Antimicrobial resistance: Charles Darwin was right; India’s drug policy isn’t

Charles Darwin’s central insight wasn’t just that species evolve but that they can’t but adapt in the presence of selection pressures. In practical terms, organisms don’t choose to change: they respond to the environments in which they’re trying to live. This insight should trouble us when we consider antimicrobial resistance (AMR): because resistance isn’t an anomaly of the antibiotic era — it is a logical consequence.

For many decades, we have governed antibiotics as static medical tools: prescribed to individuals, regulated largely by access and volume, and evaluated using short-term clinical outcomes. So when resistance emerged, we treated it as a breakdown of stewardship, compliance, and/or enforcement. Yet in the biological sense, resistance is not a failure of use. It’s the expected outcome of using antibiotics at scale.

Structural lag

Antibiotics aren’t only pharmacological agents: they are evolutionary interventions that reshape microbial populations wherever they’re deployed. Every antibiotic dose is a selective event. It means each time you take an antibiotic, you create a strong evolutionary pressure in your body and its surroundings. Bacteria that are susceptible are killed or suppressed while those that can resist survive and multiply. Repeating the antibiotic doses amplifies this selection, increasing the share of resistant strains.

Every clinic, hospital, farm, and wastewater outlet becomes a place where microbial populations are shaped by survival advantage. The problem is not that evolution is surprising but that our health systems continue to behave as though it can be ignored.

Bacteria also adapt on timescales that governance does not. Mutations arise within hours. Resistant strains circulate within days. Surveillance updates, treatment guidelines, and regulatory responses unfold over years. This structural lag ensures resistance becomes visible only after it has become widespread.

Failure of system design

In India, this lag is most evident in everyday care, including crowded outpatient clinics, district hospitals with limited laboratory support, and private practices under pressure to act quickly. In settings where rapid, affordable diagnostics are unavailable, antibiotics often substitute for testing instead of complementing it.

But from a systems perspective, the dynamics of how resistance arises and becomes visible means stewardship guidelines alone can’t counter it if they are not anchored in diagnostic capacity and real-time feedback. In fact, AMR is a failure of system design more than that of compliance. It’s particularly difficult to govern because it doesn’t belong to any single sector. Human health, animal husbandry, pharmaceutical manufacturing, sanitation, and environmental regulation all shape the microbial landscape, often without coordination.

Antibiotic residues entering water bodies create environmental reservoirs of resistance genes. Sub-therapeutic dosing in livestock selects for traits that later spill into human infections. Incomplete dose regimes in humans can increase the selection of AMR. Fragmented surveillance and uneven infection control further accelerate spread. No single actor drives this process, which also means no single intervention can reverse it.

Shared resource

India’s National Action Plan on Antimicrobial Resistance correctly recognises this complexity through a ‘One Health’ framework. However, the Plan needs to be more strongly embedded in routine healthcare delivery, especially outside tertiary institutions.

Antibiotics also reshape microbial populations inside patients’ bodies and in communities. Yet clinicians are rarely trained to think in terms of selection pressure, population dynamics, and the long-term efficacy of antibiotics yet are expected to manage patient outcomes. Likewise, while there’s renewed optimism around  discoveries driven by artificial intelligence and novel antimicrobial platforms, they won’t fall in place if the way we use antibiotics doesn’t change.

Preserving the efficacy of antibiotics  therefore depends on how diagnostics, surveillance, procurement, stewardship, and environmental controls are aligned. Market incentives that reward volume will undermine this goal. There is an opportunity for India here, not only as a manufacturer of medicines but as a country that builds public systems to treat antibiotics as a shared resource rather than just as a consumable.

Charles Darwin’s insight that adapting to one’s environs is not optional endures because it’s a question of survival. The question AMR poses is whether our health systems and policies can adapt with the same persistence as the organisms they seek to ‘treat’, or if they will continue to treat evolution as an administrative inconvenience and risk obsolescence.

Anu Raghunathan is a scientist at the CSIR-National Chemical Laboratory, Pune. Views are personal.