‘Every blast is an open wound’: how the chaos of war breeds deadly superbugs that spread around the world

The war in Gaza will leave its mark in many ways, long after the recently negotiated ceasefire deal between Israel and Hamas.

One legacy relates to how the chaos of war provides the perfect storm for the rise in antimicrobial resistance.

This is when microbes evolve to withstand the medicines designed to kill them. These microbes turn into superbugs, rendering previously effective treatments ineffective, and previously survivable infections, deadly.

We’ve already seen examples of antimicrobial resistance in Gaza and other conflict zones around the world.

Antimicrobial resistance is a growing problem globally. It not only threatens human health, but also agriculture, food security and economies.

Managing antimicrobial resistance is complex. It requires approaches including preventing infections in the first place, strategic limits on how antimicrobial agents are used, and robust health-care systems.

In conflict zones, the reverse is starkly evident.

Health-care systems are disrupted

Armed conflicts devastate health-care infrastructure. Such conflicts often occur in places with limited resources to start with.

Hospitals and diagnostic laboratories are damaged or destroyed, and supplies are depleted. Health-care workers are killed or displaced.

Conflict zones are left with less-than-ideal diagnostic capabilities, treatment and care.

This makes preventing and controlling infections incredibly difficult.

Vaccination is disrupted too

Disrupted vaccination programs can affect the development of antimicrobial resistance in a number of direct and indirect ways.

For instance, in conflict zones, less vaccination against bacterial disease leads to more infections, increasing the need for antibiotics, and the risk that antimicrobial resistance develops.

Less vaccination against viral diseases can leave people in conflict zones vulnerable to those viral infections and in turn, secondary bacterial infections. This leads to antibiotic use as a preventive measure, or as treatment, promoting the development of antimicrobial resistance.

Antibiotics are overused and misused

Widespread injuries, infections, and poor hygiene in conflict zones are common. This leads to an over-reliance on antibiotics, especially those acting against the broadest range of bacteria.

Ideally, broad-acting antibiotics would be used sparingly and after diagnostic tests. However, treatment is needed and diagnostic capabilities are compromised. So broad-acting antibiotics are used much more often, further promoting the development of resistance.

Fewer controls over who has access to antibiotics in war-torn regions is also a problem. Without prescriptions, professional oversight or diagnostic tests, antibiotics are used in ways that drive further resistance. This includes using them “just in case”, using ones not effective for that infection or injury, or using them for too long, or not long enough.

For all these reasons, overuse and misuse of antibiotics, while often unavoidable, make it more likely for resistant microbes to arise and spread.

Wounds, infections, antibiotics

Armed conflict leads to large numbers of traumatic injuries. As Chief Surgeon Sergiy Kosulnykov at Mechnikov Hospital in Dnipro, Ukraine said last year:

Every blast is an open wound, and every open wound is an infection.

Treating these injuries requires antibiotics. However, in conflict zones, the infecting microbes are often ones resistant to multiple drugs. This is especially when those microbes are acquired on the battlefield, in field hospitals or in other high-risk environments. Once antimicrobial resistance has started, these circumstances makes it easier for microbes to become resistant to additional antibiotics.

Unsanitary living conditions

Refugee camps and shelters for displaced populations are often overcrowded and lack access to clean water and proper sanitation.

So infections and resistant microbes are more likely to occur and spread, worsening outbreaks and fostering the evolution and spread of resistant microbes.

The wider breakdown in water and sanitation infrastructure also fosters the spread of waterborne microbes, increasing the prevalence and spread of resistant microbes.

Lack of surveillance and monitoring

Effective management of antimicrobial resistance depends on accurate diagnostic tests, and robust surveillance systems to track resistance patterns and inform treatment recommendations.

Conflict disrupts these systems, leaving authorities blind to emerging resistance trends. This disruption also delays the implementation of effective countermeasures.

Global spread of resistant pathogens

Conflict generates a large pool of antimicrobial-resistant microbes that may infect or colonise many people, in and beyond the conflict zone. Movement of people in and out of the conflict zone contributes to this spread across borders.

Refugees and displaced people often carry resistant microbes to regions with no or less prior exposure, contributing to the global spread of antimicrobial resistance.

Acinetobacter baumanii bacteria that are highly resistant to multiple antibiotics are one example. These have proven problematic to treat in United States military personnel that returned with combat injuries from Afghanistan and Iraq. The same bacteria have been noted in the United Kingdom as a potential source of life-threatening infections that spread readily in hospitals.

In Afghanistan, Gaza, Syria, Ukraine, Yemen and elsewhere, bacteria resistant to multiple antibiotics have emerged and thrived during conflicts, and continue to do so.

What should we do about it?

Antimicrobial resistance in regions affected by conflict requires urgent action, as well as peace. This includes rebuilding and maintaining health-care systems, improving sanitation, regulating antibiotic use, and ensuring access to clean water and vaccines.

International cooperation and sustained investment are essential to mitigating the devastating impact on those already affected by conflict.

Without this, antimicrobial resistance becomes yet another catastrophic legacy of war, threatening human health and security for generations to come.