In settings where rapid and affordable diagnostics are not available, antibiotics often replace rather than supplement testing. | Photo credit: Volodymyr Hryshchenko/Unsplash
Charles Darwin’s main insight was not only that species evolve, but that they cannot adapt in the presence of selection pressure. Practically speaking, organisms do not choose to change: they respond to the environment in which they try to live. This view should concern us when we think about antimicrobial resistance (AMR): because resistance is not an anomaly of the antibiotic era – it is a logical consequence.
For many decades, we have managed antibiotics as static medical tools: prescribed to individuals, regulated largely by access and volume, and evaluated using short-term clinical outcomes. So when resistance did occur, we viewed it as a breakdown in governance, compliance and/or enforcement. Yet, in a biological sense, resistance is not a failure to use. It is an expected result of the large-scale use of antibiotics.
Structural lag
Antibiotics are not just pharmacological agents: they are evolutionary interventions that reshape microbial populations wherever they are deployed. Each dose of antibiotic is a selective event. This means that every time you take an antibiotic, you create a strong evolutionary pressure in and around your body. Bacteria that are sensitive are killed or suppressed, while those that can resist survive and multiply. Repetition of antibiotic doses amplifies this selection and increases the proportion of resistant strains.
Every clinic, hospital, farm, and sewage 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 act as if it can be ignored.
Bacteria also adapt to timetables that management does not. Mutations occur within hours. Resistant strains circulate within days. Surveillance updates, treatment guidelines, and regulatory responses have evolved over the years. This structural lag ensures that resistance will only be visible after it has spread.
System design failure
In India, this delay is most evident in day-to-day care, including overcrowded outpatient clinics, district hospitals with limited laboratory support, and private practices under pressure to act quickly. In settings where rapid and affordable diagnostics are not available, antibiotics often replace rather than supplement testing.
But from a systems perspective, the dynamics of how resistance arises and becomes visible means that stewardship guidelines alone cannot counter it unless they are anchored in diagnostic capacity and real-time feedback. In reality, AMR is a failure of system design rather than compliance. It is particularly difficult to rule because it does not belong to any sector. Human health, animal husbandry, pharmaceutical production, hygiene and environmental regulation all shape the microbial landscape, often without coordination.
Antibiotic residues entering water bodies create environmental reservoirs of resistance genes. Subtherapeutic dosing in farm animals selects for traits that later transfer to human infections. Incomplete dose regimens in humans may increase AMR selection. Fragmented surveillance and uneven infection control further accelerate the spread. No single actor controls this process, which also means that no single intervention can reverse it.
Shared resource
India’s National Action Plan on Antimicrobial Resistance rightly recognizes this complexity through the ‘One Health’ framework. However, the plan needs to be more firmly integrated into the routine delivery of health care, especially outside tertiary institutions.
Antibiotics also reshape microbial populations in patients’ bodies and in communities. Yet clinicians are rarely trained to think about selection pressure, population dynamics, and the long-term effectiveness of antibiotics, yet are expected to drive patient outcomes. Similarly, while there is renewed optimism about AI-driven discoveries and new antimicrobial platforms, they will not pan out unless the way we use antibiotics changes.
Maintaining the effectiveness of antibiotics therefore depends on how well diagnosis, surveillance, procurement, surveillance and environmental control are coordinated. Market incentives that reward volume undermine this goal. India has an opportunity here not only as a drug manufacturer, but also as a country that is building public systems to treat antibiotics as a shared resource, not just a consumable.
Charles Darwin’s understanding that adaptation to one’s environment is not optional persists because it is a matter of survival. The question of AMR is whether our health systems and policies can adapt with the same persistence as the organisms they seek to “cure,” or whether they will continue to view evolution as an administrative nuisance and risk obsolescence.
Anu Raghunathan is a scientist at CSIR-National Chemical Laboratory, Pune. Views are personal.
Published – 12 February 2026 06:00 IST