Studies suggest that urban areas affected by prolonged conflict are prime sites for bacteria to evolve resistance to antibiotics.
Anti-microbial resistance and the emergence of ‘superbugs’ is occurring throughout the world. Prolonged and intense conflicts can create a unique set of social and environmental conditions that intensify the risk of emergence. With the help of a new pilot study in Gaza, Linsey Cottrell and Reem Shomar explain just how bad the consequences for public health can be.
When the drugs don’t work
Imagine living where you risk dying from an infection that cannot be treated by antibiotics. Antimicrobial resistance (AMR) occurs when bacteria, viruses, fungi and parasites adapt and no longer respond to medicines. Antibiotics used to save human lives become ineffective, and the infections caused by resistant microbes harder to treat. This increases the risk of disease and death, as well as increasing the risk of spreading infection to others.
The misuse and overuse of antibiotics in human and animal healthcare has placed all nations at risk from AMR. Leaving no one behind is a central promise of the UN Sustainable Development Goals but achieving this is a great challenge, especially in conflict-affected regions where the AMR risk is particularly high. Annual global deaths from AMR infections are predicted to reach at least 10 million by 2050, and AMR does not recognise geographical borders.
The level of AMR in the Middle East is already at alarmingly high levels. The findings of a pilot study conducted in Gaza,1 found AMR bacteria everywhere the researchers looked: in the water supply of health care facilities, on the surface of hygiene facilities and in the wastewater discharged to public networks. In a besieged area, like Gaza, untreated or partially treated wastewater, including medical wastewater, is discharged to the sea, or seeps back into aquifers.
The water crisis and a ‘perfect storm’
The UN Environment Programme’s 2020 State of Environment and Outlook for the Occupied Palestinian Territory presented a bleak assessment of the environmental conditions in the region. Military airstrikes by Israel in May this year have caused further damage to Gaza’s infrastructure, intensifying the population’s vulnerability to environmental pressures.
Gaza is already facing a water crisis, with climate change and predicted temperature rises due to place further pressure on vulnerable water supplies. The coastal aquifer underlying Gaza is over abstracted, with groundwater quality affected by severe pollution and salinity – such that more than 95% of the supply fails to meet WHO drinking water guidelines.
According to the UN Trade and Development Agency, Israel’s military operations and prolonged closure and restrictions on Gaza caused an estimated $16.7 billion of economic damage between 2007 and 2018. The vast majority of Gaza’s almost 2 million inhabitants have no access to safe water through networks, no reliable electricity and no proper and sustainable sewage treatment system. The destruction of infrastructure in Gaza, severe economic restrictions and ongoing hostilities have all contributed to Gaza experiencing major environmental deterioration – a fully-fledged ‘ecology of war’.
Research into AMR in conflict settings has shown how pollution from heavy metals such as chromium, mercury and lead may be driving an increase in AMR. This is largely due to heavy metals inducing AMR in microbes through a mechanism called co-selection. Although elevated heavy metal concentrations can be common in both urban and rural environments due to various pollution sources,2 significant contamination can result from conflict-related pollution due to damaged infrastructure, industrial sites, conflict debris, solid waste and the use of munitions. Heavy metals are also present in some explosives, and used in weapons primers and in coatings. The extent and nature of persistent pollutants like heavy metals may therefore also be influencing the risk from AMR in Gaza.
The conflict in Gaza has disrupted environmental governance and with limited resources or capacity, there are gaps in the regulation of natural resources, waste, wastewater and pollution control, as well as a lack of environmental monitoring. Antibiotic use is also poorly regulated. They are available without a prescription, and many antibiotics are poor quality or counterfeit. These all exacerbate the risk of AMR, creating a ‘prefect storm’ within densely populated Gaza. Nevertheless, this could equally apply to any conflict-affected region in similar circumstances.
Gaza’s water reveals high levels of anti-microbial resistant bacteria
The Gaza pilot study was completed in March 2021 and examined the connection between AMR and the provision of water, sanitation and hygiene (WASH) services. Samples were collected and analysed from the water supply, hygiene surfaces and wastewater outlets from two hospitals – the European Gaza hospital and the Al-Shifa hospital. Samples were also collected from the inlet and sea outlet at Gaza wastewater treatment plant.
Healthcare facilities receive water from the public supply, desalination units or have their own groundwater abstraction wells. With the exception of the European Gaza Hospital, which has a dedicated wastewater treatment plant, all wastewater from healthcare facilities is discharged to the municipal network, without pre-treatment. The beach is the only recreational area for people in Gaza and more than 100 million litres of untreated or partially treated wastewater is discharged daily into the sea. In spite of the poor water quality and health risks, swimming remains popular with many Gazans.
In 2019, microbiological contamination was identified in wells, the public water supply network and water storage tanks after random sampling by the Palestinian Public Health Laboratory. Results from the new study confirmed microbiological contamination not only in the wastewater samples, as expected, but – more shockingly – also in the water supply and on supposedly hygienic surfaces, with concerning levels of AMR present.
Isolates of bacteria detected in water and wastewater samples by the pilot study showed high resistance to a range of antibiotics including cephalosporins, which can be used to treat serious infections, such as septicaemia and meningitis, and carbapenems, which are normally reserved to treat the most serious life-threatening and multi-drug resistant infections.
