When we think of the frontline defenders in the fight against infections, our minds often turn to doctors, nurses or hospitals. Rarely do we think of sanitation workers. And yet, this often-overlooked community is one of the first lines of defense against infectious diseases and one of the most vulnerable to it.
Sanitation workers, known as safai karamcharis in India, operate in some of the harshest and most unhygienic environments imaginable. From cleaning public toilets to managing sewage and biomedical waste, they are exposed daily to contaminated water, hazardous waste, and dangerous pathogens, often without gloves, boots, or proper protective gear (see SASLN reports), all to ensure we have a clean environment to live in.
According to estimates, over 5 million individuals work as sanitation workers in India, with nearly 2 million engaged in high-risk jobs, including manual scavenging, an illegal and deeply inhumane practice that continues in parts of the country. For many of these workers, health and safety remain out of reach and now an invisible and growing threat of antimicrobial resistance (AMR) adds to their burden.
The invisible threat no one tells them about
India already bears a heavy burden of AMR, with nearly 300,000 deaths attributed to drug-resistant infections in 2019 alone. But the impact is far from uniform. While there is no disaggregated data specific to sanitation workers, it is not difficult to imagine that, given their constant exposure to waste, limited access to healthcare, and poor living conditions, they are among the occupation most disproportionately affected.
Sanitation work in India has long been tied to caste, with the most stigmatised and oppressed Dalit communities historically coerced into these roles. Their forced proximity to human waste has not only exposed them to severe health risks and infections but has also reinforced the deeply entrenched notion of “untouchability”, a social practice that continues to dehumanise and exclude them from mainstream society.
Even today, the majority of sanitation workers belong to Scheduled Caste (SC), Scheduled Tribe (ST), or other backward class (OBC), and without proper safeguards come in direct contact with biological waste, untreated effluents, and contaminated materials that may carry drug-resistant pathogens. Many sanitation workers report frequent infections, skin rashes, respiratory illnesses, stomach ailments and persistent fevers. But treatment is often denied, delayed or improvised. Access to quality healthcare is rare and informal advice from unqualified providers or quacks probably common. This pattern can increase the chances of incomplete antibiotic use, a key driver of AMR, making them more vulnerable.
Among sanitation workers, women face added layers of vulnerability with urinary tract infection (UTIs), reproductive infections, and anemia as widespread issues compounded by the lack of menstrual hygiene products, clean water and toilet facilities at their place of work.
When raising awareness is not enough
Organisations like the South Asian Sanitation and Labour Network (SASLN), with whom we have been engaging on AMR, are at the forefront of improving the lives of sanitation workers and their families through awareness drives, health camps, access to education, and community organising across 23 Indian states. To inform and enable them to take the message of AMR and infection prevention to their communities, we’ve simplified key concepts – what infections are, their types, how they spread, and how to prevent or treat them – while grounding everything in their lived experiences.
In these interactions, however, we also learnt that even when sanitation workers are made aware of good practices like hygiene or proper medicine use, their circumstances won’t allow it. More often than not, clean drinking water is not available, gloves or soap may not be provided at work. Going to a doctor may mean losing a day’s wages and public health centres may be far away or overcrowded. With paltry salaries, private healthcare is simply too expensive for them. Additionally, women sanitation workers may not feel comfortable talking about private health issues. In these conditions, infections are bound to occur more often and when treatment is delayed or incomplete, the chances of AMR complications can go up.
That’s why behaviour change efforts must go hand-in-hand with system change. We need public health strategies that don’t just teach hygiene, but enable it and AMR action plans that include occupational health, wastewater treatment and social protection for workers. Because AMR doesn’t just begin in hospitals, it builds silently in the slums, drains, and dumps where sanitation workers toil day and night.
Reframing the AMR conversation
There is an urgent need to reframe the AMR conversation in India, from just an antibiotic misuse issue to a broader public health and social justice challenge. The growing challenges of climate change and heat stress, again disproportionately affect sanitation workers, along with contributing to spread of infections, further compounding their vulnerability and of their communities. For these workers, AMR is not a distant or abstract problem, but one that intersects with their everyday struggle for health, dignity, and survival.
Policymakers must see sanitation and AMR as connected, investing urgently in worker safety, sanitation infrastructure and technologies, and access to healthcare is not just about rights and dignity, it is also a way to reduce the burden of AMR. Without safe sanitation, we will continue to deal with infections that keep coming back stronger.
Healthcare professionals must include sanitation workers in AMR-related work like surveillance and infection prevention. Many illnesses that start in these communities may go unnoticed but can have wider public health impacts. The broader science and health research community must include sanitation workers in the ongoing discussions and research on AMR.
Science and health communicators must tell stories from the ground as most people may not realise how AMR shows up in everyday settings and how their actions might be impacting vulnerable and marginalised communities.
The public must recognise that everyday actions, like throwing garbage along with antibiotics down the drain, directly impact the health of those who clean that very drain, often without protection.
Most importantly, as a society, instead of relegating them to the margins, we must recognise the invaluable contributions of sanitation workers and ensure they receive the respect, support, and protection they deserve.
Equity, the best defense against AMR
Many of us in AMR advocacy have come to the realisation that AMR is not just a medical problem but a social issue on various levels. Focusing only on prescription practices or patient behaviour overlooks the realities of people who are constantly exposed to infectious agents because of the work they do, the environments they live in, and the lack of protective systems around them. Sanitation workers don’t just encounter resistant microbes, they live in conditions that allow such deadly microbes to thrive and spread. Therefore the fight against AMR needs to begin where infections are most common and where prevention is most urgent. Because in the war against superbugs, no one should be left behind, especially not those who work to keep us safe from infections in the first place.
This piece draws on a series of conversations convened by SaS with SASLN and other partners on sanitation and AMR, as well as recent research by SASLN on the health of sanitation workers, available here. Inputs from Khushi Goel.