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Following the World War II, when industrially produced antibiotics emerged, our quality of life and life expectancy substantially improved. A world in awe of the new cure that could beat the once-fatal infection never suspected that bacteria could outsmart the very drugs designed to kill them. As the author of A Short History of Nearly Everything, Bill Bryson aptly puts it: “Because we humans are big and clever enough to produce and utilise antibiotics and disinfectants, it is easy to convince ourselves that we have banished bacteria to the fringes of existence. Don't you believe it. Bacteria may not build cities or have interesting social lives, but they will be here when the Sun explodes. This is their planet, and we are on it only because they allow us to be.”
Rising temperatures allow the increased contamination of our water systems by antibiotic residues, feeding the surge in resistant “superbugs”—bacteria which common medical treatments cannot kill.
With the grim reality of climate change today, society faces an unprecedented juncture of Antibiotic Pollution combined with Antimicrobial Resistance (AMR). Rising temperatures allow the increased contamination of our water systems by antibiotic residues, feeding the surge in resistant “superbugs”—bacteria which common medical treatments cannot kill. A recently published study in the Lancet estimates that more than 39 million deaths will occur due to antibiotic-resistant infections between now and the year 2050. AMR-related deaths are projected to rise by nearly 70 percent by 2050, and South Asia, which includes India, is expected to be the most hit. 11.8 million deaths would likely be attributed to resistant infections over the next 25 years in South Asia. The consequences of inaction could be disastrous, where decades of medical progress could be undone and put public health in jeopardy on a scale never before seen.
The invisible pathways of pollution
Antibiotic pollution influences the environment through several key paths, each playing a sizable role in the spread of AMR.
Pharmaceutical manufacturing: India, one of the world’s largest producers of antibiotics, accounts for more than 20 percent of the world's generic drugs. But this kind of positioning comes at a cost. The effluents discharged from the manufacturing units, like in industrial belts such as Patancheru-Bollaram industrial estate in Hyderabad, have been found to carry high concentrations of antibiotics like Ciprofloxacin, Ofloxacin, and Azithromycin, at levels thousands of times higher than what is deemed safe. A study estimated the antibiotic residue concentrations in certain Indian rivers, namely the Yamuna and Gomti, to be 2-5 times higher than the limits proposed by the Ministry of Environment, Forest, and Climate Change.
Even with wastewater treatment systems installed, systems usually fail to effectively filter out these antibiotic residues. The Indian pharmaceutical industry, valued at around US$50 billion, has yet to fully execute stricter wastewater management practices. Improved surveillance is a significant component of the new World Health Organisation (WHO) guidelines on wastewater management and limiting antibiotic pollution from manufacturing. India is far from the mark as local industries continue to discharge untreated toxic waste into nearby water bodies.
Improved surveillance is a significant component of the new World Health Organisation (WHO) guidelines on wastewater management and limiting antibiotic pollution from manufacturing.
Agriculture and livestock: Increased temperatures and changing disease patterns in agriculture have spurred overuse in livestock and crop production. A major share of antibiotics is consumed by livestock farming in India, with most farmers using antibiotics to promote the growth of their animals. This practice causes significant quantities to seep into the soil and find their way into nearby water bodies. A 2021 study by the Indian Council of Agricultural Research noted AMR in E. coli and other bacterial samples taken from livestock and shrimps in 12 states. The samples had resistance levels higher in regions where antibiotics were used extensively.
Aquaculture: Aquaculture in India, particularly within shrimp farms along the coastal regions, is highly dependent on antibiotics as infections are too common due to warmer water temperatures. A 2022 study detected Norfloxacin in the waters of the Zuari river (Goa). The concentrations were higher than the WHO recommended limits. With water temperatures rising, the demand for antibiotics also continues to rise. This not only affects marine ecosystems but also poses a risk to public health.
Climate change as a pollution multiplier
Climate change also means that the risks posed by antibiotic pollution are amplified, doubling the need for such urgent action. More flooding due to increasing global temperatures sends antibiotic residues derived from pharmaceutical plants, agricultural lands, and urban areas into rivers and lakes. An example to understand this would be to look at monsoon floods this year, the spillover from urban sewage systems, which carry waste containing antibiotics, contaminate local water bodies and create an environment conducive to the amplification of bacteria that were resistant to those antibiotics. A study finds that over 85 percent of Indian districts are exposed to extreme climate events such as floods, thereby placing more ecosystems at risk of contamination from pollution with antibiotics.
