Introduction
Israel's military operations in Gaza have created a devastating form of urban warfare, resulting in a complex and far-reaching humanitarian and ecological crisis. The deployment of highly destructive force in one of the world's most densely populated regions has not only caused extensive civilian casualties but has also led to the systematic targeting and destruction of Gaza's healthcare system. This deliberate assault on essential medical infrastructure has crippled the region's ability to manage war-related injuries and other health problems, exacerbating long-term health risks for the population.[1]
One of the most alarming and less visible consequences of this conflict is the increased risk of antimicrobial resistance (AMR) outbreaks. The destruction of healthcare infrastructure, combined with overcrowded living conditions and environmental contamination, has turned Gaza into an ideal breeding ground for “superbugs,” which are resistant to treatment with some antibiotics.[2] This report examines how Gaza has become a focal point for “war biology,” where conflict accelerates the emergence of multidrug-resistant strains, posing a threat not only to the local population but also to global public health.
Drawing on data from international health organizations, literature reviews, and case studies from other conflict zones, this analysis explores the critical yet often overlooked relationship between armed conflict and AMR. It highlights how warfare undermines infection control, fosters antibiotic misuse, and creates conditions conducive to AMR development.[3] In doing so, this report aims to illuminate the urgent need for action to address this invisible threat, which persists long after the cessation of hostilities.[4]
Background
Antimicrobial resistance is a critical global health threat that undermines the efficacy of antibiotics. Infections with resistant bugs lead to longer hospital stays, increased mortality, and significant healthcare costs. AMR spreads through various pathways, such as hospital-acquired infections, environmental contamination, and community transmission, often exacerbated by overuse of antibiotics.[5]
Conflict zones amplify AMR risks due to the destruction of healthcare infrastructure, displacement, and contamination of the environment.[6],[7],[8] In such settings, the lack of clean water, sterilization equipment, and trained personnel, combined with overcrowded living conditions, creates a breeding ground for resistant bacteria. This issue is evident in various conflict zones, including Iraq,[9] Libya,[10] Ukraine,[11] Syria,[12] and Gaza,[13] where war-related injuries and prolonged antibiotic use have led to significant AMR outbreaks. These reports highlight not only the correlation of AMR outbreaks during military operations and flare-ups but also their persistent prevalence in clinical settings among patients long after the cessation of military activities.[14] The movement of patients from conflict areas, including those seeking urgent medical care across borders, further complicates the AMR crisis.[15] These patients often receive treatment in facilities with limited resources, where infection control practices may be compromised. As a result, resistant bacteria can spread not only within the conflict zone but also to neighboring regions and beyond.[16]
In Gaza, the combination of repeated military assaults, a protracted siege, and damage to healthcare facilities has intensified the AMR crisis, resulting in a syndemic where war injuries and resistant infections interact to magnify public health challenges.[17] This phenomenon underscores the pressing need to address AMR as a hidden yet escalating consequence of prolonged conflict.
Gaza's War Ecology
The Gaza Strip, covering approximately 365 square kilometers and home to around 2.2 million people, is one of the world's most densely populated regions. Approximately 70 percent of its residents are refugees from historical Palestine, with the majority facing food insecurity and lacking access to potable water.[18] Since the 1967 war, Gaza has been under Israeli occupation, and the situation worsened dramatically after 2006, when Israel imposed a prolonged siege, transforming Gaza into a conflict zone with recurring military assaults.
The siege and repeated military campaigns have severely impacted healthcare delivery in Gaza, resulting in chronic shortages of essential medications and medical supplies.[19] These constraints have led to the rationing and misuse of antibiotics, contributing to AMR development. Access to specialized care outside Gaza is also highly restricted, with only about 64 percent of patient exit requests approved prior to the October 7 war.
A particularly devastating aspect of the military strategy is the “shoot to maim” policy, which inflicts severe injuries requiring prolonged medical care and antibiotic use.[20] During the 2018 Great March of Return, nearly all 2,000 patients treated for gunshot wounds were reported to have AMR infections.[21] Data from Médecins Sans Frontières (MSF) revealed that approximately 70 percent of bacteria identified from patients with bone infections in Al-Awda Hospital were resistant to multiple antibiotics.[22] Such high levels of resistance pose significant challenges for treatment and recovery, underscoring the impact of warfare on AMR.
