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• In conflict-affected areas, the destruction of healthcare facilities and severe shortages of medical supplies undermine effective infection prevention and control, leading to increased reliance on broad‑spectrum antimicrobials and heightening the risk of emerging AMR bacteria.
• Environmental contamination from conflict, particularly heavy metal pollution, can influence how bacteria acquire resistance and has been identified as a potential driver of novel resistance mechanisms.
• Global human mobility, including the movement of forcibly displaced people, poses new challenges for national AMR strategies worldwide in terms of managing the cross-border spread of AMR bacteria.
• In Japan, AMR bacteria that were previously only prevalent overseas have already been detected. In an era of globalization, there is an urgent need to strengthen surveillance of global AMR trends and further adapt the healthcare delivery to the globalization, including through improved multilingual support, as a key component of health security measure.
  
  

Antimicrobial resistance (AMR) occurs when bacteria (pathogens) change in response to antimicrobial use and those medicines become less effective. AMR is considered one of the most serious health threats facing humanity today. In high‑income countries including Japan, AMR measures are implemented on the basis of basic hygiene management, infection prevention and control in healthcare settings, and advanced medical technologies.

In contrast, in conflict-affected areas, the collapse of healthcare systems makes AMR control extremely difficult. In these settings, immediate life-saving care takes priority, and infection control efforts including AMR countermeasures are often deprioritized. However, AMR can directly limit available treatment options in these situations. Because resistant bacteria can spread across borders, international action is essential. In an increasingly globalized world, the status of AMR control in other countries, especially in conflict zones, is an important issue that requires attention in Japan as well.

AMR Alliance Japan (Secretariat: Health and Global Policy Institute) has been working to advance AMR policies in collaboration with people affected by AMR in Japan and overseas. As part of this work, the Alliance has been collecting the perspectives of patients, people concerned by AMR, and citizens since 2021. Previous entries in “Lived Experiences” have also shared the experiences of physicians who provided care in conflict zones and underlined the importance of AMR control in those contexts.

Against this backdrop, this policy update will provide an overview of real-world circumstances surrounding AMR in conflict zones overseas and how Japan’s healthcare and health security may be impacted by human mobility in and beyond conflict zones.

Issues caused by the destruction of healthcare facilities

In recent years, attacks on healthcare facilities in conflict zones like the Gaza Strip have greatly hindered efforts in AMR control. The destruction of microbiological testing facilities makes it impossible to perform proper pathogen identification and drug susceptibility testing during infectious disease outbreaks. Not only does this obstruct antimicrobial stewardship, it also results in greater reliance on broad-spectrum antimicrobials, which are drugs that are effective on many organisms. Excessive use of these drugs increases the risk that new AMR strains will emerge.

Access to medical services is limited in regions where existing medical facilities no longer function, and medical staff may be left with no choice but to provide treatment with insufficient equipment. In areas where access to medical services is limited and facilities are ill-equipped to provide care, shortages in supply and manpower make it difficult to maintain hygiene standards, and practices such as zoning and hand hygiene are more likely to deteriorate. Proper medical waste disposal also becomes difficult. These factors and the environmental impacts of conflict (such as heavy metal contamination or water pollution) can lead to the emergence of new AMR bacteria.

Crisis in the Gaza Strip: Diminished infection control capacity due to medical supply shortages

As conflict escalates in the Gaza Strip, medical staff are struggling to contain infectious disease outbreaks in the face of extreme shortages in medical resources caused by roadblocks and hospital bombings. Conditions have become so severe that physicians cannot use disinfectants and must treat maggot-infested wounds with vinegar. Epidemiologist Krystel Moussally of Médecins Sans Frontières describes how these conditions increase the risk of AMR, saying, “Wounds are left open much longer [and the] injured are delayed in receiving proper care or not able to get care at all, which increases the risk of infections and emergence of antimicrobial resistance.” Infections caused by such bacteria are difficult to treat with common antimicrobials and, in severe cases, they can lead to limb amputation or death.

The impact of environmental contamination and climate change

Another major concern is how the mechanisms by which bacteria develop resistance may be impacted by the environmental destruction caused by conflict, particularly heavy metal contamination. The use of weapons, explosives, and military vehicles in conflict zones can cause heavy metals like lead, mercury, chromium, copper, nickel, and zinc to accumulate in the environment, which are toxic to humans as well as to bacteria. As bacteria develop defense mechanisms against these substances, the interplay among heavy metals and AMR genes may lead to the emergence of new resistance mechanisms.

Climate change also has effects on AMR countermeasures in times of conflict. When social infrastructure like healthcare facilities, water treatment facilities, or drainage systems are destroyed in a conflict, that region becomes vulnerable to the direct impacts of flooding and extreme weather events. Flooding can cause sewage containing AMR bacteria to leak from malfunctioning sewage treatment facilities, increasing the risk of AMR spreading to areas where people live. As rising temperatures are known to facilitate bacterial growth and accelerate AMR gene transmission among bacteria, heat is another concerning factor for the spread of AMR.

International human mobility and its impact on Japanese society

As globalization progresses, international human mobility has become an important aspect of infectious disease control. One particularly serious concern is the health and wellbeing of people who have been forcibly displaced due to conflict or persecution. A 2022 report by the United Nations High Commissioner for Refugees (UNHCR) states that approximately 108 million people around the world have experienced forced displacement. This is equivalent to over 1.4% of the global population. Over half of forcibly displaced people are from Afghanistan, Syria, and Ukraine, which have experienced major conflicts in recent years. People who experience forced displacement face serious risks to health due to limited healthcare access and poor living conditions. Among those risks, the chance that someone may be infected with or infect others with AMR bacteria are particularly concerning. A systematic review of AMR among migrants in Europe showed that forcibly displaced people and other migrant groups have significantly higher rates of carriage or infection with AMR organisms.

