Catch-22: War, Refugees, COVID-19, and the Scourge of Antimicrobial Resistance

Abstract

Wars have hidden repercussions beyond the immediate losses of life, well-being, and prosperity. Those that flee wars and seek refuge in safer locations are not immune to the tragic impacts. Of particular concern is the susceptibility of the refugee populations to infectious diseases and antimicrobial-resistant pathogens. This poses a detrimental risk to these disenfranchised populations, who often have limited access to medical care, sanitation, and nutritious and safe food. Furthermore, antimicrobial-resistant pathogens in refugees can be both transmitted to and acquired from their hosting communities. The latter is particularly problematic when the host countries suffer from serious challenges such as limited resources, pollution, and widespread antimicrobial resistance (AMR). Here, we discuss AMR in refugees of the ongoing Syrian war, a conflict that resulted in the largest population displacement in recent history. We argue that Syrian refugees and their hosting communities are at an elevated risk of complicated and life-threatening AMR infections. We also call on the international community to address this grievous problem that threatens the disenfranchised refugee populations and can spill over across geographic borders to affect multiple countries.

Keywords: COVID-19; antimicrobial resistance; armed conflict; civil war; displaced populations; infectious diseases; one health; refugees.

Figure 1

Photographic examples highlighting the conditions in refugee camps in Lebanon. White makeshift tents in proximity to hosting community residence (concrete building in the background) (A) and limited-capacity water cisterns (A,B) that provide domestic and drinking water to the camp inhabitants that include a large number of youths (B,C) and elderly individuals (C). The cisterns are filled periodically via water trucks provided by non-governmental organizations (NGOs) and charitable donations. The source of the water varies, the supply is sporadic, and the cisterns are filled from underground cisterns/wells (D,E) when the trucked water supply is insufficient. The underground cisterns are very vulnerable (without proper protection) and prone to contamination from shallow and inappropriate camp sewage conduits (F), especially after rainfall. The camp inhabitants have reported that the cisterns have been contaminated with sewage on multiple occasions. This spreads persistent contamination to drinking and domestic water cisterns. Camp environments are generally unclean (dust, stones, solid waste) as can be observed in all the pictures above. Photographs were documented by Mr. Abdallah AlHaj Sulaiman.

Figure 2

The major factors that influence the emergence and spread of antimicrobial-resistant pathogens in the camps. It is important to note the interactions between all the factors and between the camps and the hosting community. These interactions can create suitable conditions for the emergence and rapid spread of antimicrobial resistance (AMR) within camps and hosting communities, highlighting the necessity to adopt a One Health approach to tackle AMR in these scenarios.