Did you know that by 2050, antimicrobial resistance (AMR) may directly account for two crore deaths annually? Or that Fleming (discoverer of penicillin) demonstrated antibacterial properties of lysozyme using his own nasal mucus? Or that he was not an inspiring speaker, which may have contributed to a muted early response? Or that penicillin found its way into consumer products, including toothpaste and lipstick?
If you find these minutiae interesting, here are a few more: during WW-II, treatments on injured soldiers were written on their foreheads (‘M’ for morphia; ‘P’ for penicillin); patient zero to receive penicillin in India, Jawaharlal Nehru, was a strong advocate of science and technology; there’s been a staggering rise of e-pharmacies (we saw the tensions these generated, including recent protests by brick-and-mortar pharmacists).
The most startling statistic in ‘A World of Resistance’, however, is that there are 23 billion chickens alive, four times the global human population. These are mostly raised in industrial farms that feed sub-therapeutic doses of antimicrobials for growth promotion and to prevent infection in cramped, unsanitary conditions.
Assa Doron and Alex Broom trace antibiotic use through Green, White and Blue Revolutions, showing progress as a double-edged sword. They discuss “protein gap”, its marketing, caste dynamics, rural versus urban healthcare, and even USA’s “ag-gag” laws.
Yet these interesting facts, while helping the narrative, are not the central theme of the book. Its focus is AMR, often framed as a problem of individual behaviour — patients demanding antibiotics for viral fever, doctors overprescribing out of habit and farmers using them indiscriminately. The authors dismantle this simplistic view.
They make a bigger argument: antimicrobial resistance is fundamentally a systemic problem, embedded within our social, economic and political systems. “AMR is not a crisis born of individual poor choices, nor can it be resolved through education or awareness campaigns alone.”
Their thesis is fundamental, clear and radical — focusing only on individuals, or isolated behaviours, while ignoring the structures producing these outcomes is unlikely to achieve meaningful progress. The critique shifts to the capitalist mode of production. Their argument is not that capitalism hasn’t delivered progress; it has indeed transformed medicine, food supply and longevity. It is that relentless incentives toward expansion, productivity and consumption have also generated conditions favouring AMR. We daily observe the irony of a system that simultaneously gives thousands of varieties of unhealthily processed snacks while also marketing anti-obesity medications to manage the consequences. This inexorable drive for more — more production, more profit, more growth — drives the engine of antimicrobial resistance.
India’s unique position is explored particularly well — we are the pharmacy to the world. But did you know that USSR helped India set up pharma manufacturing factories? Later, the Indian Patents Act of 1970 transformed the sector, allowing generic production and driving down prices globally. That same success, however, created other issues, which are well-captured. The contributions of Yellapragada Subbarow (1895-1948) get special mention; many outside medicine may scarcely know his name despite his enormous scientific legacy.
The environmental impact of antimicrobials is another of the book’s strongest sections. Industrial pollution of rivers is thoroughly discussed. Particularly striking is the account of Batte Shankar’s struggle against pharmaceutical pollution. Equally telling is the observation that after he lost local elections, activism itself appeared to diminish.
The authors repeatedly mention Kerala and Tamil Nadu — states that have consistently outperformed others on health indicators. Yet we saw how political rewards do not necessarily follow public health achievements. Ruling parties in both states recently faced heavy electoral losses.
The book offers a fascinating description of how pollution persists despite regulations. The most polluting steps of drug manufacturing, the authors describe through personal visits and discussions, are outsourced to smaller, unregistered entities operating below regulatory radar.
The authors repeatedly return to themes of “corporate interests, privatisation and marketisation”. Their critique is difficult to disagree with. While they stress that systems matter enormously, they also note that “deviant actors” exist. Personal gain motivates behaviour throughout the chain; several players exploit system weaknesses. Human behaviour remains relevant.
Their concluding message is persuasive: “Our challenge is not to wage war on resistant microbes but to transform the conditions that give rise to them.”
Overall, it’s an excellent book. It describes complex subjects yet remains accessible; references encourage deeper reading. Anyone interested in AMR, public health, pharmaceutical history, environmental policy or sociology of medicine will find much of value here.
— The reviewer is professor of pharmacology at PGIMER