First Person: Mosul made me see the threat of antibiotic-resistant infections

‘We could easily end up back in an era where what should be routine injuries become life-changing, or even life-ending.’

A patient at MSF’s east Mosul facility, shortly before undergoing his fourth surgery. The 46-year-old was injured when a bomb hit his neighbourhood, and he later developed a multidrug-resistant infection.
A patient at MSF’s east Mosul facility, shortly before undergoing his fourth surgery. The 46-year-old was injured when a bomb hit his neighbourhood, and he later developed a multidrug-resistant infection. (MSF)

I only spent one week in the Iraqi city of Mosul, but I’ll never forget what I saw.

The scars of war there are not just destroyed buildings, closed hospitals, and empty streets; they are also adults and children in severe pain, injured first by war and then infected by bacteria that defies treatment by most available antibiotics – people wondering if they will ever walk, play football with their friends, or even lift a cup of tea again.

I’ve been working as an epidemiologist with Médecins Sans Frontières for the better part of eight years, and have focused on measles, malaria, cholera, malnutrition, and other major health crises. In the Democratic Republic of Congo, I saw patients barely able to make it to the hospital’s front door because of dehydration from cholera. In northern Nigeria, I witnessed severe malnutrition: children who were severely underweight and needed immediate treatment to survive.

These conditions are life-threatening, but we understand how to treat them, and we know – for the most part – what to tell patients.

But antibiotic-resistant infections – a growing problem across the world and in areas in the Middle East where MSF works, including Gaza, Yemen’s Aden, and Mosul – are incredibly complex to manage, difficult to explain, and can take a huge psychological toll on patients.

This is World Antibiotic Awareness Week. But one week is not enough.

In April 2018, MSF opened a 30-bed hospital in east Mosul to provide post-surgical care for victims of trauma, either from war, or from other everyday injuries like car accidents.

The facility was much needed. The northern Iraqi city, which was taken by so-called Islamic State in June 2014, has been struggling to rebuild since the group was driven out more than three years later. Many of the city’s hospitals and healthcare facilities were damaged or destroyed during IS occupation or during battles with the coalition fighting it.

Since the hospital opened, about 80 percent of the people admitted with suspected infections have been found to have the sort of bacteria that cannot be treated by the vast majority of drugs on the market.

This means that a person injured by an unexploded mine – who usually could be operated on, given antibiotics, and sent home – often ends up undergoing multiple surgeries, and may even end up losing a limb as a last-gasp infection-control measure. It’s just one more way that a conflict that officially ended years ago continues to devastate Iraqi lives.

The doctors in Mosul told me they waited anxiously for lab results with each new patient, hoping the bacteria wouldn’t turn out to be resistant to antibiotics. Most of the time, their fears came true.

Treating these aggressive infections properly requires a large team: an infectious disease specialist, a surgeon, a nurse who specialises in infection control, a pharmacist, a microbiologist, and many others.

The team in Mosul told me about one patient, originally injured in a car accident, who ultimately underwent 13 surgeries in the course of a month. The bacteria in his wounds defied treatment to such an extent that they had to choose from a series of non-ideal options: using an older generation of antibiotics that can be harmful to the kidneys; performing multiple surgeries; or dressing wounds with no antibiotics at all.

The Mosul hospital was not busy with people bringing food, comfort, and hugs to their loved ones. Instead, they were separated by gloves, aprons, and sometimes doors, as patients with antibiotic-resistant infections are placed in isolation, sometimes for more than a month at a time, with two doors preventing contact with the outside world.

I can’t get one patient, in Room 3, out of my head. He wouldn’t make eye contact or speak, but had a faint smile, clearly hoping for visitors.

This isolation is necessary, but it can be heavy for patients and their families. MSF staff explain to both what antibiotic resistance is, and why a patient has to be temporarily separated from other patients in the hospital.

Patients at the Mosul facility are seen by physiotherapists to keep their limbs functional, as well as mental health counsellors to help them externalise their suffering, and hopefully ease some of their pain.

But not everyone dealing with an antibiotic-resistant infection has this standard of care, especially if you consider the toll war has taken on hospitals across Iraq, which once had some of the best healthcare in the region.

To be honest, we don’t know all the reasons antibiotic-resistant infections are on the rise, or the exact scale of the problem. Gathering more data in the future will be part of my job.

Continuous wars may be part of the puzzle, not to mention the destruction of healthcare facilities, reduced lab capacity, and delays in immediate treatment to the war-wounded. Many hospitals and clinics were destroyed during the fight between the coalition and IS in Mosul, and the city as a whole is struggling to rebuild.

In Iraq, antibiotics are easy to buy over the counter, which is likely only adding to the problem: People take them when they aren’t really needed, or don’t take the full dosage – both can lead to increased resistance.

This is World Antibiotic Awareness Week. But one week is not enough.

I’ve seen for myself that people in Mosul have been through too much already. The healthcare workers, patients, and caregivers I met there convinced me we have to do more to bring attention to this problem all year round.

If we don’t deal with antibiotic resistance now, all of us – whether we live in Mosul or elsewhere – could easily end up back in an era where what should be routine injuries become life-changing, or even life-ending.

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