Conflict is a “bio-incubator” of anti-microbial resistance (AMR) yet this is not being recognised or addressed sufficiently, according to Professor Richard Sullivan.

Drug-resistant pathogens thrive in war wounds that are treated in sub-optimal conditions and in environments contaminated by heavy metals from bombs, said Sullivan, who is co-director of the Centre for Conflict and Health Research at King’s College in London.

The risk is huge with around 30% of the global population – 2.4 billion people – currently living in conflict zones, Sullivan told an event hosted by the Geneva Graduate Institute’s Global Health Centre on Wednesday.

Sullivan, who is a surgeon, said he frequently saw patients with dirty shrapnel wounds that took a long time to heal.

“Studies of surgical site infections in most conflict situations found that 70-80% are contaminated with multi-drug-resistant organisms,” he added.

Current conflict – Gaza, Sudan and Ukraine – involves “the increasing use of heavy munitions, and fighting in built-up areas”, which is causing “extraordinary toxification of the environment”, said Sullivan.

“Every single day, about 5,000 to 6000 155 millimetre shells are dropped on Ukrainian or Russian lines. These contain about 10 kilograms of RDX TNT and they contaminate the grounds with heavy metals – and that is just the shells, never mind all the propellant contamination that’s going on from the other types of weapons,” said Sullivan.

These heavy metals cause cell mutations in pathogens that help to drive AMR within the environment. 

Dr Kefas Samson from the WHO’s AMR Division said that the impact of AMR – estimated by The Lancet to have caused five million deaths in 2019 – was likely to be under-estimated because it is hard to collect data in war zones.

Meanwhile, Sullivan added that there were a “lot of implementation gaps” to prevent AMR in wars zones, including better training of health workers to “debride wounds” (remove dead and infected flesh), and provision of kits for infected wounds.

Implementing the UN Political Declaration

Despite the huge role of conflict in AMR, this is barely acknowledged in the United Nations Political Declaration on AMR adopted at the High-Level Meeting on AMR last month.

What the Declaration does do, however, is empower the Quadripartite Alliance – the Food and Agricultural Organisation (FAO), World Health Organization (WHO), World Organisation of Animal Health (WOAH) and the UN Environment Programme – to oversee the implementation of the declaration.

WHO’s Samson said that the Quadripartite’s priority is to support member states to deliver on the declaration – the most concrete aim of which is to reduce AMR deaths by 10% by 2030.

The declaration also charges the Quadripartite with setting up an independent panel to conduct research on AMR by the end of 2025, but the mechanics of this still need to be worked out with member states, said Samson.

No targets for ‘contentious issues’

Member states declined to set targets for certain “contentious issues” because they asked for evidence, added Samson – something that the independent panel needs to address.

A huge gap in the declaration is the failure of member states to commit to a target on reducing the use of antibiotics in the agricultural sector – where 80% are consumed.

“There are commitments in terms of strengthening global governance, there are commitments in terms of financing. There are commitments for health sector targets, for the animal health sector, health sector targets, and agriculture and the environment,” said Samson.

He added that, unlike geopolitical difficulties hampering other multilateral negotiations, there was “some unanimity within the international community and member states to see AMR as a real threat to global health, which requires very urgent actions”.

Saudi Arabia hosts a Global High-Level Ministerial Conference on AMR on 15-16 November to discuss the implementation of the declaration, and how to raise the $100 million target to assist countries to develop plans to mitigate AMR.

However, Barbadian Ambassador Matthew Wilson described this amount as “modest”, and likely to be just enough to “catalyze the achievement of at least 60% of countries having achieved funded plans by 2030”.

Damien Somé from the Global Antibiotic Research & Development Partnership (GARDP) said that another massive challenge is the “dry pipeline” – only a handful of pharmaceutical companies are investing in finding new antibiotics.

Substantial investment was needed in R&D to find new antibiotics, added Somé.

Image Credits: UNDP.