November 27, 2019

When Healthcare Leads to Health Epidemics, Physician Shares Experiences with Ebola and War-Related Illnesses

Physician and medical anthropologist at the Graduate Institute Geneva and advisor to the World Health Organization and Doctors Without Borders Dr. Vinh-Kim Nguyen spoke to students as part of the Medicine and its Objects seminar series on Monday. 

Nguyen’s seminar began by describing how war is thought to cause epidemics—the destruction of healthcare, sanitation, clean water sources, and agriculture in war-afflicted areas causes poor hygiene, mass movement of refugees, and outbreaks such as cholera. However, Nguyen’s observation of American military hospitals in Syria and Lebanon led him to discover a different causal path linking war and health epidemics. 

“We have two events: the American invasion of Iraq and the global rise of antibiotic-resistant bacteria, and I want to argue that they are linked,” Dr. Nguyen said.

The lack of available healthcare due to the war in the Middle East may be the cause of a global bacterial epidemic. In resource-poor and overwhelmed American military hospitals across the Middle East, medics and doctors prescribe the strongest forms of antibiotics, which contributes to the rise of multi-drug resistant bacteria. 

The most prevalent multi-drug resistant bacteria that has spread throughout the Middle East is Acinetobacter baumannii, nicknamed Iraqibacter. This bacteria was first observed in severely wounded American soldiers. “The typical [wounded] Iraqi serviceman just dies, while the American servicemen get top-notch medical care. So it makes sense that this multi-drug-resistant bacteria arose in the American population,” Dr. Nyugen said.

The widespread use of antibiotics is not caused by irresponsible doctors who waywardly prescribe antibiotics, Nyugen argued. In Syria, military hospitals do not always have enough facilities, painkillers, and manpower necessary to treat severe wounds, so strong antibiotics are the only solution. 

Nyugen claims that these facilities are under-resourced because enemy forces aim to keep them that way as part of their war strategy. Dr. Nyugen said he has seen what he terms the Syrian “Department of Deletions” remove specific items from U.S. medical supply convoys, such as chlorine and gloves, while leaving scalpels and strong antibiotics. This is a strategy to propagate infection and strengthen bacteria in the wounds of soldiers. Other tactics used to specifically wound soldiers and propagate infection include filling bombs with nails and feces.

In military hospitals, only the strongest antibiotics are available. These powerful antibiotics, called carbapenems, may seem like a miracle drug: they can destroy nearly any bacteria. However, carbapenems prompt all kinds of initially treatable bacteria to adapt and acquire antibiotic resistance. 

“It’s not the bacteria that are resistant, it’s [that] the bacteria have the genes which confer resistance,” Nguyen said. These resistance genes code for pumps which are able to remove antibiotic medicines from the cell. The result of widespread carbapenem use is strong, drug-resistant bacteria like Iraqibacter.

Nguyen described Iraqibacter as “a reservoir for these genes that it is pumping out into more common pathogens that are infecting humans” and a “model for a broader process that may be of great epidemiological significance.” 

The spread of resistance genes leads to the rise of antibiotic-resistant bacteria, which could have an immense impact on otherwise safe medical procedures in U.S. civilian hospitals. Nguyen warned, “if we no longer have effective antibiotics, we could be forced to go back 100 years, so to speak, in medical history.” 

Iraqibacter outbreaks in the Montreal hospital where Nyugen works have already taken lives. Nyugen, though self-conscious about seeming alarmist, is confident antibiotics will be useless soon and argues there is an urgent need for alternative treatments to combat bacterial infection.

Nyugen then spoke of his more recent work in 2018, in temporary Ebola clinics in the Democratic Republic of the Congo. In the wake of the Ebola outbreak, humanitarian aid seemed to generate violence, however he distinguishes this violence from the healthcare-related war strategies he witnessed in Syria. Humanitarian organizations had to hire armed soldiers to protect healthcare facilities and locals began to take up arms against one another. 

“These are attacks on healthcare workers not as a particular tactic in war.... It was something completely different. The attacks were essentially driven by anger over the resources that were coming in and that were not being shared, enormous amounts of money that were paying all the Ebola staff.” For most citizens of the Democratic Republic of the Congo, Ebola is far from being the most pressing concern.

In February 2018, two temporary Ebola clinics were burned to the ground, prompting some humanitarian aid organizations to close down their clinics.

Though Nguyen regards himself as clinician without a background in health policy and systemic issues, the crowd pressed him to talk about system-wide solutions. He pointed to a flawed strategy in infectious disease research, called the “magic bullet approach.” In this approach, often funded by the Gates Foundation and the Chan Zuckerberg Initiative, disease epidemics are treated as “an engineering problem” to be solved. 

“Political will diminishes, the closer you get to the target,” Dr. Nyugen said. In the magic bullet approach, a few decades of intensive research yields incremental results until the epidemic has diminished but has not been eradicated, and interest in its research peters out. 

Ultimately, Nyugen put the responsibility on organizations like the World Health Organization to enact solutions, saying they need to prioritize long-term healthcare and sanitation over surge treatment of sensationalized epidemics. 

Nyugen also emphasized horizontal programs such as those for literacy and the education of women. People are going to donate for “human reasons” when they read the news about the Ebola epidemic, Dr. Nyugen said, and it’s up to organizations to take those funds and use them most effectively.