Antibiotic resistance is a major obstacle for achieving the Sustainable Development Goals. In ReAct's report "When the Drugs Don’t Work - Antibiotic Resistance as a Global Development Problem’", we have identified the vulnerability of populations in conflict and refugees to antibiotic resistance. People affected by conflict should not be overlooked, but be seen as an especially vulnerable group in the global response to antibiotic resistance.
Antibiotic resistance requires a broad response, based on access to healthcare and effective antibiotics, rational use and stewardship, but also infection prevention and control. Conflict undermines all of these and drives up resistant infections through the disruption of health systems. The instability of staff availability and supply lines for medication and vaccination make treatment and prevention even more complex in the short and long term. Also, displacement of people is a large driver of resistant infections because of the living circumstances in refugee settlements. As a result, over recent years resistance has turned up as a major problem of treatment of infectious diseases.
In virtually all recent conflicts, resistance has been reported as a problem, especially in Iraq, Syria, Yemen, Afghanistan and Palestinian territories. With the increasing length of conflicts and violence, increased concentration in cities is causing a system-wide breakdown of infrastructure and public services, reversing previous development and health gains. Populations in conflict should therefore be seen as an extra vulnerable group that requires extra attention in the international response to antibiotic resistance and work on sustainable development.
This article builds forward on ReAct’s new report: When the Drugs Don’t Work – Antibiotic Resistance as a Global Development Problem.
The effect of weapons and war wounds on antibiotic resistance
Armed conflict breaks down healthcare systems, but also specifically causes health problems that are difficult to treat without effective antibiotics. Because of the nature of the weapons used, war wounds are large open wounds – often involving fractions and amputations, or requiring very invasive surgery on the brain or spinal cord – that are prone to infections.
Another issue is that war wounds are virtually always contaminated with bacteria, like for example “Iraqibacter” (Acinetobacter) that is notorious for multidrug-resistance. Because of this, studies find that civilians that are acutely injured in conflict have an unexpectedly high level of drug-resistant infections.
Another effect of weapons are lung injuries that are common after the inhalation of dust from bombings, with subsequent requirement for intubation and the risk of ventilator-associated pneumonia.
The International Committee of the Red Cross’ (ICRC) War Surgery Handbook mentions that and old lesson for new surgeons is that ‘the best antibiotic is good surgery’, indicating that good healthcare personnel is essential for the reduction of antibiotic resistance in war wounds. With the system breakdown, antibiotic resistant infections in armed conflict become very difficult to treat.
Access to healthcare and self-medication in armed conflict
The treatment of antibiotic resistant infections is severely hampered by armed conflict. An essential element is access to healthcare and effective antibiotics. It has been suggested that the high levels of resistance in Syrian civilians may be explained by the wide availability of over-the-counter antibiotics in Syria prior to the armed conflict. Self-medication however also directly relates to the lack of access to healthcare and access to the right antibiotics in conflict.
In the case study of Medécins Sans Frontières (MSF) in Iraq it can be seen that patients often take whatever antibiotic is available to them as a last resort, but also doctors are in many cases not able to make the right diagnosis without a functioning laboratory. In Syria, during the conflict, laboratory supplies were hardly available because of companies fearing economic sanctions, in non-governmental areas procuring laboratory equipment was difficult. In both governmental and non-governmental areas staff had fled the country and the number of engineers that could maintain diagnostic machines could be counted on one hand. Self-medication and misuse of antibiotics that leads to resistance seems to be mainly a cause of lack of personnel and access to healthcare.
“Almost 40% of patients admitted to MSF’s post-operative care facility in East Mosul arrive with multidrug-resistant infections, and antibiotic resistance is a problem throughout the country. While the incidence of antibiotic resistance is particularly high in Iraq and across the Middle East, it also occurs in many of the countries around the world where MSF works.”
Medecins sans frontieres (doctors with out borders), voices from the field, January, 2019.
Effects on the long term and on post-conflict societies
In a longer conflict, antibiotic resistance can cause outbreak-prone infections that are difficult to manage, especially when combined with low vaccination coverage rates and damage made to healthcare and water and sanitation infrastructures.
An extreme example of an outbreak in a conflict-affected country has been the outbreak of extensively drug-resistant typhoid fever in Pakistan. Typhoid fever is preventable with vaccines, but Pakistan is a country with a relatively low vaccination rate. A recent study in the conflict-affected Northwest region of Pakistan on polio vaccination rates and incidence showed that insecurity is a barrier to vaccination. Vaccination campaigns dealing with more conflict-related security problems were associated with a lower rate of vaccination. This led to a higher rate of children that could not be reached. The conflict therefore likely contributed to that extensively drug-resistant typhoid fever could spread to more than 2000 people in Pakistan within 6 months according to the National Institute of Health in Islamabad. Only one oral antibiotic, azithromycin, still worked. Other options, such as intravenous drugs, are expensive and not practical in low-income countries.
Reducing antibiotic resistance in armed conflict
Antibiotic resistance is a major problem in armed conflict, but there is no real solution yet. It is important that countries, before conflict strikes, have a working system to prevent infection and limit misuse of antibiotics in case a healthcare system breaks down. Antibiotic resistance can be prevented, and wounds could be treatable, if basic health care needed for treatment of infections are kept up.
In humanitarian responses there should therefore be a role for improving laboratory supply chains, antibiotic sensitivity testing, and surveillance of antibiotic resistance. Besides that, infection control measures and water and sanitation interventions are essential in healthcare facilities. People living in conflict should not be excluded from the international response on antibiotic resistance and solutions should be considered to make sure populations in conflict can be treated for infections effectively. On the other hand, the risk of antibiotic resistance in the complex situation of armed conflict should be seen as an extra reason for keeping up basic healthcare functions that prevent infection and limit misuse of antibiotics.
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