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Earlier this year, doctors at a US military hospital in Germany came across a troubling case. They examined a wounded Ukrainian soldier who had been defending his country against Russia’s invasion, only to find that his infection was resistant to almost every available antibiotic. This incident, recently documented by the US Centers for Disease Control, is just one example of how the health effects of war can extend far beyond the battlefield. Since Russia’s invasion of Ukraine in 2014, there has been a rise in drug-resistant infections in western Europe, with a significant number of those affected being Ukrainians. Various scientific papers have highlighted the ways in which war facilitates the spread of disease and makes it difficult to control antibiotic resistance. From toxic heavy metals in bullets to damaged hospital infrastructure, there are several factors at play. The movement of populations and the lack of access to proper testing and treatment also contribute to the problem.
In recent months, there has been an increase in antibiotic-resistant infections as troops and civilians from Ukraine have been evacuated and admitted for treatment elsewhere in Europe. Some of these infections were acquired during stays in Ukraine’s strained hospital systems, while others have spread within the receiving countries among the hundreds of thousands of refugees. Despite this growing spread of antibiotic-resistant infections, the economic and political aftermath of the war has diverted governments’ attention away from addressing the health threat.
Healthcare experts were disheartened at the UN general assembly last month when three resolutions on combating disease were passed without any indications of fresh funding or firm commitments to implementing change. Dame Sally Davies, the UK’s special envoy on antimicrobial resistance (AMR), is advocating for a single, tougher resolution on AMR next year. She wants to establish measures to track progress and hold nations accountable. However, achieving this goal requires collaboration among multilateral organizations and a framework agreed upon by all countries involved.
The danger of AMR is growing worldwide due to the limited supply of effective drugs and a lack of new drug development. Stopping the spread of AMR is challenging, but efforts need to focus on better prescribing practices, compliance, infection control, and reducing the inappropriate use of antibiotics in animals to limit environmental pollution. Even in well-resourced healthcare systems, these efforts have not been successful. A patient at a prestigious New York hospital reported that antibiotics were prescribed without proper testing to ensure their suitability for the infection, and the pharmacy refused to take back unused medication for safe disposal.
While most countries have developed national action plans on AMR, an evaluation conducted earlier this year revealed significant discrepancies in their quality and a gap between self-assessments and external expert opinions. Many plans lack accountability and tend to overstate strengths while downplaying weaknesses. The quality of national policies also varies greatly from estimates of AMR-related deaths in those countries. For example, Zimbabwe and Japan received positive evaluations but have high death rates.
Another challenge is the poor quality of data on AMR-linked deaths, estimated to be around 1.27 million annually worldwide. Countries with better surveillance systems and accurate data may be penalized, while infections can easily cross national borders. Data from the Mapping Antimicrobial Resistance and Antimicrobial Use Partnership shows that only 1.3% of laboratories in 14 African countries conduct bacteriological testing. Ramanan Laxminarayan, president of the One Health Trust, observes that eastern and southern Africa have a higher AMR burden than west Africa, contrary to initial projections.
Despite these difficulties, there are some promising initiatives that could lead to improvements in the future. Artificial intelligence is being used for early-stage research, and the pharmaceutical industry-backed AMR Action Fund has provided funding for testing several experimental treatments in patients. Countries like Sweden and Germany have implemented incentives to promote the use of new antibiotics, and the UK has introduced pilot schemes that reward developers of innovative drugs. These pilots decouple payments from drug usage to prevent excessive use. Similar measures are being discussed in Canada, the EU, and the US.
However, access to newer drugs remains limited in middle and lower income countries. This puts many patients’ lives at risk and increases the likelihood of further resistance due to inappropriate use of current drugs.
The Center for Global Development suggests a new “grand bargain” that would involve responsibilities from industry, governments, and multilateral organizations. Wealthier countries should fund innovation and support access to new drugs in poorer countries, while the latter should ensure responsible stewardship of these medications. Fixing the market for antimicrobials is crucial, and there needs to be accountability in addressing AMR, which is both a political and technical issue.
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