The word “gauze” may have originated from the Palestinian territory Gaza, but even that wound care staple is running out in the besieged region. According to the Palestinian Health Ministry, over 30,000 people, mostly women and children, have now been confirmed dead in Gaza as a result of the ongoing siege and bombardment by Israel, with over 70,000 injured, although these figures are considered to almost certainly be undercounts.
The conflict was sparked in retaliation for the Hamas massacre of approximately 1,200 civilians and soldiers and kidnapping of around 250 others on Oct. 7th. Now more than two million people — the entire surviving population of Gaza — are housing insecure and living in unsanitary conditions. The majority, especially in the north, are acutely starving. The untenable situation has threatened to spill over into neighboring nations, with many implications for global conflict. One issue which might not immediately come to mind, but which ought to concern us all, is antimicrobial resistance (AMR).
AMR is a broad phenomenon, but simply describes when our tools defending against deadly microscopic nasties stop working. Bacteria, fungi, parasites and viruses can all develop resistance to antibiotic, antifungal, antiparasitic or antiviral drugs. When such medications become ineffective, even formerly mild diseases can become serious threats to public health.
Over the past century, heavy use of antibiotics and similar medications has given AMR a boost, threatening to upend the public health gains of the 20th Century that saw child and elderly mortality from common bacterial infections drop dramatically, raising life expectancies from a 19th century average of around 47 years.
Diseases of all kinds have been making a worldwide comeback thanks to societal inequities, air travel, a backlash against even basic childhood vaccinations, the tendency of bacterial infections to follow viral ones, and apparent immune dysfunction resulting from COVID-19. But to really come to grips with this new age of disease, you must add the failure of antibiotics to the mix — which brings us back to Gaza.
The situation in Gaza
The impact of antimicrobial resistance isn’t confined to a single patient, but affects all of us.
While volunteering in Gaza for the first 43 days of the war that started after Oct. 7th, Dr. Ghassan Abu-Sittah, a British-Palestinian plastic and reconstructive surgeon, volunteered under absurdly difficult conditions in Al-Ahli Arab Hospital and Shifa Hospital in the north of Gaza, as well as Al-Awda Hospital in the Jabalia refugee camp. He was at Al-Ahli when hundreds of displaced people were killed by a blast of disputed origin — some may remember him from the press conference he held in the hospital courtyard, surrounded by dead bodies.
He left Gaza on day 43 of the war after hospitals were mostly besieged and shut down in the north where he had been working. Since returning to the UK, he has testified to a British war crimes investigation unit about the apparent deliberate targeting of healthcare facilities by Israel, alleging also that he saw patients with chemical burns consistent with the use of white phosphorus, which is a war crime. While still in Gaza, Abu-Sittah co-authored a November letter in The Lancet describing a documented rise in antimicrobial resistance in the territory previous to the current bombardment and siege, and highlighting aspects of the current situation conducive to further spread of AMR.
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“War-related contributing factors to antimicrobial resistance include restricted resources, high casualties, suboptimal infection prevention control and environmental pollution from infrastructure destruction and heavy metals release from explosives,” the authors write generally, also summing up the situation in Gaza.
Abu-Sittah, who has also worked in Lebanon, Syria, Yemen and Iraq, previously described development of antimicrobial resistance in the context of war in Syria, teasing out factors contributing to the problem before the conflict started in 2011, and afterward. Others have documented AMR associated with conflict in Ukraine and Sudan.
One of Abu-Sittah’s co-authors, Antoine Abou-Fayad, has also contributed to a study of war as a driver of antimicrobial resistance in Iraq, in which the authors argued that “Contemporary conflicts, waged in urban and industrialized landscapes, pressure microbes with selective environments that contain unique combinations and concentrations of toxic heavy metals and antibiotics, while simultaneously providing niches and dissemination routes for microbial pathogens.”
Giving evolution a massive boost
Every time we pressure a doctor into giving us an antibiotic for the common cold (which is caused by a virus and therefore not responsive to antibiotics), we increase the amount of antibiotics floating around. In 2022, The Lancet published an overview of the global prevalence of antimicrobial resistance, using data current as of 2019. Antimicrobial resistance was directly responsible for 1.27 million deaths, it also played a contributing role in another estimated 4.5 million deaths that year. Clearly, the problem of pathogens like bacteria becoming resistant to commonly-used antibiotics is one of life and death.
The impact of antimicrobial resistance isn’t confined to a single patient, but affects all of us. It can cue the return of the bacterial infections that used to make life nasty, brutish and short — and in some ways, this is already happening. As the Lancet study shows, the problem of growing antibiotic resistance has been an issue for decades. In the words of the World Health Organization, which launched its new data visualization dashboard of antimicrobial resistance and antimicrobial use last month, “AMR puts many of the gains of modern medicine at risk. It makes infections harder to treat and makes other medical procedures and treatments – such as surgery, cesarean sections and cancer chemotherapy – much riskier.” In fact, the WHO considers AMR one of its top ten greatest threats to global health and it is predicted to cause ten million deaths per year by 2050.
