In a world where conflicts and fragility persist, an invisible yet deadly threat looms: antimicrobial resistance (AMR). This silent killer, identified by the World Health Organization (WHO) as one of the top global health threats, claims over a million lives annually due to drug-resistant infections. And in regions plagued by conflict and instability, this crisis is exacerbated, often remaining unseen by the rest of the world.
The Perfect Storm: AMR in Conflict Zones
War, displacement, and the disruption of essential services create an ideal environment for AMR to thrive. Health systems, already fragile, collapse or become severely fractured. Governance weakens, infrastructure crumbles, supply chains are disrupted, and healthcare workers are displaced or depleted. As a result, the very systems designed to prevent, diagnose, and treat infections are rendered ineffective.
Traumatic injuries are common in conflict zones, carrying a high risk of infection. Surgical care is often delayed or suboptimal, and studies reveal a high prevalence of drug-resistant pathogens in treated wounds. Meanwhile, diagnostic capabilities are minimal or non-existent, with laboratories non-functional and infection control measures limited or absent. This lack of infrastructure and resources makes it nearly impossible to make informed treatment decisions.
The Impact of Supply Chain Disruptions
Disruptions in the antibiotic supply chain further aggravate the situation. In places like Gaza, essential antibiotics are absent, leaving patients untreated or undertreated. In other regions, counterfeit drugs flood informal markets, fueling misuse and further contributing to the spread of AMR. The collapse of public services amplifies indirect risks, such as overcrowded camps with poor water and sanitation, malnutrition, lack of safe shelter, and environmental contamination from the remnants of war.
Cross-border displacement spreads resistant pathogens far beyond conflict zones, often into neighboring health systems that are ill-equipped to handle the influx. This creates a ripple effect, impacting regions beyond the immediate conflict zone.
Prioritizing AMR in Fragile Settings
Given the multitude of competing priorities in fragile settings, it is challenging to assign AMR the level of attention it deserves. Humanitarian actors and intergovernmental organizations often focus on immediate emergencies like epidemics, malnutrition, and trauma care. AMR is perceived as a secondary or long-term issue, even though it directly undermines the very emergencies they are trying to address.
Adapting AMR Response Strategies
In fragile settings, protecting vulnerable communities requires a basic yet comprehensive approach. Infection prevention and control are the first lines of defense. Simple hygiene standards, mobile monitoring tools, and clear protocols can significantly reduce the risk of infections for both patients and frontline workers. Vaccines against outbreak-prone infections, such as cholera, typhoid, meningitis, measles, and rotavirus, must be included in humanitarian health packages to prevent unnecessary antibiotic use.
Accurate diagnosis is equally crucial. Field laboratories, even in harsh conditions, can guide treatment decisions. By adapting existing rapid diagnostic systems for broader use, we can expand access to diagnostics and gain a clearer understanding of resistance patterns.
Treatment strategies must be smarter. Emergency antibiotic kits should follow the WHO's AWaRe system (Access, Watch, Reserve), with simplified stewardship protocols to ensure consistency. Surveillance systems must capture resistant infections early, utilizing mobile tools, sentinel sites, and integration into existing alert systems to enable prompt action. Resilient supply chains for safe and quality-assured essential antibiotics, diagnostics, and vaccines are essential to ensure availability.
Community-Centric Approach
None of these interventions will succeed without putting communities at the center. Training local health workers and first responders in hygiene, wound care, and appropriate antibiotic use builds capacity and trust. Listening to affected communities ensures that interventions are realistic and sustainable. Offering a core package of services for infectious diseases, which considers infection control and stewardship, in both primary and mobile health services reduces dependence on informal drug markets where misuse is rampant.
Integrating AMR into the Humanitarian Agenda
While these interventions face significant challenges, such as destroyed infrastructure, disrupted utilities, and displacement of healthcare workers, there are also opportunities to build upon. International organizations and global funding mechanisms are increasingly open to fragile contexts, and new technologies offer innovative diagnostic and monitoring solutions. With predictable financing, stable supply chains, and quality-assured essential medicines, integrating AMR into humanitarian response initiatives is feasible.
World AMR Awareness Week (WAAW) serves as a reminder that resistance knows no borders. When hospitals are bombed, laboratories destroyed, or water systems contaminated, these are not just immediate tragedies; they contribute to the emergence and spread of AMR. If we fail to act now, AMR will continue to erode the defenses of some of humanity's most vulnerable populations, with consequences extending far beyond conflict zones, such as when patients and wounded individuals are evacuated for medical care.
AMR is not a distant, abstract threat. It is a pressing reality, especially on the frontlines of fragility and conflict. The global community possesses the tools, knowledge, and frameworks to respond, but only if they are adapted to the harshest realities where they are needed most. As we observe this WAAW, let us heed the call to 'act now to protect our present and secure our future'.
