Afghan citizens are already dying because of the war, but drug resistance will mean even more deaths.
As the conflict in Afghanistan and Iraq evolved, military doctors who were already grappling to treat soldiers maimed by roadside bombs began facing another challenge. Patients were developing multi-drug-resistant infections in their wounds, meaning they couldn’t be treated with usual antibiotics.
Colonel Clinton Murray, 48, an infectious diseases doctor, was deployed to the region four times between 2003 and 2015, working in military hospitals and clinics across the country, and also ran the infectious diseases department at Brooke Army Medical Center in Texas, one of two US hospitals which received soldiers with injuries so bad they had to be evacuated back to America.
He said drug resistant, or ‘superbug’ infections, meant some soldiers had problems for years after their initial life-altering injury. When common antibiotics failed, higher doses of antibiotics, new drug combinations or alternative drugs with severe side effects were tried, but many suffered repeat and prolonged infections. Some had to undergo extra surgeries or amputations because the bacteria couldn’t be stopped and had spread.
The US army soon realised drug resistance was a serious problem and from 2009 onwards introduced programmes in military hospitals to reduce antibiotic resistance. Yet superbugs were an even bigger problem in civilian hospitals without the resources to deal with them, and where civilians could not be evacuated abroad.
Doctors, WHO representatives and NGO workers warn patients in Afghanistan are still dying of drug resistant infections, in a public health crisis that is going undetected, adding strain to a health system vulnerable after decades of conflict.
Afghan citizens are already dying because of the war, but drug resistance will mean even more deaths, said Dr. Nasimullah Bawar, head of health programme at BRAC Afghanistan, an NGO providing drugs and maternity, child health, immunisation, nutrition, mental health and malaria and TB control services in four provinces.
He compares superbugs to another scourge, Islamic State or Daesh, because it will disrupt the country and kill high numbers of Afghan citizens: “This is going to be another Daesh, I can say.”
The military had been struggling with resistant infections since the start of the war but it wasn’t until years later that military physicians identified the scope of the problem.
Infections from a resistant form of one type of bacteria, Acinetobacter baumannii, became so common in Iraq and then Afghanistan the soldiers gave it a nickname: ‘Iraqibacter.’ The bug had usually been a problem in older or very sick patients who had spent months in hospital, but doctors were now seeing it in young, fit, soldiers.
At the peak of the problem, between 2004 and 2006, the budget for one class of last resort antibiotics – carbapenems – used for the severe and multi-drug-resistant infections commonly seen in blast wounds, went up by more than 400%.
The use of another drug, colistin, called the ‘last hope’ drug as it is used to save the lives of critically ill patients with multi-drug-resistant infections, became so common the army had to restrict it.
Targeted control programs introduced in military hospitals in 2009, including guidelines on antibiotic use, better surveillance of drug resistance, improved record keeping and better infection control, led to a reduction in cases within six years.
These improvements, combined with the ability to evacuate soldiers back to the US, meant although some died, many survived. “I have folks I’ve been following for 10 to 15 years,” said Murray. “First couple of years we wrestled with infection. Then for the next 11 they’ve done great. You know, they live functional lives.”
He recalls one patient who lost both his legs after being hit by a roadside bomb in Iraq. Three weeks after the blast, back in the US, infections developed in his stumps. Doctors swabbed the wounds and found a plethora of dangerous organisms, including three different types of multi-drug-resistant bacteria: Acinetobacter baumannii, Pseudomonas aeruginosa, Klebsiella pneumoniae as well as Staphylococcus aureus. To stem these infections they had to give him antibiotics which caused kidney failure, though luckily his organs recovered after the drug therapy was stopped a few days later.
The patient went on to suffer more superbug infections. On one occasion the antibiotics given poisoned his bone marrow, which affects the body’s immunity and clotting. He was given a different antibiotic which cleared the infection in that stump, and fortunately the poisoning did not turn out to be permanent. However he developed a superbug infection in his other stump. Doctors suggested more surgery to cut away the infected part of his leg, but he opted to take antibiotics long term to quash the infection instead.
Now, 12 years after being hit, he still has to take antibiotics to keep the infection at bay, but he lives a normal life with prosthetic legs. “His kids and my kids knew each other and now they’re in college and doing great,” Murray said.
The same standards of care were not provided to civilians. Superbugs made the civilian population in war zones an object of fear, said Dr Christian Haggenmiller, a former senior NATO medical officer in Afghanistan. Military medical facilities sometimes rejected civilian patients because of fear that they carried resistant bacteria which could infect the intensive care unit (ICU) for military personnel. As a result, they were often treated separately, in isolation tents away from the main medical facilities.
“It’s your worst nightmare, having a drug resistant strain in your health facility that you can’t control. It’s like a new disease,” he said.
The gains made in military hospitals were not seen in public facilities, which are still struggling with drug resistant infections. The health system in Afghanistan has been fragmented by decades of war, and civilian hospitals are understaffed, underfunded and overburdened.
Despite improvements in recent years, it still has one of the worst healthcare systems globally. One woman dies every two hours from pregnancy-related causes, according to conservative estimates, and one in 25 newborn babies dies – the third highest neonatal death rate in the world.
Life expectancy at birth is 64, compared to 79 in the US and a global average of 72.