AMR has massive economic costs and threatens the global food supply. By increasing pressure on health care systems and killing livestock, it is predicted to push some 24 million people into poverty by 2030. What may seem at first like a minor problem is in fact a multi-sector, cross-issue catastrophe in the making. In an attempt to develop an adequately robust response, the United Nations General Assembly will convene its second high-level meeting on antimicrobial resistance in September 2024. There is a metaphorical arms race between microbes and drug development, and the literal military-industrial complex is increasingly creating conditions in which AMR can thrive.
Casual overuse of antibiotics is not the only factor that favors development of resistant pathogens like bacteria. Although The Lancet study does refer to the challenges of accurate and ample data collection in poor countries and to the difficult conditions that can increase the risk of antimicrobial resistance, it notably fails to mention the role that conflict and war-related collapse of health care and other infrastructure play in its development.
For example, Acinetobacter baumannii, a cause of hospital-acquired bacterial infection that can attack most parts of the body, was once sensitive to first-line antibiotics, but the AMR-favoring conditions of war have led to an alarming number of multidrug resistant strains — and growing incidence well beyond the Middle East. In fact, A. baumannii was dubbed “Iraqibacter” after causing many multidrug resistant bloodstream infections among U.S. service members returning from Iraq. A. baumannii, is on the rise in both the U.S. and the U.K., and has not remained confined to military veterans.
Likewise, both injured military personnel in Ukraine and refugees from that country have brought AMR to Germany and the Netherlands, and rising rates of multidrug resistant bacteria in Europe more generally have been linked to the ongoing conflict in Ukraine.
Highly polluted sites contaminated with heavy metals are further known to provide an environment that selects for antibiotic-resistant strains of bacteria. Hair analysis of infants in Gaza demonstrated heavy metal contamination in utero following major military attacks in 2009, 2012 and 2014 that could be seen in persistently high levels in the children by the end of the study in 2019. The 65,000 tonnes of bombs dropped on Gaza between Oct. 7th and Jan. 4th have left unknown levels of heavy metals in and around a population among whom nearly 100,000 people are dealing with injuries, including emergency amputations, burns and blast wounds.
Three pillars of antimicrobial resistance
Work was being done to combat growing antimicrobial resistance in Gaza well before the current war and siege.
"All of the injuries we’ve seen since November, since October really, are blast injuries. And so 99 percent, we could say are explosive injuries."
Dr. Amber Alayyan is a pediatrician who works for Doctors Without Borders as deputy cell manager for the Middle East. Her teams have observed antibiotic resistance in Syria, as well as in Yemen and in Iraq, and she closely followed the impact of antimicrobial resistance in Gaza since well before Oct. 7, 2023.
In fact, Alayyan told Salon that over the past 15 years, Doctors Without Borders has worked in Gaza’s Shifa and Nasser hospitals treating infected wounds resulting from burns (often children injured by ground-level stoves in refugee camps) and traumatic injuries. “When I talk about traumatic [injuries] I think of bombs, bullets, violence-related trauma, but it’s not necessarily violence-related [wounds] that are going to get infected. And so the burn cases as well, and those are a lot of women and children.”
Then came March 2018, the start of the so-called Great March of Return. This involved sometimes weekly demonstrations against the blockade of Gaza and for the right of return of Palestinian refugees, largely along the border fence between Gaza and Israel and involving as many as 50,000 protesters. The vast majority were peaceful, but stone-throwing, tire-burning, attempts to damage the fence, and the launching of burning rags on kites or balloons into Israel by protesters set off a violent response from Israeli security forces.
Over the course of a year, nearly 30,000 people were injured and 175 killed. Injuries to both adults and children resulted from tear gas, rubber-coated bullets and live ammunition, with 7,000 wounds caused by the latter. A year on, the already-strained health care system was in dire condition, and the impact on wound care became impossible to ignore.
“We were already seeing high rates of antibiotic resistance, and very complicated infection and multidrug-resistant types of bacteria. And so it was complicated. [Treatment is] doable, but it’s complicated. And what it requires is that patients have to come back over and over, not just for surgery, but also to make sure that the wound is healing.”
"We were already seeing high rates of antibiotic resistance, and very complicated infection and multidrug-resistant types of bacteria."
To tackle the gamut of problems leading to wounds that don’t heal, become infected, or don’t respond to first or second-line antibiotics, Alayyan and her team then set up Gaza’s only bone and tissue lab, allowing for the identification of specific pathogens infecting wounded tissue. This allows doctors to prescribe only antibiotics that are going to work on the particular pathogen. They also employed doctors specifically trained in antimicrobial resistance and antibiotic ‘stewardship’ — the careful and restrained use of antibiotics to prevent development of resistant bacteria.
