Peter
Schwartzstein

Mohammed Abu Ara is the face of a grave new threat, but propped up on his bed in an airy segregated hospital ward in Jordan, there’s not a hint of menace about him. With his left arm cut off above the elbow and one of his legs encased in a metal splint, he looks like thousands of others whose lives have been shredded by the violence of the Syrian civil war.

Yet for many regional health analysts, Abu Ara and several others at the Doctors Without Borders Special Hospital for Reconstructive Surgery in Amman are part of a terrifying new trend: the growing number of Syrians who are immune to almost all antibiotics. The only way to treat them is to amputate their affected limbs and inject them with last-resort drugs. For those suffering from less peripheral wounds, the prognosis is even grimmer. “If the infection is in the chest or brain, he will die,” says Rashid Fakhri, surgical coordinator for the organization, known internationally as Médecins sans frontières (MSF), in Amman. “You can’t amputate there.”

After five and a half years of death and destruction, those working at hospitals and makeshift clinics along the Syrian border thought they’d seen every injury imaginable—from chest wounds stanched with hookah pipes to twin brothers whose skulls were dented by an undetonated rocket-propelled grenade. But as the conflict escalates and conditions worsen for civilians and soldiers alike, doctors and aid workers fear antibiotic resistance could soon become deadlier than the Islamic State group (ISIS) or Bashar al-Assad’s dreaded air force. And with resistant bacteria spreading fast, Syria might even become the place where antibiotics, one of the biggest lifesavers of the 20th century, stop working altogether.

There are few reliable statistics on the number of fatalities in Syria related to failing drugs, and for now the problem seems manageable. Last month, a 14-year-old boy from a barrel-bombed Damascus suburb, whose body had rejected all available antibiotics, succumbed to multiple infections not long after he arrived at a Jordanian clinic. At a field hospital in Lebanon’s Bekaa Valley, medics say ineffective antibiotics appear to have increased the death rate over the past year. “In 2015, we lost two people,” says Mariam Mohamed, a volunteer nurse at an emergency refugee clinic outside Chtoura, halfway between Beirut and the Syrian border. “So far this year, we’ve already lost four who weren’t responding to treatment.”

Frazzled medical professionals believe the problem is quickly getting worse, especially in besieged swathes of Syria that doctors can’t reach. At MSF’s hospital in Amman, half of the patients now arrive with some sort of chronic infection; of those, 60 percent are resistant to multiple drugs. United Nations officials are so concerned they recently called for an emergency General Assembly summit on superbugs in late September. “If we start seeing even more of these cases,” Fakhri says, “it will be disastrous.”

Syria’s antibiotic resistance comes at a time when similar problems are plaguing other parts of the world. About 700,000 people die every year from antimicrobial resistance, according to a U.K. government study that suggests that figure could rise to 10 million by 2050. The reasons vary, but many blame widespread drug use in agriculture, as farmers force-feed antibiotics to animals to fatten them up. In the U.S., large-scale livestock farming has hastened the speed by which bacteria develop resistance to antibiotics, environmentalists say, though representatives of major agricultural companies insist the animals need those pills to stay healthy. Either way, the world has reached a point where every existing antibiotic—from penicillin to last-resort drugs such as polypeptides—has been compromised, according to Antibiotic Research U.K., a British group that campaigns to raise awareness of antibiotic abuse.

In Syria, part of the problem is rooted in the country’s lax attitude toward medications. As in much of the Middle East, antibiotics have long been available without a prescription and are often seen as cure-alls with no side effects. For years, doctors doled them out for everything from headaches to common colds. Farmers in isolated areas self-medicated. Pharmacists who knew the risks prescribed them anyway, fearing their customers would go elsewhere. And with dozens of pharmaceutical factories churning out products across the country, antibiotics became available at low cost to pretty much everyone.

The outbreak of war and the subsequent breakdown of Syria’s health care system appear to have sparked this crisis and created an environment perfectly suited for the spread of germs. The Syrian regime’s systematic targeting of doctors with barrel bombs and cluster munitions has destroyed much of the country’s medical know-how, and its repeated bombings of hospitals have set emergency room sanitation back decades in some areas. In the besieged mountain resort of Madaya, for instance, a veterinarian and a dentist in training have been left to treat the wounds of a town of several thousand people. “When we started to receive Syrians in 2012, we thought: They have serious injuries, but they don’t have multi-drug resistance,” says Nagham Hussein, director of medical operations at MSF’s Amman hospital. “But then, when the crisis became older and older, the nice innocent bacteria changed into nasty bacteria. Everything is more difficult now.”

Analysts still aren’t sure whether this resistance is spread in the streets or strictly at battlefield clinics. There are insufficient micro-laboratories in the relevant areas, which are needed to scrutinize bone cultures for signs of deep infection, and Syrians, it seems, are being killed too quickly for analysts to keep up. It’s possible, doctors say, that explosions—from car bombs to airstrikes—are spreading resistant bacteria through body parts and flesh that flies through the air after a blast. Or it could be that under-trained medics, forced to deal with so many casualties, have inadvertently created fertile breeding grounds for infectious diseases. Regardless, it’s a hellish scenario that wounded Syrians—and the doctors who treat them—are struggling to comprehend.

“There’s really no luck for us,” says Abdel Salem, a 20-year-old from the southern Daraa area who lost a leg in an airstrike in March 2015 and risks losing the other to an infection that took root in his shrapnel-ridden ankle. “Even when we are safe in Jordan, we are not safe.”

First treated in a field hospital run by the Free Syrian Army, Salem was given whatever drugs the rebel group had inside the blockaded town by a fighter who doubled as a paramedic. After the Syrian army conquered the area, he says, the government troops refused to treat him, and his wounds were left to fester until his family smuggled him out of the country. Before he reached the border, five different doctors operated on his legs, which were oozing puss by the time he arrived in Amman.
More Syrians may wind up like him, depending on the direction of the war, which shows few signs of abating. As long as doctors continue to perform complex operations in poorly lit basements and caves with recycled equipment, infections will remain common. And until the number of qualified medics corresponds to the high volume of injuries, analysts say it will be difficult to thwart the spread of resistant bacteria within Syria.

There is, however, cause for some guarded optimism. Jordan, which has taken in more than a million Syrian refugees, has been implementing tight new controls on the use of Colistin, an extra-strength antibiotic that can be used as a last resort. Only four pathologists across the country are licensed to distribute the drug, and even they seldom prescribe it. Patients also seem increasingly open to recounting what happened to them, unlike in the war’s early days, when many were wary of saying how they were injured for fear of Assad’s forces. And if the situation continues to deteriorate and Colistin loses its effectiveness (there have already been a number of recorded cases of resistance in a few countries), then the possible discovery of a new class of antibiotics—derived from human nasal mucus—offers some hope.

Yet with the Syrian war still killing and maiming at a pace unmatched in recent memory, doctors and scientists say there’s only one guaranteed way to preserve one of our world’s greatest discoveries. “The problem is not the mentality of the doctors; it’s the conflict,” says Fakhri. “We have to treat the conflict to stop antibiotic resistance.”