The central theme of this work is antimicrobial resistance (AMR), with the authors choosing to specifically highlight India’s role within this public health challenge. Before evaluating the book’s specific arguments, it is useful to discuss what AMR means. It is a global problem flagged by the World Health Organization where existing treatments are no longer effective against bacterial and other infections, leading to more severe illnesses, prolonged hospital courses, and worse clinical outcomes.

AMR has several contributing factors. When a colony of bacteria gets exposed to an antibiotic, those that are vulnerable to the drug are eliminated, while those capable of surviving will endure. As time goes on, the remaining colony consists entirely of bacteria that possess the ability to survive the drug.

Incidentally, bacteria have always possessed the biological ability to overcome antibiotics. This is a natural part of their evolutionary survival over billions of years, helping them resist lethal chemicals deployed by other organisms in the environment. Thus, contrary to popular perception, it is not a case of bacteria suddenly acquiring an all-new AMR ability after man started using antibiotics.

Systemic drivers

It is true that antibiotic overuse and environmental contamination create bacterial populations that are relatively more resistant through a process of selection. However, the clichéd narrative that blames individual prescribing patterns obscures the deeper, systemic drivers of AMR globally. These drivers range from large-scale livestock antibiotic use, urban overcrowding, inadequate sanitation, shortcomings in infection prevention strategies, non-availability of diagnostics and limitations in healthcare access, compounded by economic and educational disparities.

Ultimately, the entire world needs to work together to reduce resistance, particularly because the number of new drugs in the pipeline does not match the rising need.

In the first paragraph of their introduction, the authors mention the controversial term New Delhi metallo-beta-lactamase-1 (NDM-1), which was branded as “India’s superbug” by the international media in 2008. This created an unfortunate perception that India was exporting dangerous bacteria to the rest of the world, and was therefore an unsafe place to travel to. The terminology drew sharp criticism as scientifically inaccurate, given that resistance genes evolve over billions of years and cannot be attributed to any single geography.

For the record, such geographical naming practices have been discarded in academic circles. Unfortunately, when the COVID-19 pandemic struck in 2020, the global community repeated these patterns, using stigmatising terms like “the UK variant” before the practice was corrected by experts worldwide. Today, the scientific and public health community has unequivocally moved away from framing complex, multifactorial global problems as the responsibility of any single nation.

In subsequent sections, the authors discuss the considerable number of tuberculosis patients in India, noting that many suffer from drug-resistant strains. To provide necessary context, tuberculosis remains a monumental global challenge, and drug resistance is an escalating crisis present across several populous and developing nations.

Doron and Broom present historical references to advisories regarding antibiotic use in India. However, these patterns must be read in the context of the early post-Independence era, when bacterial infections claimed a vastly larger share of illness and death than they do today. It was the advent of antibiotics, improved sanitation, vaccination and modern aseptic practices that allowed life expectancy to rise quickly beyond the fourth decade. An unintended consequence of this successful historical transition was a lingering cultural and clinical practice: utilising an antibiotic whenever an infection was suspected.

Fuelled by an earnest desire to heal their patients, doctors in developing nations — not just in India — err on the side of overprescribing rather than under-prescribing. This is a multi-faceted process driven by a lack of rapid diagnostic tests that can differentiate between bacterial and viral infections, a mutual reluctance to perform these tests due to cost concerns and patient compliance, a higher community prevalence of bacterial diseases, avoidance of patient dissatisfaction at not receiving a prescription, and a defensive fear of missing a serious bacterial infection when initial symptoms mimic a viral fever.

Challenge compounded

In India, unfortunately, this challenge is compounded by self-medication and the over-the-counter availability of antibiotics without a physician’s prescription — a structural scenario that differs significantly from the tightly regulated, insured systems of Western nations. The authors describe the over-the-counter availability of antibiotics in India, a practice that the medical profession has repeatedly flagged to regulatory authorities.

The next portion of the book addresses the rise of India as a hub for generic drug manufacturing, where the authors discuss environmental pollution caused by pharmaceutical effluents. Environmental contamination is indeed a recognised variable in AMR. When industrial waste containing active antibiotic residues enters water bodies, it exposes environmental bacteria to sub-lethal doses of these agents, selectively promoting the growth of resistant organisms. The book notes that environmental resistance occurs as a side effect of lower-cost manufacturing, as well as widespread antibiotic use in agriculture, citing similar studies from China. While it is easy to point fingers at the developing world’s manufacturing processes with suboptimal oversight, ironically, wealthy countries are the beneficiaries of this cost-cutting, which incentivises pharmaceutical firms to manufacture generics at the lowest cost possible.

When discussing the veterinary use of antibiotics in India, the book highlights recent measures undertaken to regulate these practices. On a global scale, veterinary and agricultural antibiotic use (which consumes three-quarters of all antibiotics produced) remains the hidden elephant in the room, even as the more frequently discussed individual doctors’ prescribing habits and corporate promotional activities grab public attention more readily.

Ultimately, the book, A World of Resistance, presents a diverse array of perspectives collected from various stakeholders in India, which will be useful for policymakers in the country to comprehend the multifaceted nature of AMR. Although the authors describe India as the “ground zero of the growing AMR crisis”, several processes that drive AMR in India are common to many other nations, including wealthy ones. AMR is an issue where all countries — wealthy or otherwise, big or small, provider or recipient — have a vital role to play.

Besides large-scale antibiotic usage for livestock, some wealthy nations contribute to the AMR crisis through clinical settings. For instance, hospitals and intensive care units (ICUs) routinely and repeatedly admit frail individuals of advanced age from nursing homes, many of whom receive multiple courses of antibiotics for various indications, driving the rise of AMR within the hospital systems. These resistant bacteria travel back to nursing homes with discharged patients, where they can spread to other residents, staff, and visiting family members.

In their conclusion, the authors quote from a journalist’s article in Nature about “300,000 deaths in India in 2019 being attributed to AMR infections” . However, this statement does not reflect the global context of the original research paper by GRAM (Global Research on AntiMicrobial resistance), published in Lancet in 2022. Deaths per 100,000 population due to AMR were highest in Sub-Saharan Africa followed by South Asia (which includes India, Pakistan, Bangladesh, and other countries), followed closely by Eastern Europe and Latin America, with the wealthiest nations predictably having about half of that rate.

This illustrates the fallacy of citing absolute numbers in a populous country rather than the more pertinent metric: deaths per 100,000 population. Clearly, while it’s true that antimicrobial resistance results in a greater proportion of deaths in developing countries than in wealthy nations, it is not a case of India being the lone contributor, or victim. For instance, studies in wealthy nations reveal high AMR levels in less affluent and overcrowded pockets of the population — indicating that AMR is shaped by living conditions, healthcare access, and educational status — even within the same country. A comprehensive understanding of the global AMR crisis would, arguably, require similar scrutiny of the remaining 194 nations — each contributing their own chapter to this story.

The reviewer is a Physician and Gastroenterologist, and Convener, Research Cell of IMA Kerala State

Title: A World of Resistance: India and the Global Antibiotic Crisis

Authors: Assa Doron and Alex Broom

Publisher: The Belknap Press of Harvard University Press

Price: ₹699

Published on June 26, 2026