Healthcare-Generated Co-pollutants as Environmental Determinants of Antimicrobial Resistance: Governance Challenges at the Healthcare–Environmental Interface

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Antimicrobial resistance (AMR) is commonly framed as resulting from antimicrobial misuse in clinical practice. While antimicrobial stewardship remains key, this individual behavioural focus limits engagement with how healthcare systems create material conditions under which resistance can emerge, persist, and spread, impacting AMR governance. Every day, clinical practices generate healthcare waste, including per- and polyfluoroalkyl substances (PFAS), microplastics, and antimicrobials that flow into wastewater systems and local water environments. Acting as co-pollutants, they may contribute to selective microbial environments that favour microbial adaptation and may increase horizontal gene transfer and the dissemination of antimicrobial resistance genes. While environmental determinants of AMR have gained increasing consideration in research, policy and practice, healthcare waste remains marginal within AMR governance. Responsibilities for healthcare waste management, wastewater treatment, and environmental monitoring are institutionally fragmented with different government institutions responsible for health, wastewater management and environmental regulation operating in separate governance domains, resulting in accountability gaps at the healthcare-environmental interface, especially in low- and middle-income countries (LMICs). Drawing on a One Health approach, this conceptual paper reframes AMR at the healthcare–environmental interface as emerging within a socio-ecological system through the interaction of four interlinked domains: (i) clinical practices, (ii) healthcare waste infrastructures, (iii) environmental microbial ecologies and (iv) governance arrangements. Integrating healthcare waste governance, wastewater-based resistance surveillance and antimicrobial stewardship into national and global AMR policies may strengthen efforts in addressing resistance dynamics as well as preventing water environments from functioning as long-term reservoirs of resistance that might undermine clinical and community-level AMR efforts.