India’s Battle Against Antimicrobial Resistance

This editorial is based on “Strengthening the Frontline Against AMR: Building Progress Through Collective Commitment” which was published in The Hindustan Times on 24/11/2025. The article brings into picture the rising threat of AMR, which now spans humans, animals, and the environment, endangering modern medicine and food systems. It highlights India’s policy steps, including Kerala’s PROUD/AMRITH initiatives, and stresses that only a coordinated One Health approach can curb this crisis.

For Prelims: Antimicrobial resistance, One Health framework, Superbugs, Schedule H1, NDM-1 (New Delhi Metallo-beta-lactamase), Red Line Campaign, E. coli, Klebsiella and Pseudomonas.  

For Mains: Factors Fueling the Growing AMR Crisis in India, Measures that can be Adopted to Effectively Counter AMR Crises in India

Antimicrobial resistance (AMR) has evolved into a critical development challenge that threatens to undo decades of progress in health, agriculture, and poverty reduction. The problem extends far beyond hospitals, resistant microbes contaminate soil, water, and food chains, endangering everything from routine medical procedures to livestock production. India has responded with strong policy measures, including bans on certain antibiotics in food animals and innovative state programs like Kerala's PROUD and AMRITH initiatives, which have demonstrated both health and economic benefits. Addressing this crisis requires coordinated action across human, animal, and environmental health sectors under the One Health framework. The stakes are clear: without effective antimicrobials, the foundation of modern medicine and sustainable development faces unprecedented risk.

What is Antimicrobial Resistance?

• About: Antimicrobial Resistance (AMR) is often termed the "Silent Pandemic." It occurs when microorganisms (bacteria, viruses, fungi, and parasites) evolve and stop responding to medicines (antimicrobials) that were once effective in treating them. 
  • The result is the emergence of "Superbugs"- pathogens that are resistant to multiple drugs, making standard treatments ineffective, persistent infections more likely, and increasing the risk of spread to others. 
• Core Mechanism: AMR is a natural evolutionary process, but human activity has accelerated it dangerously. Microbes develop resistance through four main mechanisms: 
  • Limiting Uptake: The microbe changes its cell wall to prevent the drug from entering. 
  • Target Modification: The microbe alters the specific protein or molecule the drug is supposed to attack, so the drug can no longer bind to it. 
  • Efflux Pumps: The microbe develops biological "pumps" to physically spit the drug out of the cell before it can do damage. 
  • Drug Inactivation: The microbe produces enzymes (like beta-lactamases) that chemically destroy or neutralize the drug. 

Think of it like this 

Twenty years ago, a simple mosquito coil or a basic mat was enough to kill them or chase them away. Today, you can run a liquid vaporizer on "High/Turbo" mode, and the mosquitoes will still fly around it. 

Why? The mosquitoes didn't change species. The weak ones died years ago. The ones that survived the coil "learned" how to tolerate the poison. They bred and created "super-mosquitoes" that are immune to the old weapons. 

Antimicrobial Resistance is exactly this, but with bacteria inside your body. When you misuse antibiotics, you kill the weak bacteria, but you teach the strong ones how to survive.

What Factors are Fueling the Growing AMR Crisis in India? 