The combination of prolonged siege repeated military assaults, and a collapsing healthcare infrastructure has created an environment in Gaza that is highly conducive to the emergence and spread of AMR. This situation reflects the broader dynamics of “war biology,” where conflict accelerates AMR development, posing severe risks to public health in Gaza and beyond.
Water and Sewage
Gaza's water and sewage infrastructure has suffered prolonged damage, compounded by the siege and repeated military assaults. Since 2006, critical failures in sewage treatment have led to the direct discharge of untreated sewage into the Mediterranean Sea, resulting in widespread environmental contamination.[23] The coastal aquifer, Gaza's primary water source, has also been polluted by salinity and sewage infiltration, severely degrading water quality.[24] In 2007, the flooding of the Beit Lahia wastewater treatment plant worsened the situation,[25] and by 2008, an OCHA report indicated that 50–60 million liters of untreated and partially treated sewage were being discharged into the Mediterranean Sea daily.[26]
Military operations have further damaged Gaza's water infrastructure, with the May 2021 escalation alone resulting in damage to 290 water-related facilities, 109 of which were linked to wastewater treatment.[27] This damage has forced many residents to live in unsanitary conditions, significantly increasing the risk of waterborne diseases.
A pilot study in 2021 revealed high levels of antimicrobial-resistant bacteria in Gaza's water sources, indicating that the destruction of water treatment facilities contributes to the spread of AMR.[28] The inability to repair this infrastructure due to restrictions on importing essential construction materials exacerbates the environmental crisis, creating an ideal setting for AMR to thrive.
Herbicides and Agriculture
Since 2015, the Israeli military has periodically sprayed herbicides inside Gaza to destroy agricultural crops.[29] This practice has continued over the years, with Israeli airplanes spraying herbicides over farmlands near the border fence, significantly impacting Gaza's agriculture and livelihoods.[30]
A 2019 report by OCHA highlighted that since 2014, periodic aerial spraying of herbicides by the Israeli military affected farmland on the Gaza side of the fence, with an incident in January 2018 impacting 550 acres of agricultural land and resulting in an estimated loss of $1.3 million.[31] These practices contribute to environmental degradation, complicating the region's ability to sustain agricultural production and exacerbating public health challenges linked to AMR.
The October War and the Weaponization of Healthcare
The ongoing conflict in Gaza has significantly intensified the risk of AMR, largely due to the systematic targeting and destruction of healthcare infrastructure.The deliberate attacks on hospitals and clinics have not only decimated Gaza's capacity to provide essential medical services but have also forced the treatment of war-related injuries in makeshift, often unsanitary, conditions.[32] As healthcare facilities are destroyed or rendered nonoperational, patients are treated in overcrowded and poorly equipped settings, where maintaining infection control is nearly impossible. This creates an environment where wounds are more susceptible to becoming infected, and healthcare workers are often left with no choice but to rely on antibiotics that target a large array of different bacteria, without the ability to target the specific bacteria causing infections directly. This increases the risk of developing antibiotic-resistant bacteria.[33]
The deliberate destruction of hospitals and healthcare facilities in Gaza constitutes a serious violation of international humanitarian law, amounting to a war crime.[34] This devastation has led to the breakdown of essential infection control protocols, including sterilization processes, hand hygiene practices, and the isolation of infected patients. The lack of access to clean water, proper waste disposal, and reliable electricity has forced healthcare workers to treat patients in makeshift conditions that serve as breeding grounds for infections.[35] These unsanitary environments, combined with severe shortages of essential medical supplies like antiseptics and antibiotics, have significantly increased the spread of infections,[36] thereby accelerating the development and transmission of AMR.
Displacement further amplifies the crisis, with nearly half of Gaza's population living in overcrowded shelters with extremely poor sanitation.[37] These conditions increase the spread of infectious diseases, resulting in more frequent and often inappropriate use of antibiotics, which contributes to the rise in resistant strains of bacteria.
The movement of patients across borders for medical treatment, particularly into Egypt and other regional countries, presents another critical challenge. [38] Many of these patients receive care in conditions that are not adequately equipped to handle AMR, facilitating the transfer of resistant bacteria across borders and contributing to the regional and potentially global spread of AMR.
