Olivia is a member of the War Studies Department at King’s College, London. She wrote this piece as part of her internship with Arts4Refugees. Her motivation was to help her peer group understand the unique experiences of post-conflict communities. This article was edited by Cassia Jefferson, a fellow student journalist from Oxford University.
Backstory podcast
Combating Health Insecurity in Post-Conflict Iraq: The Fight Against Antimicrobial Resistance
Conflict has many negative impacts on the health of communities, even after the fighting stops. It's a difficult task to repair health systems damaged by war, and Iraq is a nation embarking upon this long road to recovery.
AMR- What is it?
One health impact caused by conflict is antimicrobial resistance (AMR). AMR is what happens when pathogens that cause disease stop responding to medicine. It can be the result of antibiotic misuse or overuse, but this doesn't tell the whole story. Many things can cause AMR to spread, and AMR and conflict go hand-in-hand.
The WHO listed AMR as one of the Ten threats to global health in 2019. Alongside this, ‘Fragile and vulnerable settings’ were named as another threat, which also are the kind of places where AMR thrives. A ‘global influenza pandemic’ was also listed. Now that we've experienced COVID-19, the severity of these threats is more palpable than ever.
Although a lot of the language surrounding AMR is scientific, it's important to see it as a humanitarian issue. AMR has affected the short- and long-term health of Iraq's internal and refugee population. Healthcare services during conflict often lack an ideal water, sanitation and hygiene (WASH) environment. Improper treatment of wounds also makes it harder to stave off drug-resistant infections. The connection between trauma wounds and AMR during the Iraq War led to one pathogen becoming known as ‘Iraqibacter’.
After the invasion of Kuwait in 1990, the UN Security Council imposed sanctions on Iraq. One highlighted health consequence of this was the shortage of disinfectants such as chlorine. Chlorine is essential to upholding WASH; it helps make water safe to drink. These sanctions harmed civilians, leading to years of unsafe conditions.
AMR will always pose the greatest threat to those in the most vulnerable situations. People at risk of infection in conflict-affected places don't have the support of a robust health system behind them, meaning their treatment may be disrupted. This includes those with diseases which weaken your immune system, such as cancer. There will also be less availability and choice of treatment or medicine. In Iraq, these situations were caused both by the conflict and sanctions.
Our lack of attention to the issue of AMR in Iraq is evident in its continued impact on current conflict zones. Syria and Yemen are under sanctions, leaving both combatants and non-combatants more vulnerable to AMR. In Ukraine, injuries on the battlefield are being found to be antibiotic resistant.
AMR also impacts refugee populations. Many people are still unable to return to Iraq, whilst 1.2 million Iraqis are internally displaced. Iraq also hosts other refugees. There are almost 260,000 Syrian refugees in Iraq, 86% of them living in camps. AMR flourishes in places without safe WASH, or access to proper medical treatment, or both. In other countries, Iraqi refugees may also be unable to receive full medical care. This is the case for many refugees living in Jordan - a country without universal healthcare.
AMR as a Political Issue
Anti-refugee narratives can emerge from the perception of refugees as health risks, yet refugees are among those most vulnerable to AMR due to conditions outside of their control. They are in no way the cause of the problem, and denying people equal access to healthcare does nothing to aid their post-conflict recovery.
This is not the only way that AMR is a political issue. The continued spread of AMR in post-conflict environments is a reflection of how civilian health is overlooked during conflict. As the situation in Iraq has shown, bodies like the UN have often ignored the health consequences of sanctions.
The Iraqi government did publish a National Action Plan for Antimicrobial Resistance, but this didn't happen until 2018. The impact of AMR on Iraq has been evident, but under-discussed, for a long time. This lack of attention is also reflected in the worldwide response to AMR. In recent years, many countries have started publishing National Action Plans (NAPs) for AMR, in accordance with the WHO’s Global Action Plan. Whilst NAPs are helpful measures, AMR does not recognise borders. It remains a shared problem that requires a coordinated international response.
What next?
A 2014 review predicts that by 2050, we could see up to 10 million deaths a year from drug-resistant diseases. However, it's hard to predict the nature and level of the threat of AMR over time when we don't have thorough worldwide data. We need a greater level of cooperation to gain a greater understanding of how AMR continues to affect post-conflict communities.
What is being done today?
In spite of this, it’s not all bad news. There are people working at an international, national, and community level to combat AMR. One organisation working at all three levels is Médecins Sans Frontières. MSF have been setting up labs to improve treatment for conflicted-affected people in the Middle East. A person may have been given various antibiotics, often over the counter, to treat an infection. MSF's labs discover the specific bacteria causing the infection. Identifying the bacteria means that doctors can implement correct and effective treatment. This both helps the patient and prevents further antibiotic misuse. Work like this brings services, such as microbiology labs, to the post-conflict communities that need them most.
Conclusion
The impact of AMR raises questions about what being ‘post-conflict’ looks like for countries such as Iraq (Iraq has also contended with ISIS conflict, which has only compounded the issue). In some ways, the spread of AMR is like other less visible conflict wounds, such as the impact of trauma and mental health issues. They are all without simple, quick, or wholly tangible fixes.
Everyone deserves equal access to healthcare. Governments, international organisations, and health experts need to work together to tackle AMR. Post-conflict communities should be able to rebuild and move forward with dignity. We cannot keep recreating the same conditions that leave conflict-affected people vulnerable to AMR.
Thank you for reading an A4R 🎨 Post. Don’t forget to share it with your friends and family.