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Iraq's war-battered cities grapple with rising resistance to antibiotics

Six years after the liberation of Mosul from the Islamic State, the city battles a silent enemy: abnormally high rates of multidrug-resistant infections. It's a phenomenon fueled by decades of war that poses a massive threat to global health.
A medic works at a laboratory at the Nablus hospital, run by Doctors Without Borders (MSF), in Iraq's northern city of Mosul on Dec. 16, 2021.

MOSUL, Iraq — Sitting in a small office in the Mosul General Hospital, Emad Ahmad, a member of the hospital’s Antibiotics Committee, sighs as he consults the results of the latest antibiogram compiled by his department.

“It’s a silent tsunami. Little by little, we are losing the only medicines that we have hope in,” Ahmad says, gesturing toward a spreadsheet displaying monthly data from the hospital’s testing labs. “Here, we see that Ceftriaxone doesn’t work on 90% of samples we tested in June. We are even witnessing resistance to Meropenem, which was until now one of the most effective [antibiotics].”

Ceftriaxone and Meropenem are two antibiotics used to treat a wide range of bacterial infections like meningitis and pneumonia. But like many antibiotics used in Iraqi hospitals, they are less and less effective in treating patients because the bacteria they target are becoming resistant to them.

Antibiotic resistance occurs when bacteria become less sensitive to antibiotics designed to eliminate them. Resistance normally develops naturally over time, but the process goes much faster when drugs are misprescribed or misused, leading bacteria to be exposed to levels of antibiotics that are insufficient to kill them but that still allow them to adapt.

Open-air sewage runs through much of the old city of Mosul. Poor sanitation is one of the factors driving Iraqi doctors to overprescribe antibiotics to their patients. (Lyse Mauvais)

Open-air sewage runs through much of the old city of Mosul. Poor sanitation is one of the factors driving Iraqi doctors to overprescribe antibiotics to their patients. (Lyse Mauvais) 

This phenomenon has reached alarming highs around the world in recent years as simple infections become harder and harder to treat. Antibiotic-resistant bacterial infections killed 1.27 million people in 2019, according to a study by The Lancet medical journal — more than HIV-AIDS or malaria. Experts say antimicrobial resistance (which refers not only to resistant bacteria but also to viruses, fungi and parasites) could kill up to 10 million people a year by 2050.

Iraq already stands out as one of the places hardest hit by this developing crisis, particularly the city of Mosul where worrisome rates of antibiotic resistance were recorded by international medical nongovernmental organizations that intervened there in the wake of the war against the Islamic State (IS). In 2019, a staggering 40% of patients admitted to a post-operative care facility run by Doctors Without Borders (MSF) in Mosul carried multidrug-resistant infections, according to MSF.

Five years later, this silent health crisis is still sweeping unchecked through the city’s private and public hospitals. “There’s a real danger,” Ahmad told Al-Monitor. “But when you look at the official response, it doesn’t feel like we are in a crisis. Iraq is behind on tackling this issue.”

Researchers and doctors familiar with Iraq’s health care system blame a culture of antibiotics misuse fueled by decades of war and sanctions. But recent research has also linked this phenomenon to the most recent wars, which have left a toxic legacy of heavy metal pollution that can also fuel antibiotic resistance.

A culture of overprescription

Antibiotic resistance was flagged as an issue of concern more than 20 years ago in Iraq, notably after multidrug-resistant Acinetobacter baumannii were found in the wounds of US veterans deployed there in 2003. Given how resistant the germ was to treatment, many soldiers had to have infected limbs amputated to avoid a deadly general infection.

Nicknamed the “Iraqibacter” by US practitioners, A. baumannii was not the only drug-resistant bacteria plaguing hospitals. Everywhere around the world, a plethora of bacteria responsible for common urinary, pulmonary or intestinal infections was quickly developing resistance to treatments.

But in Iraq, the phenomenon was exacerbated by years of antibiotics overuse and misuse — which partly developed as a response to the difficult environment Iraqi doctors have operated in since the 1990s.  

“My hypothesis so far is that this is a problem that has been ongoing for more than 30 years,” Omar al-Dewachi, a medical anthropologist and associate professor of anthropology at Rutgers University in New Jersey, told Al-Monitor. “Since the 1990s, with the sanctions, Iraqi doctors have become used to overprescribing antibiotics to deal with the breakdown of the sanitation system. Across Iraqi hospitals, people used to prescribe broad-spectrum antibiotics [to prevent infections].”

It's a habit that remains deeply rooted in the health care system, several doctors and medical nurses in Mosul acknowledged. “Here, most doctors prescribe antibiotics for any simple disease. They don’t follow a scientific protocol or a gradual approach with syrups and pills; they don’t send samples to the lab to see which antibiotics are needed. Many prescribe injectable antibiotics right away,” Omar Mudhafar, the head of an awareness-raising unit at the Mosul General Hospital, told Al-Monitor.

Rising resistance

The legacy of years of overprescription is blatantly visible today in Mosul, where multidrug-resistant infections have become the norm rather than the exception.

“We see that antibiotic resistance is spreading because very often, in patients who need antibiotics, the standard drug of choice doesn’t work,” Mohannad Akram, an Iraqi pediatrician who heads the pediatric rehabilitation center at the Mosul General Hospital, told Al-Monitor. “For a simple infection, the first-line antibiotic doesn’t work, so we have to prescribe a heavier drug.”

