Antimicrobial Resistance (AMR)?
Antimicrobials – including antibiotics, antivirals, antifungals, and antiparasitics – are medicines used to prevent and treat infectious diseases in humans, animals and plants.
The discovery of penicillin, one of the world’s first antibiotics in 1928 marked a paradigm-shifting moment in human history. Scottish physician and microbiologist Alexander Fleming’s accidental observation of a mould that killed bacteria laid the foundation for modern antibiotics, which revolutionised modern medicine and treatment of infectious diseases. It saved millions of lives during the Second World War and cemented antibiotics as wonder drugs and an essential public good.
However, the blessings of this revolution came with a warning. Fleming himself warned, during his 1945 Nobel Lecture Speech, that misuse of antibiotics could lead to microbial resistance. “There may be a danger, though, in underdosage. It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them, and the same thing has occasionally happened in the body,” he said at the time, adding that “the time may come when penicillin can be bought by anyone in the shops. Then 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.”
What he was talking about was antimicrobial resistance, which is a reality today because we did not pay heed to his warnings.
Antimicrobial Resistance (AMR) occurs when bacteria, viruses, fungi and parasites no longer respond to medicines. This is caused by underdosing or patients not completing their full antibiotic regime, like Fleming had warned, but can also be caused by other factors—such as over-prescribing of antibiotics, over-use of antibiotics in livestock, and even poor infection control in healthcare institutes, among others.
As a result of such drug resistance, medicines become ineffective and infections/diseases become difficult or impossible to treat, increasing the risk of disease spread and leading to severe illness, disability and even death.
While AMR is a natural process that happens over time through genetic changes in pathogens and the principle of natural selection, where organisms/microbes adapt and develop resistance to harsh conditions through the survival of the fittest principle, human activities have accelerated this process due to the misuse and overuse of antimicrobials to treat, prevent or control infections in humans, animals and plants.
Historical trajectory: How did AMR become a global policy concern?
It is key to understand AMR’s historical trajectory to understand how it has become the global health crisis it is today. The post-war decades witnessed the explosion of antibiotic discovery and the mass production of drugs. However, resistance emerged and problems of bacterial resistance became evident.
Within a few years of Fleming’s speech, penicillin resistance appeared in the 1950s, indicating emergence of microbial resistance. However, we did not seem to have realised the potential consequences of the issue—AMR was initially seen as a clinical issue, not a public health risk.
Resistance became increasingly common during the 1960s–1980s with the rapid expansion of antibiotic use in agriculture, creating conditions for resistance within the food chain and further enabling the silent spread of AMR. By the 1980s, multidrug-resistant tuberculosis and gonorrhoea underscored the scale of the problem.
In the late 1990s and 2000s, the WHO convened a series of consultative groups, workshops, and meetings to assess the growing public health threat of antimicrobial resistance and resulted in a publication policy document WHO Global Strategy for Containment of Antimicrobial Resistance in 2000.
Furthermore, the emergence of the NDM-1 enzyme as a “superbug”in 2008–2010, conferring resistance to nearly all known antibiotics, led to the realisation of the gravity and nature of the problem as a global public health crisis that cuts across transnational borders, highlighting the need for global cooperation to address it.
Finally, in 2015, all WHO member states adopted the Global Action Plan on AMR, formalising the One Health approach by integrating human, animal, and environmental factors. AMR reached the UN General Assembly discussion table in 2016 and countries began developing National Action Plans and strategies to address AMR.
How did the AMR Policy take shape in India?
In India, a National Task Force on AMR Containment was constituted in 2010, leading to the development of the National policy on AMR containment in early 2011. Despite the early interventions, a National Action Plan on Antimicrobial Resistance (NAP-AMR) was only launched in 2017, in response to the WHO and UN’s calls for national plans, and it was to be implemented over the next 5 years, until 2021.
However, data show that AMR-related deaths in the country continue to rise. In 2021, there were an estimated 267,000 deaths attributable to AMR and 987,000 deaths associated with AMR in India. The number of deaths associated with AMR has reduced slightly since 1990, but deaths directly attributable to AMR have, in fact, risen during the same period.