Overall, the destruction of Gaza's healthcare infrastructure, the shift to makeshift treatment conditions, and the deterioration of environmental sanitation have created an ideal environment for the rapid emergence and spread of AMR, turning the October war into a catalyst for this growing health threat.
The Day After?
This report reveals the alarming and largely invisible threat of AMR emerging from the ongoing conflict in Gaza. While immediate efforts focus on saving lives and treating injuries, infection control often becomes a secondary concern, creating ideal conditions for the development and spread of antibiotic-resistant bacteria.
The crisis in Gaza represents a broader pattern observed in other conflict zones, where the destruction of healthcare infrastructure, combined with prolonged warfare, accelerates the emergence of AMR. Lessons from Iraq, for example, demonstrate that even after a ceasefire, the long-term effects of AMR persist, as resistant bacteria continue to thrive in damaged infrastructure, contaminated water supplies, and within the bodies of those who have survived the conflict.[39]
Addressing this crisis requires urgent action on multiple fronts. Immediate priorities include securing a ceasefire, scaling up humanitarian aid, and rebuilding healthcare infrastructure with a focus on infection control and antibiotic stewardship. Long-term strategies must emphasize improving water and sanitation systems, monitoring and tracking AMR, and enhancing public health education to prevent the further spread of resistant bacteria. International collaboration will be crucial to support research, surveillance, and resource sharing to manage AMR effectively.
Ultimately, the war in Gaza has sown the seeds of a public health crisis that could echo for generations if not addressed. As the visible wounds of conflict are treated, the unseen microbial legacy of AMR must be integrated into efforts toward recovery, ensuring that rebuilding efforts include robust infection control, antibiotic stewardship, and environmental remediation.
[1] A. Shorrab et al., “Health in the Crossfire-Analysing and Mitigating the Multifaceted Health Risks of the 2023 War on Gaza,” Public Health Research 14, no. 1 (2024): 1–11.
[2] Krystel Moussally et al., “Antimicrobial Resistance in the Ongoing Gaza War: A Silent Threat,” The Lancet 402, no. 10416 (25 November 2023): 1972–73.
[3] Scott J. C. Pallett et al., “The Contribution of Human Conflict to the Development of Antimicrobial Resistance,” Communications Medicine 3, no. 1 (25 October 2023): 1–4.
[4] Omar Dewachi, “War Biology as Aftermath of Empire,” PoLAR, 2023.
[5] Christopher J. L. Murray et al., “Global Burden of Bacterial Antimicrobial Resistance in 2019: A Systematic Analysis,” The Lancet 399, no. 10325 (12 February 2022): 629–55.
[6] Pallett et al., “The Contribution of Human Conflict to the Development of Antimicrobial Resistance.”
[7] Guido Granata et al., “The Impact of Armed Conflict on the Development and Global Spread of Antibiotic Resistance: A Systematic Review,” Clinical Microbiology and Infection 30, no. 7 (Epub 29 March 2024).
[8] Pallett et al., “The Contribution of Human Conflict to the Development of Antimicrobial Resistance.”
[9] X.-Z. Huang et al., “Molecular Analysis of Imipenem-Resistant Acinetobacter Baumannii Isolated from US Service Members Wounded in Iraq, 2003–2008,” Epidemiology & Infection 140, no. 12 (December 2012): 2302–7.
[10] Allison E. Berndtson, “Increasing Globalization and the Movement of Antimicrobial Resistance between Countries,” Surgical Infections 21, no. 7 (September 2020): 579–85.
[11] Heike Granzer et al., “Molecular Epidemiology of Carbapenem-Resistant Acinetobacter Baumannii Complex Isolates from Patients That Were Injured During the Eastern Ukrainian Conflict,” European Journal of Microbiology & Immunology 6, no. 2 (24 June 2016): 109–17.
[12] Aula Abbara et al., “A Summary and Appraisal of Existing Evidence of Antimicrobial Resistance in the Syrian Conflict,” International Journal of Infectious Diseases 75 (1 October 2018): 26–33.