• Rampant Clinical Misuse & "Watch" Category Abuse: Doctors often prescribe broad-spectrum antibiotics for simple viral infections due to a lack of rapid diagnostics, while lax enforcement of Schedule H1 allows pharmacies to sell high-end drugs without prescriptions.  
  • This "pill-popping" culture accelerates resistance by exposing bacteria to drugs unnecessarily, forcing them to evolve survival mechanisms rapidly.  
    • A striking example of India’s growing pill-popping culture is the widespread use of Dolo-650 after the pandemic—one doctor even joked that Indians take it like Cadbury Gems. 
    • This trend is worsened by the easy over-the-counter availability of antibiotics, leading people to self-medicate without understanding the risks. 
  • About 59% of total antibiotic consumption in the country in 2022 was from the “Watch” group with 8 in 10 patients entering a hospital carrying drug-resistant bacteria.  
• Growth Promoter Epidemic in Livestock: The poultry and aquaculture industries prioritizing profit over public health routinely use critical antibiotics like Colistin not to treat sickness, but to fatten animals faster.  
  • This creates a massive "reservoir of resistance" in the food chain, where drug-resistant bacteria transfer directly from meat/fish to the human gut. 
  • India is the 4th largest consumer of animal antibiotics globally, with usage projected to rise 82% by 2030; recent studies found 100% resistance to Ampicillin in shrimp samples collected from retail markets in Kerala. 
• Pharmaceutical Pollution-The "Hyderabad Model": As the "Pharmacy of the World," India suffers from manufacturing units dumping untreated antibiotic residues into local water bodies, creating "evolutionary pressure cookers."  
  • In these antibiotic-rich rivers, bacteria are forced to mutate into superbugs to survive, which then seep into groundwater and community water supplies. 
  • Recent Environmental studies found antibiotic concentrations in Hyderabad’s Musi River were 1,000 times higher than safe limits. 
• Proliferation of Irrational Fixed-Dose Combinations (FDCs): The Indian market is flooded with unscientific "cocktail drugs" that combine multiple antibiotics or antibiotics with vitamins, which exposes pathogens to sub-therapeutic doses and accelerates resistance.  
  • The regulatory crackdown is ongoing, but these irrational formulations continue to drive resistance by offering "shotgun therapy" instead of targeted treatment. 
  • In August 2024, the Government banned 156 FDCs (including antibiotic cocktails) citing "no therapeutic justification". 
• The "Scavenger" Spread via Poor Sanitation: Inadequate sewage treatment allows resistant "superbugs" like NDM-1 (New Delhi Metallo-beta-lactamase) to escape hospitals and thrive in public water systems.  
  • According to a recent epidemiological study, urban wastewater frequently carries high loads of antibiotic-resistant E. coli, Klebsiella and Pseudomonas.  
    • When sewage networks are flawed or untreated, these bacteria can re-enter natural water bodies, soils and even toilets, turning common sanitation infrastructure into bridges for superbug transmission. 
• Surveillance Blind Spots & Diagnostic Deficits: India's AMR data is heavily skewed toward tertiary ICUs, missing the "silent pandemic" in rural primary care where doctors prescribe empirically due to a lack of labs.  
  • Without affordable rapid diagnostic kits, healthcare providers cannot distinguish between bacterial and viral infections, leading to massive unnecessary prescriptions.  
  • For instance, NCDC’s NARS-Net submissions rely mainly on public sector medical colleges and sentinel hospital labs, under-representing small private clinics and rural facilities, which together handle a huge share of everyday infections. 

What are the Key Threats Posed by Antimicrobial Resistance? 

• Economic Threats:  
  • Trade & Export Losses (The "Shrimp & Poultry" Crisis): 
    • Seafood Exports: India is a leading global exporter of shrimp. However, high antibiotic residues (traces of drugs used to treat aquatic disease) have triggered frequent rejections by the EU and USA.  
      • For instance, the US FDA has refused entry to multiple Indian shrimp lines due to banned antibiotics like nitrofurans and chloramphenicol. 
    • Poultry & Livestock: As global markets (specifically the EU) enforce strict "antibiotic-free" regulations, India’s poultry sector faces the risk of being locked out of high-value supply chains.  
      • The rampant use of antibiotics as "growth promoters" acts as a significant compliance hurdle. 
  • Healthcare Cost Explosion: 
    • Treatment Costs: Treating drug-resistant infections is exponentially more expensive.  
      • It necessitates "last-resort" antibiotics (like Colistin or Meropenem), prolonged hospitalization, and expensive isolation protocols. 
    • Financial Toxicity: With 39.4% of India’s Total Health Expenditure being Out-of-Pocket (OOPE) according to the National Health Accounts Estimates 2021-22, AMR pushes families into poverty.  
      • A single episode of resistant sepsis can wipe out a low-income family's life savings. 
  • Loss of Productivity & GDP: 
    • Workforce Impact: AMR disproportionately affects the working-age population. Prolonged illness leads to absenteeism and wage loss.  
      • The World Bank estimates that AMR could cause a global GDP shortfall of up to 3.8% by 2050; for a high-burden country like India, the impact could be even more severe. 
    • Demographic Dividend Risk: India's primary economic advantage is its young workforce. If a significant demographic cohort is debilitated by chronic resistant infections (like MDR-TB), this "dividend" risks turning into a "demographic liability.” 
• Societal & Public Health Threats 
  • Return to the "Pre-Antibiotic Era": 
    • Routine Procedures Become Deadly: Modern medicine relies on antibiotics for prophylactic safety. Without them, standard procedures, such as C-sections, hip replacements, and chemotherapy, become life-threatening due to infection risks. 
    • Neonatal Mortality: India faces a tragic burden where an estimated 50,000+ newborns die annually from sepsis caused by organisms resistant to first-line antibiotics.  
      • This directly undermines national efforts to reduce the Infant Mortality Rate (IMR). 
  • The Rise of "Superbugs": 
    • Hospital-Acquired Infections (HAIs): ICMR reports indicate that common pathogens (like E. coli and Klebsiella) in Indian hospitals are increasingly resistant to potent antibiotics.  
      • Carbapenem-resistant organisms are now widespread, leaving doctors with few to no treatment options. 
    • Drug-Resistant TB: India bears the highest global burden of Multi-Drug Resistant Tuberculosis (MDR-TB). This airborne threat creates a vicious cycle of disease and poverty, particularly among the urban poor and slum dwellers. 
• Environmental Threats (The "One Health" Crisis) 
  • Pharmaceutical Pollution: While India is the "pharmacy of the world," this manufacturing prowess comes at an environmental cost.  
    • Effluents from pharmaceutical hubs (notably in Hyderabad) often contain high concentrations of antibiotics.  
    • These contaminate local water bodies, turning them into "breeding grounds" for superbugs, which eventually cycle back to humans. 
  • Agricultural Runoff: Antibiotics used in agriculture seep into the soil and groundwater.  
    • This creates a transmission loop where resistant bacteria enter the human food chain through crops and drinking water. 