A testing laboratory in the pediatric service of the Mosul General Hospital (Lyse Mauvais)

A testing laboratory in the pediatric service of the Mosul General Hospital (Lyse Mauvais) 

This is a major issue in children, who get sick more often than adults. Fatma Sultan, a nurse at the same hospital, witnessed it first-hand: Her 3-year-old daughter struggles with recurrent urinary and kidney infections, but penicillin and ordinary oral antibiotics don’t work, which has led her to rely on injections instead.

“Children can’t bear a disease with the same patience as adults, and the parents want fast treatment. They expect to get medicine,” Akram said. But as doctors turn to heavier drugs, patients are more likely to suffer side effects. “Some children develop renal problems as a result. We see a lot of cases here — recurrent UTIs, renal impairments and some even need dialysis,” he added.

In recent years, environmental factors have fueled this dynamic further. “Pollution and dust storms have increased across Iraq, so allergic problems and respiratory infections have also gone up,” Akram said. “People are using antibiotics to treat them although antibiotics are not needed, and so resistance is increasing.”

At the same time, “The private sector in the country is becoming increasingly dependent on private pharmacies, and overprescription is common across Iraqi private sector clinics,” said Dewachi, who conducted multiple interviews with health practitioners in Mosul. Across pharmacies, wide-spectrum antibiotics are available over the counter, allowing families to self-medicate and access the drugs even when they’ve not been prescribed.

The Mosul syndrome

Over the past five years, growing attention has been drawn to Mosul’s antibiotic resistance crisis, mostly because the situation there has been better documented than in other Iraqi cities.

More than six years after the battle to liberate the city from IS, wounds linger and needs for treatment remain high, as Al-Monitor observed during a visit to Sahtak Awalan (Your Health First), a small charity that helps Mosul’s families cover their medical expenses.

Most of the patients who crowded the tiny consultation room of the charity on this day were there for health issues related to wartime wounds such as impaired hearing due to explosions, severe burns on the bodies of young children and shrapnel remnants lodged in the face of a little boy. One elderly woman needed antibiotics for her daughter-in-law who had just undergone surgery to remove shrapnel lodged in her body for years and was now grappling with a violent infection.

As the needs for surgery remain high, so does the potential for resistant infections. “One of the reasons we see more [antibiotic resistance] in conflicts is because there’s an increase in wounded people; there’s an increase in exposure to bacteria through these wounds,” Dewachi said.

But he and others investigated the toxic legacy of decades of war, which have directly contaminated Iraq’s environment with antibacterial agents.

“It is well noted and documented that whenever there is conflict, whenever there is war, antimicrobial resistance spreads faster, wider and is more difficult to control,” Antoine Abou Fayad, an assistant professor at the American University of Beirut and author of a study on antimicrobial resistance published in BMJ Global Health, told Al-Monitor.

“There are factors that we all know: chaos, displacement, the lack of medication, the lack of laboratories, the lack of nurses. But there are others too: We noticed a link with heavy metals coming from the destruction, from bombings, from chaos,” he added.

Abou Fayad and his team investigated the link between conflict and rising antibiotic resistance. Their findings, published in BMJ Global Health, also point to the role of lead, mercury, chromium, copper, lead nickel, zinc, antimony, barium and boron — metals that are used in weapons and military equipment and have built up in Iraq’s natural environment over time from one conflict after the other.

Nine of thirteen public hospitals were damaged during the battle of Mosul. The Mosul General Hospital still shows signs of the last battles to retake the city. (Lyse Mauvais) 

Nine of 13 public hospitals were damaged during the battle of Mosul. The Mosul General Hospital still shows signs of the last battles to retake the city. (Lyse Mauvais) 

These metals have long been known to play a role in the emergence of bacterial resistance. Long before modern-era antibiotics were invented, mercury, arsenic, silver and nickel had been used to treat infections for thousands of years. Now, their presence in Iraq’s environment is likely a big contributor to antibiotic resistance — but that relationship remains understudied and little understood.

The tip of the iceberg

For Dewachi, the situation in Mosul is “only the tip of the iceberg” in Iraq because no comprehensive and publicly available data on antibiotic resistance in other Iraqi cities are available.

MSF, which first raised the alarm on the silent health crisis sweeping through Mosul in 2019, was the only organization “systematically reporting on antimicrobial resistance,” Dewachi said. But in July of this year, MSF halted its medical activities in the city after a Mosul-bound cargo of medical supplies was held back in Baghdad by Iraqi customs for over five months, leading much of it to expire. The cargo contained supplies for a microbiology laboratory, an essential tool to analyze bacteria cultures and determine which antibiotics they respond to.

Meanwhile, data is collected by public hospitals like Mosul General Hospital less systematically and is not easily accessible to independent researchers. “In Iraq, there’s almost no collaboration from the state on this issue,” Abou Fayad said. “We have to collaborate with private hospitals to get data.”

According to public hospital employees, Iraqi authorities are now paying increasing attention to the phenomenon. “Since maybe three or four years, we feel that Baghdad has really started to focus on this problem, and the Ministry of Health instructed hospitals to form a committee to collect data on antibiotics resistance,” Ahmad said. Mosul General Hospital’s own Antibiotics Committee was established in 2019 and tracks lab results as well as data on the volume of antibiotics prescribed each month.

But the committee lacks resources to do enough sampling, Ahmad regretted. “We’d like to do more systematic testing, but we don’t have enough budget to buy culture media.”

Through his eyes, the silent tsunami is building up. In 2020, the World Health Organization (WHO) warned that “without urgent action, we are heading for a post-antibiotic era in which common infections and minor injuries can once again kill.”

And as practitioners in Mosul know all too well, Iraqis are on the frontline of this health crisis.

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