There are hundreds of different types of antibiotics and worryingly, new strains of bacteria can emerge that cannot be treated by any existing antibiotics. In the pilot study and Enterococcus isolates (see summary table below) – a bacteria group found in the gut and bowels – all water samples showed resistance to the widely used antibiotics Vancomycin, Gentamicin and Linezolid, and all water and wastewater samples were resistant to Penicillin.
Enterococcus does not usually cause problems for healthy people but can cause serious and life-threating infections for people with underlying health conditions. How AMR in water resources compare across the Middle East is uncertain. A study on the antimicrobial resistance of Enterococcus faecium in samples collected from wells and surface water in Iran, for example, found no resistance to the antibiotics Vancomycin, Gentamicin and Linezolid.
Summary table showing the antibiotic resistance for the different bacterial groups detected in water and wastewater samples collected in the Gaza pilot study
An earlier study in 2016 had indicated high AMR rates among potential pathogens isolated from seawater samples collected along the Gaza coast. Sea spray and the aerosol droplets caused by breaking waves, are recognised as a pathway for exposing people to marine-based pollutants, including bacteria. The 2016 study called for immediate action by the authorities to prevent the discharge of untreated wastewater into the sea but the practice continues.
Whilst other diffuse pollution sources may also be contributing, such as agriculture or aquaculture, the lack of investment in water and water treatment infrastructure improvements, severe economic hardship, unreliable power supply and pressures from the ongoing conflict continue to put people at risk from the transfer of AMR pathogens in the marine environment. If all exposure routes are not addressed, the risks will remain in spite of any local improvements in WASH services, or in infection and prevention control measures in healthcare facilities themselves.
Responding to the threat of AMR in Gaza and other conflict areas
The collection of data on AMR prevalence and transmission routes in Gaza is critical to breaking the cycle and tackling healthcare needs. Data collection in conflict settings is inherently difficult, with limited time or resources to undertake the research. In the future, civilian science could be one route to support this. The data from the Gaza pilot study is important for developing and implementing appropriate interventions in the short-term. But the study has also identified follow-up research that is necessary to develop effective and long-term mitigation measures, and which could be adopted in Gaza and elsewhere.
The pilot study highlighted the immediate problems in WASH service provision to Gaza’s healthcare facilities, and the action necessary to prevent the spread of AMR bacteria. Nevertheless, further research is still needed to investigate the root causes of AMR in Gaza, transmission routes and AMR prevalence within the wider environment, including at water supply wells, desalination units and the water distribution network.
Environmental interactions are intrinsically complex. COVID-19 – a zoonotic disease – has already demonstrated the relationship between health and the environment. Recognition of the link between conflict, environmental degradation and AMR is vital, and collaboration is needed between states, UN agencies, NGOs and impacted communities to reduce the risks it poses.
Consideration of the linkages between pollution, pathogens and conflict should also form part of how we conceptualise victim assistance and environmental remediation for the toxic remnants of war. These secondary or reverberating risks, which can be caused or exacerbated by pollution or environmental degradation, are a reminder of the importance of multi-disciplinary approaches in assessing and responding to civilian harm linked to environmental damage in relation to armed conflicts.
Finally, it is important that humanitarian organisations providing healthcare in conflict areas, such as Médecins Sans Frontières and the International Committee of the Red Cross increase efforts to evaluate and address AMR interventions.
Linsey Cottrell is CEOBS’ Environmental Policy Officer and Reem Shomar is a Public Health Specialist at the Palestinian Water Authority, Program Coordination Unit.
Our thanks to Mark Zeitoun, Professor of Water Security and Policy at the University of East Anglian and Antoine Abou Fayad, Assistant Professor of Experimental Pathology, Immunology and Microbiology at the American University of Beirut for their contributions.
Shomar R. Anti-Microbial Resistant Bacteria in Health Care Facilities in Gaza: exploring links with WASH. Final Report of a pilot study conducted under the GCRF/UK Academy of Medical Sciences Networking Grant Networking Grant GCRFNGR4\1490.
Zeitoun, M & Abu Sitta, G 2018, Gaza now has a toxic ‘biosphere of war’ that no one can escape.
- The Pilot Study was conducted by Reem al Shomar in cooperation with the Islamic University of Gaza and Al Azhar University, as part of ESRC project and in turn part of GCRF/UK Academy of Medical Sciences Networking Grant Networking Grant GCRFNGR4\1490. It was led by the Global Health Institute of American University Beirut, and the Water Security Research Centre of the University of East Anglia. See: https://ghi.aub.edu.lb and https://research-portal.uea.ac.uk/en/organisations/water-security-research-centre The work was also part of the 2020 CREEW fellowship offered by the Global Health Institute at the American University of Beirut (AUB-GHI) in partnership with the SwissCross foundation. Funding for the work was supported by the Center for Research and Education in the Ecology of War (CREEW) at the Global Health Institute at the American University of Beirut (AUB-GHI) and the SwissCross foundation.
- Pollution sources can include traffic, power plants, industrial emissions, waste disposal, mineral extraction and processing, or farming practices.