What Major Initiatives has the Indian Government Undertaken to Tackle the AMR Crisis? 

• National Action Plan on AMR 2.0 (2025-29): A recently launched updated framework focusing on "One Health" surveillance, infection prevention, and antimicrobial stewardship across human and animal sectors. 
• Chennai Declaration: It is the result of the first ever joint meeting of medical societies in India addressing antibiotic resistance. 
• Delhi Declaration on Antimicrobial Resistance (AMR): It is an inter-ministerial consensus signed in April 2017 to combat antimicrobial resistance through a holistic "One Health" approach. 
• Red Line Campaign: A public awareness drive requiring antibiotics to carry a vertical red line on packaging, signalling they must not be sold or consumed without a doctor's prescription. 
• Fixed-Dose Combination (FDC) Ban (2024): A regulatory crackdown banning 156 irrational "cocktail" drug formulations (many containing antibiotics) that lacked scientific justification and fuelled resistance. 
  • Also, the government has banned the use of colistin in animal feed to curb the rising threat of antimicrobial resistance (AMR).  
  • This step aims to prevent the development of resistance to this critical “last-resort” antibiotic in humans. 
• Schedule H1 Implementation: A legal amendment to the Drugs and Cosmetics Rules that mandates pharmacies to maintain a separate register for antibiotic sales and prevents over-the-counter availability. 
• ICMR's Antimicrobial Resistance Surveillance Network (AMRSN): Established in 2013, is a system for collecting, analyzing, and reporting data on antimicrobial resistance (AMR) from various tertiary care hospitals across India.

What Measures can be Adopted to Effectively Counter AMR Crises in India? 