[13] Ayah Kamal Abu Qamar, Tasneem Mohammed Habboub, and Abdelraouf Ali Elmanama, “Antimicrobial Resistance of Bacteria Isolated at the European Gaza Hospital before and after the Great March of Return Protests: A Retrospective Study,” The Lancet 399 (1 June 2022): S14.
[14] Sabreen M'Aiber et al., “The Challenge of Antibiotic Resistance in Post-War Mosul, Iraq: An Analysis of 20 Months of Microbiological Samples from a Tertiary Orthopaedic Care Centre,” Journal of Global Antimicrobial Resistance 30 (1 September 2022): 311–18.
[15] Benedikt Lohr et al., “High Prevalence of Multidrug-Resistant Bacteria in Libyan War Casualties Admitted to a Tertiary Care Hospital, Germany,” Microbial Drug Resistance (Larchmont, NY) 24, no. 5 (June 2018): 578–84.
[16] Angel N. Desai et al., “Antimicrobial Resistance and Human Mobility,” Infection and Drug Resistance 15 (13 January 2022): 127–33.
[17] Merrill Singer et al., “Syndemics and the Biosocial Conception of Health,” The Lancet 389, no. 10072 (4 March 2017): 941–50.
[18] OCHA, “Humanitarian Needs Overview: Occupied Palestinian Territories” (January 2023), accessed 4 October 2024.
[19] “The Gaza Strip | The Humanitarian Impact of 15 Years of Blockade - June 2022 | UNICEF Middle East and North Africa,” accessed 3 June 2024.
[20] Jasbir K. Puar, The Right to Maim: Debility, Capacity, Disability (Durham: Duke University Press Books, 2017).
[21] Qamar, Habboub, and Elmanama, “Antimicrobial Resistance of Bacteria Isolated at the European Gaza Hospital before and after the Great March of Return Protests.”
[22] Moussally et al., “Antimicrobial Resistance in the Ongoing Gaza War.”
[23] “OPT: Unicef Action in Gaza - Update as of 27 July 2006 - Occupied Palestinian Territory | ReliefWeb,” 27 July 2006.
[24] “OPT: Palestinians Cope with Water Scarcity in Gaza - Occupied Palestinian Territory | ReliefWeb,” 22 March 2007.
[25] ReliefWeb, “OPT: Beit Lahia waste water treatment plant floods situation report, 30 Mar 2007,”.
[26] ReliefWeb, “OPT: Narratives under Siege - Swimming in Sewage,” 26 June 2008.
[27] CEOBS, “Reverberating Civilian and Environmental Harm from Explosive Weapons Use in Gaza,” November 2022.
[28] CEOBS, “Antimicrobial Resistance in Gaza, and the Ecology of War,” 20 September 2021.
[29] Gisha, “Untargeted destruction, 2015,”.
[30] Gisha, 2016; Al Mezan, 2016; Gisha, 2017; OCHA, 2017.
[31] OCHA, “The humanitarian impact of restrictions on access to land near the perimeter fence in the Gaza Strip,” 3 August 2018.
[32] “Over 22,500 Have Suffered ‘Life-Changing Injuries' in Gaza: WHO | UN News,” 12 September 2024.
[33] Moussally et al., “Antimicrobial Resistance in the Ongoing Gaza War.”
[34] “Gaza: Unlawful Israeli Hospital Strikes Worsen Health Crisis | Human Rights Watch,” 14 November 2023.
[35] Abdullatif Husseini, “On the Edge of the Abyss: War and Public Health in Gaza,” Policy Paper, no. 032 (2024).
[36] “‘Nowhere Is Safe': Doctors in Gaza Describe the Horror of Caring for Children Affected by War,” NBC News, 2 August 2024.
[37] “Gaza's Displaced People Face a New Peril: Hepatitis A Outbreak,” UNRWA, accessed 22 September 2024.
[38] Mada Masr "مستشفيات مصى لمواطني غزة "سجن" بلا علاج" , June 6 2004.
[39] Antoine Abou Fayad et al., “Antimicrobial Resistance and the Iraq Wars: Armed Conflict as an Underinvestigated Pathway with Growing Significance,” BMJ Global Health 7, no. Suppl 8 (6 January 2023): e010863.
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