International human mobility also has an impact on measures for AMR in Japan. Each year, approximately 32 million people from overseas visit Japan, and some have a history of travel in South Asia or Southeast Asia. It has been reported that people who travel to South Asia and Southeast Asia have high rates of acquiring multidrug-resistant Enterobacterales (MRE). In fact, a Dutch study reported that 75.1% of people who traveled to South Asia acquired MRE during their visit.

Furthermore, when treating people who are not fully proficient in Japanese, medical staff may encounter language barriers that prevent the accurate communication of medication instructions. There are cases when they cannot fully convey important instructions such as, “Make sure to take your full course of antimicrobials.” A survey of hospital pharmacists in Japan found that they felt there are language barriers when communicating with inpatients from overseas, with over 72% of them responding, “I can only do the bare minimum.” There were also cases in which it was difficult for patients and pharmacists to communicate their intentions with translation devices or in which patients responded to statements even when they did not fully understand what was being said. Another noteworthy concern is the difficulty of conveying technical medical terminology to patients through translation. In particular, even when translation devices are used, regional differences in meaning or phrasing can hamper multilingual support, particularly for commonly-used languages in Japan like Portuguese or Chinese. It has also been suggested that linguistic and cultural differences may lead to gaps in mutual understanding. Due to incomplete treatments that result from such scenarios, antimicrobials act as a selective pressure that allows only AMR bacteria to survive. It has also been noted that medical facilities in Japan have a shortage of medical interpreters and offer limited multilingual support. Given the growth in international visitors, there is an urgent need to internationalize healthcare as part of AMR control.

Domestic trends in AMR

There are reports of AMR bacteria that were mainly prevalent overseas being detected within Japan. These include cases of imported strains of highly-pathogenic microorganisms such as carbapenem-resistant Enterobacterales (CRE) and Candida auris being detected in domestic medical facilities. Responding to such outbreaks will require implementing new measures in real-world healthcare settings.

While these AMR strains may not have been directly imported from conflict zones, the fact that such outbreaks have occurred suggests that AMR strains from around the world can spread through underinvestigated pathways as globalization further increases the movement of people and goods.

In conclusion

At first glance, AMR in conflict zones may seem like an issue that only affects distant regions, but in an era of globalization, it is a direct concern for our health security. As discussed in this policy update, multiple factors caused by conflict are contributing to the spread of AMR, including the collapse of healthcare infrastructure, environmental pollution, and international human mobility.

While Japan’s medical facilities have been implementing sophisticated measures for infectious disease control, responding to the emergence of new AMR bacteria or mechanisms will be a challenge for the future. As environmental pollution and inappropriate antimicrobial use in conflict zones may accelerate the development of novel AMR mechanisms, ongoing surveillance will be necessary.

Moving forward, while carefully monitoring domestic trends in AMR, measures must also be advanced to respond to new infectious disease outbreaks that may occur as a result of international human mobility. This is not a short-term problem related to treatment; rather, it will be a key challenge for ensuring the continued sustainability of healthcare.

 

References

1. Khan, M. (2024). Gaza bombardment worsens superbug outbreaks [News article]. The Bureau of Investigative Journalism. Retrieved May 1, 2025, from https://www.thebureauinvestigates.com/stories/2024-11-19/gaza-bombardment-worsens-superbug-outbreaks
2. Moussally, K. (2024). Gaza bombardment worsens superbug outbreaks [Interview]. The Bureau of Investigative Journalism. Retrieved May 1, 2025, from https://www.thebureauinvestigates.com/stories/2024-11-19/gaza-bombardment-worsens-superbug-outbreaks
3. Desai, A. N., Mohareb, A. M., Hauser, N., & Abbara, A. (2022). Antimicrobial resistance and human mobility. Infection and Drug Resistance, 15, 127–133. https://doi.org/10.2147/IDR.S305078
   
4. Kurihara, O., Hosono, M., Kudo, K., & Shimomura, F. (2023). A survey on the actual practices of hospital pharmacists in caring for inpatient foreigners. Proceedings of the 17th Annual Meeting of the Japanese Pharmaceutical Communication Society (in Japanese), Abstract No. P-04.
5. Nellums, L. B., Thompson, H., Holmes, A., et al. (2018). Antimicrobial resistance among migrants in Europe: A systematic review and meta-analysis. The Lancet Infectious Diseases, 18(7), 796–811. https://doi.org/10.1016/S1473-3099(18)30219-6
6. Abou Fayad, A., Rizk, A., El Sayed, S., et al. (2023). Antimicrobial resistance and the Iraq wars: Armed conflict as an underinvestigated pathway with growing significance. BMJ Global Health, 7, e010863. https://doi.org/10.1136/bmjgh-2022-010863
7. United Nations High Commissioner for Refugees. (2023). Global trends: Forced displacement in 2022. Geneva: UNHCR.
8. Yusuff, A., et al. (2023). Antimicrobial resistance and the human mobility nexus: A review of the evidence. Tropical Diseases, Travel Medicine and Vaccines, 9, 12. https://doi.org/10.1186/s40794-023-00198-6
9. Pallett, S. J. C., Boyd, S. E., O’Shea, M. K., et al. (2023). The contribution of human conflict to the development of antimicrobial resistance. Nature Medicine. https://doi.org/10.1038/s43856-023-00386-7

 

Authors

Shotaro Tsukamoto (Senior Associate, Health and Global Policy Institute)
Gail Co (Program Specialist, Health and Global Policy Institute)
Eri Cahill (Associate, Health and Global Policy Institute)
Yui Kohno (Manager, Health and Global Policy Institute)