“Across 204 countries, India has the 57th highest age-standardised mortality rate associated with AMR in 2021,” according to the Institute of Health Metrics and Evaluation.
India has the largest share of the global number of people estimated to have developed multidrug-resistant TB (incident cases) in 2022 (27 per cent of global cases) and bears one of the world’s heaviest burdens of antimicrobial resistance, alongside treatment efforts. It not only increases the length and cost of hospital stays for patients but also increases the cost of developing new drugs.
The government has now announced the second version of the national plan this year, the development of which began almost three years ago in 2022, and it looks at plans for until 2029. A government release says that the new plan, referred to as the NAP-AMR 2.0, “addresses the gaps identified in the first NAP-AMR by increasing the ownership of AMR-related efforts, strengthening inter-sectoral coordination and ensuring stronger engagement with the private sector.”
“The updated NAP-AMR includes specific action plans of each key stakeholder ministry/department with timelines and budget to enable effective monitoring of progress in implementation of the national action plan. The updated NAP AMR also includes well-defined mechanisms for coordination and collaboration within and across the sectors,” it added.
What is the way forward?
Despite these initiatives, at the global, national and state levels, AMR is a rising threat. Policymakers and decision makers continue to struggle with AMR because structural gaps exist in global and national health governance. A major bottleneck lies in regulatory gaps in the prescription and use of antibiotics.
For instance, in many countries, including India, antibiotics can still be purchased without prescription, and enforcement of regulatory norms is inconsistent. While states like Kerala and Gujarat have set an example by becoming the first ones to ban over-the-counter sales of antibiotics, in most other states of the country, one can still freely walk up to a pharmacy and pick up antibiotics of any composition, any dose, or any strength without a legitimate prescription.
In the animal and food-production sectors, oversight of antibiotic use is even more challenging. Furthermore, inadequate surveillance and monitoring capacity act as a blind spot, as many developing countries lack robust data on antibiotic consumption or resistance trends. The insufficient existing market incentives remain a bottleneck in the development of novel antibiotics.
Public awareness remains another critical weak link, and limited understanding of AMR leads to suboptimal behaviours such as self-medication, incomplete treatment courses, and reliance on informal healthcare providers.
AMR as a public health crisis is a ‘tragedy of the commons’ problem, which needs a collective action to address it at the global, national and local level. The global governance framework outlined by WHO in the form of the One Health Approach proposes an integrated and holistic framework to address it.
Nearly a century after penicillin transformed modern medicine, the emergence of antimicrobial resistance (AMR) poses a threat to years of progress. Fleming’s early warning about AMR has materialised into a global health crisis. Addressing this silent pandemic now requires far more robust health governance structures embedded with strong surveillance, regulations, and public health communication.
Through collective action, we can safeguard the gains of modern medicines and prevent AMR from reversing the decades of progress. The World Antimicrobial Awareness Week, observed annually from 18 to 24 November, offers a window of opportunity to reinforce public awareness, mobilise collective action, and reaffirm global commitment to address AMR before it becomes unmanageable.
It is key to address the governance structure related to public healthcare ecosystems at national and subnational levels. On the public awareness level, behavioural science strategies such as nudge and identifying the nodes of incentives and disincentives in the public healthcare system is key to ensuring people and the healthcare system reduce the overuse of antibiotics.
Monitoring and surveillance are the key in tracking the AMR issue, and Big Data and Artificial Intelligence (AI) can aid the public healthcare system to integrate and identify the emerging patterns and developments related to resistance. Additionally, innovating public health communication in the age of misinformation is key to building a robust awareness campaign against AMR. It is therefore critical that AMR-related communication is delivered in a lucid, contextual, and actionable manner. Overall, it needs a holistic approach to address this global common crisis.
Deepak Gautam is the Public Policy Lead at DataLEADS, where he works at the intersection of public policy, health, and emerging technologies, including AI and misinformation resilience.
This story is done in collaboration with First Check, which is the health journalism vertical of DataLEADS.
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