Wars are breeding superbugs that will spread ‘everywhere’

Drug-resistant infections thrive in the chaos of war, spilling over to neighboring regions.

By RORY O’NEILL

^{Illustration by Victoria Tentler-krylov for POLITICO}

When treating patients, doctors want choices. In Gaza, they have none: Amid a severe shortage of medicines, drug-resistant infections are forcing doctors to amputate the limbs of wounded children to save their lives, a leading global health expert has warned.

After 11 months of Israeli bombardment, Gaza has become a breeding ground for superbugs that are immune to standard antibiotics. The spillover from Gaza and other war zones such as Ukraine to neighboring regions will only add to a growing antimicrobial resistance (AMR) crisis, which experts fear will be among the biggest public health emergencies in the years ahead.

“I see everything leading to a disastrous upsurge of resistance in Gaza, and it will definitely spill over to the hospitals in the region,” AMR specialist Hanan Balkhy, the World Health Organization’s regional director for the Eastern Mediterranean, told POLITICO.

“In no time, if not already, it will be in Europe, the U.S., in the east, the south. It’s going to be everywhere,” said Balkhy, who recently returned from a visit to Gaza to observe the health crisis.

The discovery of penicillin in 1928 changed medicine, launching a wave of new antibiotics that greatly improved resilience to everyday infections. But the overuse and misuse of these drugs, plus a collapse in antibiotic discovery, has allowed bacteria to catch up and become resistant.

In 2019, drug-resistant infections contributed to 5 million deaths worldwide and were directly responsible for 1.3 million. In the worst-case scenario, humanity could be headed for a return to the pre-penicillin age.

Global leaders will meet at the United Nations in New York this month in search of agreement on how to deal with the problem. So far, early progress has been watered down, while the wars in Gaza and Ukraine continue to make the problem worse.

A perfect storm

War is known to increase the risk of bacteria developing drug resistance, but scientists are still learning exactly how it happens and to what extent.

For starters there are wounds: “Imagine pulling out a tiny body from under a destroyed building with all this cement, and you’re yanking this child … bones that are sticking out of the skin, that have been crushed into tiny pieces,” Balkhy said.

Then there is sewage: streets overrun with human and animal waste; the “fermented smell in the air,” Balkhy described. She has never seen anywhere more conducive to the spread of drug-resistant bacteria than Gaza, she said.

Emerging research on the impact of concentrated heavy metals on drug resistance has also shown that heavy metals are toxic to bacteria — but as with antibiotics, germs can adapt. Some research suggests that in becoming resistant to heavy metals, bacteria can protect themselves from antibiotics as well.

Antoine Abou Fayed, a microbiologist at the American University of Beirut, told POLITICO he was concerned that heavy metals from bombs and destroyed buildings, including lead and zinc, could lead to drug resistance in Gaza.

Faced with a torrent of infections, doctors have almost nothing with which to treat them —no reliable access to tests, labs or basic medicines — making drug resistance a more likely outcome, Sameer Sah, director of programs for Medical Aid for Palestinians, told POLITICO.

“The shortage of medicines is a contributing factor to AMR as it can result in incorrect medicine use and make it difficult to complete a course of antibiotics,” Sah said by email. “This is compounded by the fact that people are being displaced and facing daily Israeli military bombardments across Gaza, making follow-up with patients difficult or even impossible.”

Gaza might be the most dangerous breeding ground for drug-resistant bacteria in the world, but it’s not the only one, Balkhy said — conditions in Sudan aren’t much better, whereas in Ukraine, AMR was already a major problem before Russia invaded in 2022.

Worst public health outcome

Drug resistance could be one of the worst public health outcomes of the Ukraine war, Dmytro Skirhiko, a Kyiv GP who promotes greater awareness of the dangers of antibiotic misuse, told POLITICO.

Not only are there more infections — among wounded soldiers and civilians, and in crowded, poorly-ventilated bomb shelters — but it’s also harder to regulate the sale of antibiotics, he said.

Some pharmacies only do perfunctory checks on whether patients were prescribed antibiotics by a doctor — nothing new in Ukraine, but “a really big problem” nevertheless, Skirhiko said.

Unlike Gaza, Ukraine’s health infrastructure hasn’t been largely destroyed, and before the war the Ukrainian government was able to improve the country’s testing capabilities, Jarno Habicht, the WHO representative in Ukraine, told POLITICO. The country now has 100 labs carrying out surveillance on drug-resistant bacteria, compared to just three in 2017, Habicht said.

Even so, Ukraine’s hospitals are under pressure and health workers are forced to make rapid decisions. If wounded patients don’t get better after starting a round of antibiotics, he explained, doctors may switch them to another drug. Ordinarily this process would be tightly controlled, but in wartime best practice is not always attainable.

The doctor’s primary task is to save the patient’s life, Habicht said — and they might not have five or six days to wait for lab results before deciding on treatment.

In Gaza, meanwhile, no laboratories remain: Whatever AMR testing occurs happens in facilities elsewhere. According to Abou Fayed, it’s impossible to calculate the spread of drug-resistant bacteria in Gaza due to the level of destruction.

“At the moment, we don’t have concrete evidence because everything is destroyed in Gaza … nobody is testing,” he said, adding that everything that is known about AMR and war zones suggests it’s only a matter of time before the world pays a “hefty price.”

“People don’t understand that this is not something that will affect only Gaza. It will affect the globe, Israel being the first affected party due to the spillover.”

Even through the fog of war, AMR experts such as Balkhy are convinced that a global health crisis is coming. “There’s no doubt, not one iota, not even 0.001 percent doubt, that AMR is there,” he said.

“Gaza will probably be the birthplace of many resistant bacteria that will spread around the world.”

This article is part of the A global emergency: Tackling antimicrobial resistance special report, presented by Wellcome. The article is produced with full editorial independence by POLITICO reporters and editors. Learn more about editorial content presented by outside advertisers.