It was two days after the young Yemeni man was released from surgery that the doctors first noticed the smell. The bullet that wounded the leg of the 22-year-old college student had shattered bone and torn a hole in the soft tissue. Now, the wound was emitting a distinct smell, described in the medical literature as “offensive.” It strongly suggested infection, perhaps life-threatening, and the wound was not getting better.
Realizing that normal antibiotics were not working, the doctors at a trauma center run by Doctors Without Borders sent a blood culture for analysis to their new microbiology lab, the only one of its kind in the region. The tests found a bacterium, Acinetobacter baumannii, resistant to most standard antibiotics. Nobody knows how the student — who was identified using his initials, A. S., to preserve his privacy — acquired the drug-resistant infection, but it is so common in Yemen that it could have come from the bullet itself or the sand on the ground when he fell, said Dr. Nagwan Mansoor, the chief physician in Doctors Without Borders’s antibiotic stewardship program.
Doctors started the gunshot victim on a program of specialized antibiotics, medicines rarely used because of their potentially dangerous side effects. He required numerous surgeries, seven in all. What would normally have been a five-day stay became three weeks, during which the man was put into isolation to prevent him from infecting other patients. When his family came to visit, they could not touch him without wearing protective clothing.
A. S. survived. “We captured the patient from the mouth of death,” said Dr. Mansoor. But A. S. was lucky: Most hospitals in Yemen do not have the capacity or protocols in place to detect and treat drug-resistant infections; if he had been anywhere else, he would have lost his leg, or died.
The Saudi-led bombing campaign in Yemen has produced thousands of casualties and created vast numbers of refugees. But the real cost may not become apparent for years to come. After years of bombardment that has crippled the food supply, destroyed basic infrastructure and disrupted medical care, Yemen has become a breeding ground for antibiotic-resistant disease, with potentially catastrophic consequences — and not just for Yemen.
When penicillin was first widely introduced in 1942, it was a revolution in medicine. Infections that used to kill no longer did. Similar breakthroughs followed, but the threat of microbes developing resistance to these wonder drugs has been a concern from the beginning. Until recently, the threat of drug-resistant disease was largely theoretical, a generalized fear rooted in a few isolated cases.
It’s happening now in Yemen. The conflict is taking on aspects of warfare once found only in history books, when the real toll of a military campaign is not the immediate damage from weapons, but the long-term and far greater impact of disease that spread in the chaos of armed conflict. “It’s a huge burden on the health system that can barely take care of primary health care,” said Ana Leticia Nery, the medical coordinator for Doctors Without Borders in Yemen, which has long been the poorest country in the Middle East. More than 60 percent of the patients admitted to the medical organization’s hospital in Aden have antibiotic-resistant bacteria in their systems.
The widespread prevalence of multidrug-resistant infections has nearly quadrupled the amount of time patients must spend in a field hospital to recover from war wounds. This extra time, plus the specialized antibiotics a patient requires to overcome a drug-resistant infection, means far fewer patients can be treated than the norm, and the care is much more expensive and difficult.
Similar problems are reported to be occurring through the war-torn regions of the Middle East, including Iraq and Syria, and countries with extensive refugee populations, like Jordan. “There is a scary, scary prevalence of multidrug resistance we see in the Middle East,” Dr. Nery said.
In humanitarian crises, the focus is on emergency care, and other problems are often missed. Surveillance of drug resistance is spotty, but it appears that “many people are dying of infections” in Middle Eastern conflicts, said Susan Elden, a health adviser on Syria for Britain’s Department for International Development. Findings similar to Doctors Without Borders’s Yemen experience have appeared in small studies in Syria, she said, adding, “The global aid architecture has not caught up with the realities” of multidrug-resistant infections in conflict zones.
It’s a threat to American national security, too. Forces in Iraq and Afghanistan were laid low by drug-resistant infections for many years before the military began a program in 2009 to tackle it. The causes of drug resistance in the American military were many of the same as in civilian populations: poor hygiene, overuse of antibiotics and treatment in multiple facilities, said Dr. Kent E. Kester, a retired colonel who led the Walter Reed Army Institute of Research and oversaw the drug resistance program.
Doctors Without Borders is unusual among relief organizations in that it is paying attention to drug resistance at all. This was born of necessity. The normal protocols it uses for antibiotics in sub-Saharan Africa often do not work in Yemen and other war-torn Middle Eastern countries because of the high prevalence of drug resistance, Dr. Nery said. “We saw that our patients are not improving with the usual antibiotics. Our patients are not getting better.”
Before the war, Yemen had a functioning, if fragile, health system. The war destroyed it, along with the country’s water and sanitation infrastructure. Many small children are not even getting routine vaccinations. Nearly 18 million people are hungry, with many close to famine levels. By conservative estimates, 10,000 civilians have been killed, with 52,000 more wounded — fertile ground for drug resistance.
Antibiotic consumption was already very high in the region. A 2014 study found a prevalence of nonprescription antibiotic use by 48 percent of the population in Saudi Arabia and 78 percent in Yemen. Syria was a major producer of antibiotics, both for itself and for export.
It’s a recipe for catastrophe: a struggling health system where antibiotics remain widely available with little oversight, combined with an overwhelming number of wounded in hospitals and weak hygiene and infection-control practices. Doctors in Yemen, struggling to treat the rush of patients, often use broad-spectrum antibiotics on even simple infections. “This creates a new generation of multidrug-resistant bacteria,” Dr. Mansoor said, and inadvertently sets the stage for a public health meltdown.
Diseases from the 19th century have re-emerged in force. Yemen faces the fastest-growing cholera outbreak ever recorded, with more than one million people affected, a quarter of them small children. Diphtheria has emerged as well.
Doctors Without Borders, which has been in Yemen since 1986, appears to be the only relief agency tracking drug resistance in the area, and last year it set up its dedicated microbiology lab. Other medical-relief agencies I contacted said that they were too busy to be following the issue.
This goes to a core problem: a lack of surveillance and infection-control procedures as part of humanitarian response, which are increasingly a necessity with so many prolonged conflicts. “Where we need the most information, we don’t have it,” Ms. Elden said.
Sam Loewenberg is a public health reporter. This article, part of the Bureau of Investigative Journalism’s Global Superbug Crisis series, was funded with support from the European Journalism Centre.
Opinion | Will the Next Superbug Come From Yemen? | New York Times | April 14, 2018