Antimicrobial resistance (AMR) in India remains a huge public health problem in terms of mortality and economic loss. The country has been labelled as ‘the AMR capital of the world,’ and globally it has been ranked first in total human consumption of antibiotics.

In India, antibiotics are easily purchased over the counter from community pharmacies without a prescription and without providing any significant counselling or information. Often, few or no questions are asked about symptoms, clinical history, previous allergies or any medication the patient may be taking. Some people have been known to buy antibiotics to bring back to the UK and United States so they can be shared among friends and family.

Over the years, I have visited several community pharmacies while in India and witnessed how easy it has been to obtain antibiotic supplies. For example, I was once offered a choice of azithromycin or augmentin (co-amoxiclav) for a simple dry non-productive cough, which I said was for someone else. I was also offered something similar at an airport pharmacy.

I must emphasise, however, that this dangerous practice is not restricted to India: it is widespread in many countries around the world.

In my role as a pharmacist and health advocate, I see it as important to help spread the message of the dangers of AMR wherever appropriate. In December 2019, I became the first pharmacist from overseas to be awarded a fellowship of the Indian Pharmaceutical Association (IPA). I took this opportunity to make good use of the IPA network and use pharmacy as a vehicle to spread the important public health message of AMR throughout India.

In particular, I am determined to promote Public Health England’s (PHE’s) Antibiotic Guardian initiative in India: to create antibiotic guardians (AGs), and to raise wider awareness of AMR and the inappropriate and unnecessary use of antibiotics.

I am now on a mission to encourage people in India to join me in the recruitment of Indian AGs. The IPA, and members of the British and Global Associations of Physicians of Indian Origin, support my intentions. In addition, I have linked with senior members of the Indian Hospital Pharmacists’ Association and the Association of Pharmaceutical Teachers of India, as well as pharmacy colleges and universities, and some government and regulatory officials. My campaign is further strengthened by the support from Rao Vadlamudi, the president of the Commonwealth Pharmacists’ Association, who is also Indian.

Younger pharmacists and students have a noticeable hunger to bring about change; however, they need support, education and resources to achieve this

During a three-day trip to India in February 2020, I visited pharmacy colleges in Hyderabad, Rajahmundry and Visakhapatnam. I met with various university principals and pharmacy staff, and gave talks to students. On 28 February 2020, I spoke at the 11th National IPA Students Annual Congress in Visakhapatnam.

I found that students and staff were extremely keen to become AGs and help champion the cause.

Some students have even begun their own initiatives, working with their local communities to promote antibiotic guardianship. One IPA student member, whom I met at a conference in Chennai in 2019, helped recruit 156 AGs within a matter of days. There are many others following suit, although there is still clearly a lot of work to be done.

Some of the colleges I visited are now claiming that more than 100 students and staff have pledged to become AGs. Although these figures are anecdotal, early figures provided by PHE, through Google Analytics, indicate a huge spike in those making pledges — potentially doubling of the number of AGs registered in India over the past five years.

Younger pharmacists and students have a noticeable hunger to bring about change; however, they need support, education and resources to achieve this. Local government involvement would help significantly, alongside the already strong support from the IPA.

The Royal Pharmaceutical Society (RPS) brand is highly regarded internationally and has certainly helped strengthen my cause in India. There was huge interest from my students, pharmacists, academics and pharmaceutical scientists in becoming international members of the RPS. The colleges were particularly keen to tap into the variety of RPS tools and resources I was promoting, as an aid to support their wider teaching and learning.

It is crucial to continue building and strengthening these relationships at all levels. This needs regular communication and dialogue with the right people at the right levels. I strongly believe there is a huge potential for international RPS engagement on antimicrobial stewardship: it is just waiting to be realised.

Moving forward, I will keep regular contact with the various Indian professional bodies; government and regulatory officials; and pharmacy institutions in different parts of the country. Purposeful, targeted education with buy-in from all sectors is going to be vital as we tackle AMR. With the current pandemic levels of COVID-19, this initiative could not be more pertinent — there is a danger that inappropriate and unnecessary use of antibiotics could escalate even further.

India continues to be a huge learning experience for me, even with my Indian heritage, and I will not give up the hope that India may one day be the global leader in reducing AMR — with the right belief, the right attitude and the right support.