• "Hub-and-Spoke Diagnostic Grid: To tackle the "blind" prescription epidemic especially in rural India, we must operationalize a Hub-and-Spoke Diagnostic Model. 
  • In this system, Tertiary Care Centers (Hubs) with advanced microbiology labs are digitally linked to Primary Health Centers (Spokes).  
  • Peripheral health workers merely collect samples and transport them via defined cold-chain logistics to the Hub, receiving digital reports within 24 hours.  
  • This eliminates the need for expensive labs in every village while ensuring that rural doctors prescribe based on evidence (antibiograms) rather than empirical guesswork, drastically reducing unnecessary antibiotic use. 
    • Encourage the use of indigenous, low-cost rapid diagnostic kits—such as Assam’s DOSA project or IITs’ Lab-on-a-Chip innovations—that can distinguish viral from bacterial infections in minutes, helping avoid unnecessary antibiotic use. 
• "Antibiotic Smart Villages" (WASH-First Defense): Prevention is better than cure; we should launch "Antibiotic Smart Villages" that prioritize Water, Sanitation, and Hygiene (WASH) infrastructure to break the chain of infection.  
  • By ensuring 100% coverage of potable piped water and sewage treatment in targeted clusters, we reduce the incidence of waterborne diseases like Typhoid and Diarrhea.  
  • If fewer people get sick, fewer people need antibiotics, naturally lowering the selection pressure for resistance without needing complex medical interventions. 
• Incentivized "Green Pharma" Procurement: The government, being the largest buyer of drugs, should enforce a "Green Procurement Policy." 
  • Pharmaceutical companies that can prove their manufacturing units achieve "Zero Liquid Discharge" (ZLD) and treat effluents to remove antibiotic residues should receive preferential weightage in government tenders.  
  • This uses market forces ("Pull" incentives) to make pollution control financially profitable for companies, stopping the release of active pharmaceutical ingredients into India's rivers and soil. 
• "Farm-to-Fork" Antibiotic Traceability: To secure the food chain, we need a Blockchain-based Traceability System for the poultry and aquaculture sectors. 
  • Feed manufacturers and hatcheries would be required to log batch details on a decentralized ledger, certifying that their products are free from growth-promoting antibiotics like Colistin.  
  • Consumers could scan a QR code on the final meat/egg product to see its "Antibiotic-Free" journey.  
    • This consumer demand for transparency would economically force producers to abandon the use of antibiotics as cheap growth substitutes. 
• Integrated "One Health" Surveillance Platform: We must move beyond theoretical collaboration to a Unified National AMR Dashboard that legally mandates data integration from human, veterinary, and environmental sectors.  
  • By using AI to cross-reference data—for example, correlating a spike in Colistin sales in local poultry farms with a rise in drug-resistant gut infections in the nearby human population district authorities can identify and isolate "transmission hotspots" immediately, treating the ecosystem as a single biological unit rather than separate silos. 
  • Kerala model successfully implements a strict ban on over-the-counter (OTC) antibiotic sales through a comprehensive, multi-pronged strategy that combines strict regulatory enforcement, public awareness campaigns, and a multi-sectoral 'One Health' approach. 
  • Subsidising animal vaccines can significantly cut antibiotic misuse; a vaccinated chicken is far less likely to fall sick, reducing the farmer’s dependence on routine antibiotic feeding. 
• Behavioral Change Communication (BCC) Campaigns: Instead of passive awareness posters, we need Targeted Behavioral Nudges based on local psychology to break the "pill-popping" habit.  
  • This involves structured community engagement where trusted local leaders (religious heads, teachers) explain that antibiotics are "precious resources," not "quick fixes."  
  • By framing antibiotic preservation as a moral duty to the next generation (similar to the Swachh Bharat narrative), we can shift the societal norm from expecting a prescription for every fever to understanding that "time and rest" are often the best healers. 
• The "Blue Envelope" Protocol: In India, pharmacists often cut strips and sell just 3 or 4 pills in a generic white paper bag. To address the risk of loose pill dispensing (where the original 'Red Line' warning is lost), mandate a distinct color-coded envelope exclusively for antibiotics.  
  • This visual distinction acts as a critical safeguard. The Blue Envelope does not tell you to start taking the drug; it tells you: "If you have started this, do not stop halfway, or you will make the bacteria stronger."  
  • By distinguishing these from common painkillers, it ensures patients complete the full course to achieve total bacterial eradication, rather than leaving surviving bacteria to mutate into superbugs. 
  • Also, another major issue in India is patients saving leftover antibiotics and popping them later for a viral flu. 
    • If the pills are in a standard white bag, they look like any other medicine. 
    • If they are in a specific Blue Envelope, it creates a mental category: "This is that serious medicine for heavy infections." It discourages casual use for a common cold later on because the packaging denotes severity. 

Conclusion:

AMR is no longer just a medical issue but a multidimensional development threat demanding urgent, systemic action. India’s recent policies and state-led innovations show that progress is possible with coordinated efforts. Strengthening surveillance, regulation, and WASH infrastructure under a robust One Health approach is essential. Only sustained, cross-sectoral collaboration can safeguard the future of effective antimicrobials and public health.

Drishti Mains Question: 

“Antimicrobial resistance (AMR) is no longer a health-sector issue but a cross-sectoral development crisis. Critically examine the key factors driving AMR in India and evaluate the effectiveness of recent government initiatives in addressing it under the One Health framework.”

UPSC Civil Services Examination, Previous Year Questions (PYQ)

Prelims 

Q. Which of the following are the reasons for the occurrence of multi-drug resistance in microbial pathogens in India? (2019)

1. Genetic predisposition of some people  
2. Taking incorrect doses of antibiotics to cure diseases  
3. Using antibiotics in livestock farming  
4. Multiple chronic diseases in some people  

Select the correct answer using the code given below.  

(a) 1 and 2  

(b) 2 and 3 only  

(c) 1, 3 and 4  

(d) 2, 3 and 4  

Ans: (b)

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Mains

Q. Can overuse and free availability of antibiotics without Doctor’s prescription be contributors to the emergence of drug-resistant diseases in India? What are the available mechanisms for monitoring and control? Critically discuss the various issues involved. (2014)