“We looked at it as really sort of three pillars: the doctors who are the stewards, the microbiologists, and the nurses and pretty much everybody is included in what we call IPC: infection, prevention and control,” Alayyan told Salon. “Without those three things, you can’t even talk seriously about antimicrobial stewardship.”
Alayyan stressed the importance of multidisciplinary treatment to prevent the spread of antimicrobial resistance. “At the base of the pyramid is hygiene, so infection prevention and control.” There’s also an important component of patient education, and she includes mental health care as a vital factor in ensuring compliance with the strict requirements of effective wound care.
“Our surgeons are running out of basic gauze”
“That was before, and you throw in October 7 … and it’s a bit of a no-holds-barred kind of situation right now,” Alayyan said.
Israel’s siege and bombardment of Gaza began after Hamas' Oct. 7th attack, but ever since, those three things – physician stewardship, microbiology and infection prevention and control – have become essentially unattainable.
"Supply issues can always exist, but the deliberate blocking of supplies and staff and labs … That is unique. Usually no one does this."
“At that point, there were tens of thousands of internally displaced people living in Nasser [hospital] so that made follow up care for patients difficult because you had to find your patients,” Alayyan explained. “There were so many internally displaced people all over the hospital, including not only the patients but their families. All of the injuries we’ve seen since November, since October really, are blast injuries. And so 99 percent, we could say are explosive injuries." Such injuries result in damaged limbs, burns and injuries to soft tissue of the chest or abdomen. On February 22nd, Christopher Lockyear, the secretary general of Doctors Without Borders, told the U.N. Security Council, “Our surgeons are running out of basic gauze to stop their patients from bleeding out. They use it once, squeeze out the blood, wash it, sterilize it and reuse it for the next patient.”
Karin Huster is a nurse, also with Doctors Without Borders, who just returned from working at Rafah Hospital, in a city whose former population of 300,000 has increased several times over thanks to a million or so displaced people from elsewhere in Gaza. Huster told Salon that surgeons in Rafah Hospital still had access to clean gauze, but not much else.
“Right now we’re talking about basic war surgery,” she said.
Others have referred to being forced to practice 18th century medicine. “It is incredibly difficult to do the work as it should be done,” Huster said. She has worked in conflict zones across the globe — confronting famine in Nigeria, Ebola in Democratic Republic of Congo, cholera outbreaks in Haiti and war in Iraq — but said the situation in Gaza cannot be compared to anything she has seen before.
“Supply issues can always exist, but the deliberate blocking of supplies and staff and labs … That is unique. Usually no one does this. Here, we are blocked. Things are deliberately not making it in for a variety of reasons.”
According to reports by international news outlets, these include aid trucks being held en masse at the border by the Israeli government, Israeli protestors preventing even that access going through, and the Israeli government’s policy of siege.
It is considered a war crime under the Geneva Conventions to starve civilians as a weapon of war, or to “attack, destroy, remove or render useless” items needed for civilian survival.
Doctors Without Borders has a specialized microbiology lab that hasn’t been accessible since the start of the war, and one of their microbiologists was killed with his children in a strike on his home back in October. Nasser hospital, where the group had a surgical team working on soft tissue and burn injuries, has been under assault for days and is no longer operational. Previously, two surgeons were doing up to 20 surgeries every day.
“And I can tell you,” said Alayyan, “that having a team of exhausted surgeons does not make for great antimicrobial stewardship.”
Doctors in Gaza are using whatever is available or can be brought in by international teams, which is typically broad-spectrum antibiotics. They are used prophylactically, with health care workers aware that their patients are vulnerable to infection due to poor conditions, and may be unable to finish a full course of antibiotics or receive follow-up care. This increases the likelihood that resistant pathogens will develop.
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“You want to protect the patient,” Alayyan said. “But at the same time, you’re not necessarily protecting the patient if what it means is that they’re going to get to a point where nothing works on the infection. It’s just an impossible situation for the medics to be in.”
This is the background for the letter by Abu-Sittah and colleagues.
“I worked for many years on [antimicrobial resistance] in the war in Syria. And I never saw anything like this,” Alayyan said. “When a body is not well nourished, any of the healing processes are either slowed or stopped completely [...] The problem is that when the wounds don’t heal, and when you’re malnourished, you’re more at risk for sepsis, so blood infections, things like that, or wound infections, which then of course means more antibiotics. It’s sort of a dirty spiral, really.”
When asked what one essential factor could mitigate or prevent the further growth and spread of antimicrobial resistance in Gaza, Alayyan answered with a single word: “Ceasefire.”
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