Sick people today have a better chance at recovery than they did more than a century ago. The invention and development of antibiotics have fundamentally contributed to it. Worryingly, though, some of these antibiotics have stopped working for millions of people around the world. Most people still think of antimicrobial resistance as a medical problem—a case of overprescribed antibiotics, irresponsible individuals, or hospital hygiene. It is, unfortunately, much bigger than that.

The Spread of Antibiotic Resistance

Antibiotic resistance or antimicrobial resistance (AMR) refers to what happens when bacteria, viruses, fungi, and parasites evolve to resist the drugs designed to treat them. This condition turns once-manageable infections into potentially fatal ones. 

In 2019, it directly caused 1.27 million deaths globally, more than HIV/AIDS or malaria. It also played a role in nearly 5 million more deaths that year. By 2050, 39 million deaths are projected from AMR, taking roughly three lives every minute. 

The AMR narrative starts in farms, rivers, and factory drains, not just hospitals. Globally, up to 75% of antibiotics used in aquaculture are never absorbed by the fish they are intended to treat. They, instead, dissolve into surrounding water and create precisely the conditions under which resistant bacteria thrive. Meanwhile, in the livestock sector, there is a common practice that drives antimicrobial resistance across entire ecosystems. Instead of using them to treat diseases, farms routinely use antibiotics to accelerate animal growth.

From Pollution to Antimicrobial Resistance

Pharmaceutical manufacturing compounds the problem further. A global river study measuring antibiotic contamination across 258 rivers in 104 countries found that only two locations on Earth had no pharmaceutical pollution: Iceland and an Indigenous Venezuelan village with no access to modern medicine. One site in Bangladesh, downstream of a drug manufacturer, had antibiotic concentrations more than 300 times above safe targets. 

Southeast Asia and the Western Pacific are home to some of the world’s largest antibiotic manufacturers. Yet most wastewater treatment planes there cannot filter antibiotic residues out completely. As a result, these regions have also been identified as major reservoirs of resistance genes.

Once antibiotic residues enter waterways, they mix with resistant genes and other chemicals. Then, they create selective pressure for resistant pathogens to multiply, spread, and eventually reach drinking water, food, and people. 

As usual, a pollution problem becomes a public health problem. This feedback loop is one that UNEP has identified as one of the key drivers of the global AMR crisis. And yet, the systematic and environmental dimension of AMR remains chronically underfunded and underregulated compared to the clinical side.

Who Bears the Burden

Like most environmental crises, AMR does not distribute its harm equally. The Lancet’s analysis of 204 countries found AMR death rates highest in western sub-Saharan Africa, at 27.3 deaths per 100,000 people. South Asia, including India, Pakistan, and Bangladesh, is projected to see 11.8 million AMR deaths between 2025 and 2050. 

These are precisely the regions with the highest concentrations of pharmaceutical manufacturing. They are also where wastewater infrastructure is weakest and where antibiotic pollution in rivers is highest. Low- and middle-income countries are producing the drugs the world consumes, absorbing the environmental costs of that production, and then dying at higher rates from the antimicrobial resistance it generates.

Addressing Antimicrobial Resistance

In 2024, world leaders endorsed a landmark political declaration on AMR at the UN General Assembly. They pledged that at least 60% of countries would have national action plans by 2030. They also supposedly committed $100 million in catalytic funding. While it was a step in the right direction, it cannot stand alone.

As UNEP’s Executive Director has noted, AMR challenges cannot be understood or addressed separately from the triple planetary crisis of climate change, biodiversity loss, and pollution, all of which are driven by unsustainable production patterns. It requires a One Health approach that treats human, animal, and environmental health as inseparable. 

Concretely, that means mandatory discharge standards for pharmaceutical manufacturing effluents, phasing out antibiotic use for livestock growth promotion, and investing in wastewater infrastructure in lower-income countries that are currently bearing the highest environmental and human cost of a crisis they did the least to create. 

Antibiotics took decades to develop. Addressing antimicrobial resistance early and systemically is what is necessary to prevent losing their critical functions in mere years.

Editor: Nazalea Kusuma

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