Simultaneously, in northern India and much of the country, the increasing intensity of drought is concentrating pollutants (with evaporation), including antibiotic residues, in shrinking water bodies such as local lakes. This creates a “perfect storm” for bacteria to develop resistance.
The high temperatures make it possible for bacteria to exchange genes, i.e. horizontal gene transfer, thus spreading the genes carrying antibiotic resistance between additional bacterial strains.
In addition to this, a warming climate directly drives the proliferation of bacteria. Elevated temperatures allow bacteria little time to multiply; in this case, chances of developing resistance increase. The high temperatures make it possible for bacteria to exchange genes, i.e., horizontal gene transfer, thus spreading the genes carrying antibiotic resistance between additional bacterial strains. One 2020 article reports that a 10°C temperature increase predicts an added ~5 percent rise in the antibiotic resistance rate of common pathogens like E. coli and S. aureus. In India, with a 0.7°C increment in temperature compared to that in 1901, the accelerated growth of bacteria is contributing to the vicious cycle of escalating antibiotic use and resistance.
AMR: A global and Indian public health crisis
It is staggering to realize that drug-resistant infections kill approximately 1.27 million every year, and will rise by 10 million every year by 2050 if rapid action is not taken. Projections estimate that AMR will cause a death toll of 2 million annually in India by 2050 due to its heavy use in health care and agriculture.
India is at the centre of this emerging crisis. With ~1.4 billion people and the world's highest use of antibiotics, it has very particular challenges with both use and pollution. Resistance to antibiotics accounted for an estimated more than 56,000 neonatal deaths in India in 2019 alone, according to an analysis published in The Lancet Microbe. Antibiotic misuse has been rendered possible in light of prevalent over-the-counter availability and lax regulations in human and veterinary medicine.
With WHO support, India drew up the National Action Plan on AMR (NAP-AMR) in 2017, which targets improvement in regulation, education, and surveillance.
The healthcare systems are overworked in rural areas, where a course of antibiotics is often used as a quick fix for most general ailments, whether required or not. With WHO support, India drew up the National Action Plan on AMR (NAP-AMR) in 2017, which targets improvement in regulation, education, and surveillance. Yet, the implementation has been sluggish, and the country remains a global hotspot for AMR.
Policy and solutions: What needs to change
Antibiotic pollution requires more than just awareness; it needs stringent regulatory reform. India, as one of the world's largest antibiotic producers, needs to take greater responsibility for the environmental consequences of this industry. It needs stricter regulations that will offer better governance in terms of disposing of antibiotic waste, with mechanisms to ensure compliance.
According to the WHO 2024 guidelines on wastewater management, monitoring the antibiotic residues in manufacturing effluents is vital. The broad plan for tackling AMR is given in India's NAP-AMR, but it needs to go further to the local level. Needless to say, stricter regulations are needed concerning the disposal of pharmaceutical waste and the improvement of standards for the treatment of wastewater to cope better with the residues of antibiotics. The country should also strengthen its agriculture by advocating antibiotic stewardship and Climate Smart Agriculture to reduce overdependence on antibiotics.
India, along with major antibiotic producers like China, must work within global frameworks to enforce limits on pharmaceutical waste. Partnerships between countries, international organisations like WHO, and global industries are vital to stem the tide of antibiotic pollution.
Urgency in action
The time to take action on antibiotic pollution is now. Still, with climate change gathering at an accelerated pace, the dispersal of antibiotics in the environment will continue to worsen. The consequences of inaction are dire: millions of lives are at risk, and modern medicine itself could be undermined. This calls for coordination by governments, industries, and the community to reduce antibiotic pollution by bringing in stricter regulations. It is only through such collective action that the dual crises of climate change and antimicrobial resistance can be mitigated.
KS Uplabdh Gopal is an Associate Fellow with the Health Initiative at the Observer Research Foundation.
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