Antimicrobial resistance (AMR) – the ability of bacteria to survive antibiotic treatments – is often seen as a slow-burning crisis. Yet, armed conflict could significantly accelerate its spread. My expertise lies in monitoring AMR in environmental settings, where we see firsthand how pollutants, including antibiotics, select for resistant bacteria (Singer et al., 2016). While I have not directly studied war zones, the evidence clearly shows that conflicts amplify environmental conditions ideal for creating and spreading resistant pathogens (Abbara et al., 2018). This makes war-torn areas potential hotspots for AMR, posing risks far beyond their borders.
Battlefield Environments and the Rise of Superbugs
Wars create a dangerous mix of conditions ideal for bacteria to develop antibiotic resistance. Explosives contaminate soil and water with heavy metals, chemicals, and antibiotic residues. These contaminants put immense evolutionary pressure on bacteria, allowing only the most resistant to thrive (Bazzi et al., 2020). Research demonstrates that metals such as lead and mercury, frequently found in munitions, drive the co-selection of antibiotic resistance in environmental bacteria (Pal et al., 2017).
War injuries, typically severe and contaminated, require immediate antibiotic use, often without precise diagnostics. Studies from recent conflicts, including Ukraine, indicate that broad-spectrum antibiotics administered in frontline hospitals significantly increase the prevalence of resistant bacteria (Ljungquist et al., 2023). For instance, recent research identified an increase in multidrug-resistant bacteria isolated from Ukrainian soldiers' wounds during 2022-2023 compared to the period before the war from 2014-2022 (Kovalchuck et al., 2024).
Destruction of Infrastructure: A Public Health Catastrophe
Conflicts devastate healthcare and sanitation systems, crucial in controlling infections. Destroyed hospitals, limited medical supplies, and compromised sanitation foster uncontrolled outbreaks of resistant infections. Data from Gaza highlights how conflict-related destruction of infrastructure leads to widespread water contamination with resistant bacteria (Moussally et al., 2023). Similar patterns appeared in Iraq, where decades of conflict resulted in severely compromised sanitation, fueling AMR outbreaks (Abbara et al., 2018).
These conditions not only threaten immediate survival but also allow resistant bacteria to circulate widely within communities, refugee camps, and eventually across borders as populations are displaced or evacuated.
Global Spread of AMR from Conflict Zones
AMR does not respect political or geographic boundaries. Refugees, wounded soldiers, and humanitarian workers frequently carry resistant bacteria to neighboring regions and distant countries. After recent conflicts in the Middle East and Ukraine, hospitals in Europe observed resistant bacteria previously uncommon in their regions, directly linked to transferred patients (Ljungquist et al., 2023).
Such global mobility means antibiotic resistance emerging in one region can rapidly become a worldwide public health crisis, making it imperative for the international community to pay close attention to AMR in conflict settings (Yaacoub et al., 2022).
Recommendations: Military and Defence Considerations
To mitigate the threat of AMR exacerbated by conflicts, military and defence authorities can take proactive steps:
- Enhanced surveillance and monitoring: Regular wastewater and environmental surveillance to monitor antibiotic resistance in conflict zones to quickly identify and address emerging threats.
- Strict antibiotic stewardship protocols: Implementing guidelines to ensure antibiotics are used judiciously, employing rapid diagnostic tools to improve accuracy in treatment.
- Infrastructure protection and rapid response: Prioritizing protection and rapid restoration of essential sanitation and healthcare infrastructure to maintain infection control.
- Training and preparedness: Training military medical personnel in advanced infection prevention and control practices, emphasizing the importance of AMR management.
- Collaboration and intelligence sharing: Establishing international partnerships for real-time sharing of AMR-related data and best practices to limit the global spread.
Conclusion
It is clear that conflicts significantly worsen conditions conducive to antibiotic resistance. Recognizing war’s role in exacerbating AMR is essential for safeguarding global public health and security. Addressing this threat requires urgent international collaboration to reduce antibiotic misuse and overuse, protect essential infrastructure, and enhance global surveillance capabilities.
References
- Abbara, A., et al. (2018). Antimicrobial resistance in the context of the Syrian conflict: Drivers before and after the onset of conflict and key recommendations. International Journal of Infectious Diseases, 73, 1-6.
- Bazzi, W., et al. (2020). Heavy metal toxicity in armed conflicts potentiates AMR in Acinetobacter baumannii by selecting for antibiotic and heavy metal co-resistance mechanisms. Frontiers in Microbiology, 11, 68.
- Kovalchuck V., et al. (2024). Temporal evolution of bacterial species and their antimicrobial resistance characteristics in wound infections of war-related injuries in Ukraine from 2014 to 2023. Journal of Hospital Infection, 152, 99-104.
- Ljungquist, O., et al. (2023). Highly multidrug-resistant Gram-negative bacterial infections in war victims in Ukraine, 2022. The Lancet Infectious Diseases, 23(7), 784-786.
- Moussally, K., et al. (2023). Antimicrobial resistance in the ongoing Gaza war: a silent threat. The Lancet, 402(10416), 1972-1973.
- Pal, C., et al. (2015). Co-occurrence of resistance genes to antibiotics, biocides and metals reveals novel insights into their co-selection potential. BMC Genomics, 16, 694.
- Singer, A. C., et al. (2016). Review of antimicrobial resistance in the environment and its relevance to environmental regulators. Frontiers in Microbiology, 7, 1728.
- Yaacoub S., et al. (2022). Antibiotic resistance among bacteria isolated from war-wounded patients at the Weapon Traumatology Training Center of the International Committee of the Red Cross from 2016 to 2019: a secondary analysis of WHONET surveillance data. BMC Infectious Diseases 22(1):257.
