The Disproportionate Impact of Antimicrobial Resistance in Conflict: A Call for Action

The development of medicines capable of successfully preventing and treating infections caused by pathogens such as bacteria, viruses, fungi, and parasites, have achieved immense health gains and decreased mortality from most common infectious diseases during the past century. These gains are challenged today by what the WHO warns would become a ‘post-antibacterial era’. [3]  When antimicrobial agents are no longer effective in the treatment of common infections, antimicrobial resistant (AMR) pathogens or “superbugs” emerge and develop into life-threatening conditions.[4]

Antimicrobial resistance, specifically antibiotic resistance, is not a new phenomenon; it is linked to the extraordinary evolutionary and adaptation capacities of bacteria that present themselves with every use of antibiotics, no matter how prudent, and this has been historically documented.[5] Over the past few decades however, AMR pathogens that cause tuberculosis, malaria, sexually transmitted diseases, bloodstream, and foodborne infections among others, have been increasing.[6] The reasons for this are well documented in the literature and include an unregulated and irrational use of antibiotics in animals and humans, poor adherence to therapy and inadequate dosing, compounded with low investments in the production of new antibiotics.[7] Consequently, these pathogens have evolved to become resistant to widely used antimicrobials, some even to last resort medicines.

Globally, the number of these resistant pathogens continues to rise at a worrying rate, placing AMR at the top of the Global Health and Global Health Security agendas.[8] Tackling AMR requires a multidisciplinary approach[9] and is central to the success of complex medical surgeries and interventions, to the effective prevention and treatment of many infectious diseases, and to achieving the Sustainable Development Goals (SDGs)  by 2030.[10]

In 2015, the global health community set out to establish a framework to respond to the AMR threat. The WHO’s Global Action Plan on Antimicrobial Resistance highlights a set of strategies and concerted efforts across multiple sectors, actors, and countries to be able to tackle AMR.[11] The framework for action includes improving awareness on antimicrobial resistance; strengthening knowledge on AMR through surveillance and research; reducing the incidence of infection; optimizing the use of antimicrobial agents; and ensuring sustainable investment in countering antimicrobial resistance.[12]

To achieve the intended goal, national action plans should be established by member states.[13] This however poses a conundrum particularly in developing countries affected by conflict such as in the Middle East and North Africa (MENA), rendering the region especially vulnerable to AMR’s devastating consequences. In 2014, the largest AMR surveillance data gaps were reported for countries in Eastern Europe, the Middle East, and Africa.[14] A recent paper on Syria reveals the myriad of AMR drivers that already existed in the country before the conflict, and how these factors have been amplified with the onset of war in 2011.[15] Among these pre-conflict factors were the rampant misuse of antibiotics as a result of a lack of regulation in prescription and antibiotic availability over the counter, poor infection prevention and control, and lack of capacity in terms of microbiologists and infectious diseases experts.[16]  Compounded with the impact of conflict that has resulted in the destruction of infrastructure, the lack of basic elements of water, sanitation, and hygiene, the exodus of the health workforce, and the emergence of parallel health systems, curbing the AMR threat through implementing national plans in this context becomes far from being realistic.

The impact of AMR extends beyond the direct medical and health ramifications to include various socioeconomic consequences that disproportionally affects everyone on the globe. The increasing futility of antimicrobial medications translates into significantly longer hospital stays. Longer treatment periods result in higher hospitalization costs per patient, further compounding the issue: incidents of drug-resistant infections increase the total number of infections, largely due to a longer window of interaction that poses others at the risk of encountering infection.[17] This combination of more patients and higher costs per patient can exert tremendous pressure on the health care system.  Developing economies and economies struck by armed conflict are worst equipped to absorb it; for the most part, their hospitals do not have the capacity or funding to cope. In parts of the MENA affected by conflict, where hospitals are already struggling to handle the patient-load, this could prove especially problematic. Increased AMR causes the risk of infection during surgical operations to skyrocket, potentially limiting the treatment options of those most in need. Additionally, the financial shortcomings of most MENA populations imply that people cannot afford to mitigate the ineffectiveness of an antibiotic by opting for a pricier alternative.

In its 2017 report on the threat of AMR on economy, the World Bank compares the overuse of antibiotics to a tragedy of the commons, whereby the collective overuse of antibiotics as a resource for short term personal benefit leads to it running out, despite the fact that no one wants it to run out.[18] In an optimistic simulation that considers low AMR impact on the global economy, the World Bank estimates the global threat of AMR to be equivalent to a global gross domestic product (GDP) loss of 1.1 % by 2050, exceeding USD 1 trillion every year after 2030.[19] In other words, AMR could become a potent driver into poverty, mainly in low-income and lower middle-income states.

Countries in the MENA that are impacted by protracted conflicts are already lagging well behind their Western counterparts in the development of sustainable and efficient health systems that ensure equitable access to healthcare. Failure to address the issue of AMR in a timely manner could see the gap grow irreparably wide, and result in irreversible health and socioeconomic consequences particularly among populations struggling to subsist in the context of conflict. Taking immediate action to curb the AMR threat and achieving the SDGs for Universal Health coverage is the responsibility of everyone before this becomes a far-fetched goal.

The Global Health Institute at the American University of Beirut addresses an array of health concerns in conflict settings through its Conflict Medicine Program. More information on this program is available, here: Conflict Medicine Program

Filters: Conflict, AMR

Contributors

[1] Programs Division Manager and Conflict Medicine Program Coordinator, Global Health Institute, American University of Beirut, Lebanon

[2] Intern, Global Health Institute, American University of Beirut and Student, Williams College, USA

References

[3] World Health Organization (2018), Antibiotic Resistance, Retrieved at: https://www.who.int/news-room/fact-sheets/detail/antibiotic-resistance

[4] Ibid

[5] Davies J. & Davies D. (2010), Origins and Evolution of Antibiotic Resistance, Microbiology and Molecular Biology Reviews,74(3), pp. 417-33

[6] Ibid

[7] Ventola C. L. (2015), The Antibiotic Resistance Crisis: Part 1: Causes and Threats, P & T: A peer-reviewed journal for formulary management, 40(4), 277-83

[8] GHSA (2019), Global Health Security Agenda: Action Packages 2019, Retrieved at: https://www.ghsagenda.org/packages

[9] World Health Organization (2018), Tackling AMR Together: Working Paper 1: Multi-sectoral Coordination, Retrieved at: https://www.who.int/antimicrobial-resistance/publications/Tackling-AMR-multisectoral-coordination-june2018.pdf?ua=1

[10] Ibid

[11] Ibid

[12] Ibid

[13] World Health Organization (2015), Global Action Plan on Antimicrobial Resistance, Retrieved at: https://www.who.int/antimicrobial-resistance/global-action-plan/en/

[14] World Health Organization (2014), Antimicrobial Resistance Global Report on Surveillance, Retrieved at: https://www.who.int/antimicrobial-resistance/publications/surveillancereport/en/

[15] Abbara A., Rawson T. M., Karah N., 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 Infectuous Diseases, 73, pp. 1-6, Retrieved at: https://pubmed.ncbi.nlm.nih.gov/29793039/

[16] Ibid

[17] Ibid

[18] World Bank (2017), Drug-Resistant Infections: A Threat to Our Economic Future, Retrieved at: https://www.worldbank.org/en/topic/health/publication/drug-resistant-infections-a-threat-to-our-economic-future

[19] Ibid