My seventy-year-old grandmother* had never been so seriously ill that she required hospitalisation. A slip-and-fall last year changed that. She fractured her spine and was advised to rest in bed and needed a urinary catheter. A few months later, she developed a urinary tract infection and was prescribed a widely used antibiotic for catheter-associated infections. But it didn’t work. Her fever rose, her condition worsened, and she had to be hospitalised again. The urine culture report left everyone stunned. The bacteria were resistant to all the antibiotics tested.
My grandmother’s infection came from the world she lived in, a world where antibiotic-resistant bacteria have become part of our environment.
AMR is also an ecological crisis now
For years, particularly in the Global South, Anti-Microbial Resistance (AMR) has been framed primarily as a problem of human behaviour of irrational prescribing, unregulated sales, and self-medication, often placing responsibility on individuals and health systems rather than the broader environmental and structural determinants that shape resistance. While these factors matter, stories like my grandmother’s reveal a larger truth: AMR is no longer a problem confined to hospitals or human decisions. It is an ecological crisis, one that thrives in the intersections of pollution, poor waste management, and climate change.
WHO’s Global antibiotic resistance surveillance report 2025 reinforces how grave the AMR crisis has become. According to the report, in 2023, approximately one in six laboratory-confirmed bacterial infections worldwide were caused by bacteria resistant to antibiotics. Median resistance was most common in urinary tract infections (approximately 1 in 3) and bloodstream infections (1 in 6). It shows rising resistance among bacteria such as E. coli, Klebsiella pneumoniae, and Acinetobacter infections common in hospitals. Yet despite advocating for a One Health approach that integrates human, animal, and environmental health, the report’s focus remains heavily on human and clinical factors. While environmental surveillance data is still scarce, the omission is not just a gap; it’s a contradiction. The report acknowledges that resistant organisms are found in water bodies, soil, and food systems, yet stops short of integrating these findings into action frameworks or accountability mechanisms.
In India, the environment is a silent amplifier of resistance. Investigations by the Centre for Science and Environment (CSE) have shown that antibiotic pollution is widespread in the ecosystem, with residues from pharmaceutical manufacturing, hospital sewage, and agricultural run-off contaminating soil and water. Effluents released from industrial and healthcare facilities carry traces of antibiotics such as Ciprofloxacin and Azithromycin, which eventually contaminate waterbodies into reservoirs of resistance, where microbes not only survive but also develop new defence mechanisms. These resistant bacteria travel through irrigation systems, food chains, and air, connecting hospitals, households, and farms in an invisible circuit of exposure. The line between hospital-acquired and community-acquired infections is blurring rapidly, making resistance not just a medical challenge but an environmental and governance crisis.
Climate change has deepened this crisis. Rising temperatures accelerate bacterial growth and horizontal gene transfer, the process by which resistance spreads between microbes. Floods further mix the sewage, hospital waste with surface water, spreading resistant bacteria over wide areas. A 2023 Nature Climate Change study found that even a one-degree rise in temperature is associated with a significant increase in antibiotic resistance. Yet climate policies and AMR strategies continue to function in silos, missing the deep ecological link between the two.
Bengaluru, a South Indian city that represents both India’s aspirations and its vulnerabilities, stands at this intersection. The Bengaluru Climate Action Plan, aligned with the Global C40 Cities initiative, aims to build resilience to climate hazards. But like most such plans, it does not consider AMR within the framework of climate vulnerability. At the national level, India’s National Action Plan on AMR and the National Action Plan on Climate Change and Human Health are also disconnected. Both mention the environmental factor, but neither gives it the weight it deserves. For a country ranked 115th on the ND-GAIN Climate Vulnerability Index, this oversight could prove costly.
Global projections and the need to adjust AMR strategies & governance
AMR is projected to cause an additional US$1 trillion in healthcare costs annually by 2050, according to WHO estimates. By then, common infections, minor surgeries, and cancer treatments could all become high-risk. Already in 2019, 4.95 million deaths were associated with bacterial antimicrobial resistance, with 1.27 million directly caused by it. As climate pressures mount, the risk multiplies.
These projections reinforce the way we should conceptualise and respond to AMR matters. To see AMR only as a medical or behavioural problem is to ignore its true nature. Resistant microbes do not emerge merely from misuse, but also from other sources. Controlling prescriptions alone won’t stop them. What we need is environmental regulation, cross-sectoral data sharing, and urban planning that acknowledges microbes as part of our changing ecology. Wastewater surveillance, climate-adapted infection control, and stringent industrial discharge norms must become part of the AMR strategy.
AMR is a result of a world that has changed more rapidly than our ability to protect ourselves, including my grandmother. AMR does not just alter how we treat disease; it alters what it means to be well.
* Informed consent was taken to include the details in this blog