By Omar Dewachi

Emergent Conversation 18

This essay is part of the series Remnants of Empire, PoLAR Online Emergent Conversation 18 

A Biological Affair

Over the past twenty years, Iraq has experienced a scale of violence unmatched in the country’s modern history. The aftermath of the US-led occupation (2003–2011) has resulted in a corrupt political system, massive population displacement, sectarian and ethnic wars, and city and ecosystem devastation. As Iraqis strive to rise above these violent legacies, they confront another looming threat—a war biology that thrives amid the wreckage of human bodies and infrastructure.

In February 2023, my decade-long investigation into war injuries and the escalation of antimicrobial resistance in Iraq led me to Mosul, where local doctors in collaboration with MSF (Médecins Sans Frontières) teams have been dealing with the clinical impacts of war-induced antimicrobial resistance (AMR) first hand at al-Wahda Trauma Hospital (Dewachi 2019). A recent report indicates that nearly 90 percent of patients treated at the hospital with microbiologically confirmed infections were diagnosed with multi-drug resistant microorganisms–one of the highest figures seen in the region (M’Aiber et al. 2022). There is a history to this war biology.

Since 2003, injured bodies in Iraq have increasingly shown higher rates of multidrug-resistant bacterial infections, linked to decades of war in the country (Abou Fayad et al. 2023). Throughout the occupation, returning US soldiers wounded in Iraq contracted superbugs that were carried back to military and civilian medical hospitals in the United States (Brown 2006). Over the following decade, antimicrobial-resistant infections became commonplace in Middle Eastern healthcare settings, where Iraqis sought treatment away from their dysfunctional healthcare system (Fily et al. 2019). Unfortunately, Iraq’s primary care hospitals, where most newly injured individuals receive treatment, have failed to produce AMR data due to the crumbling research and medical surveillance infrastructures, and the failure of subsequent governments to invest in responding to this critical crisis in the country’s healthcare systems.

Battle of Mosul

MSF’s al-Wahda is a makeshift hospital with 40-bed that was established in 2018 after the Battle of Mosul (2016-2017), one of the largest and catastrophic urban military operations since WWII. This ten-month military campaign, initiated by the Iraqi government with the aerial support from international forces (primarily the US), aimed to reclaim Mosul from the Islamic State (IS), which seized the city in 2014.

All kinds of horrors were permissible during the Battle of Mosul. During the Islamic State reign, civilians suffered numerous atrocities, which continued during the subsequent military operation to retake the city. Civilian transgressions were committed by the Iraqi government and pro-government militias, as well as the international coalition supporting them (Khan 2021). Despite the US and Iraqi governments refusing to publish a final casualty report, it is estimated that over twelve thousand people died, with hundreds of thousands displaced. Approximately 65 percent of the old city of Mosul and its historical center was decimated. More than 138,000 homes were destroyed, with 53,000 in West Mosul alone. Significant damage was inflicted on the University of Mosul, with about 70 percent of its buildings and laboratories destroyed, and the main library, housing 3 million books, incinerated. The estimated cost of the damage inflicted on the housing sector alone is approximately US $6 billion. Moreover, it is projected that the 12 million tons of war debris will take a decade to clean-up. The death toll continues to rise with the ongoing discovery of bodies and mass graves amid the rubble (OCHA 2020). Additionally, the number of stubborn infections marking the bodies of the survivors of this catastrophe is also increasing.

Witnessing

Today, al-Wahda hospital stands as a critical trauma center amid the scars of the city, a site of MSF’s “witnessing” of the visible and invisible aftermath of that war and its biological afterlives. Since the Battle of Mosul ended, this MSF hospital has been providing medical and surgical care to thousands of injured civilians and systematically documented the spectrum of resistant bacterial infections they carry. Osteomyelitis, or bone infection, is a frequent complication of wounds treated at the hospital, the majority of which are caused by antimicrobial-resistant bacteria–a significant challenge in post-conflict healthcare delivery and city recovery (M’Aiber et al. 2022).

At Al-Wahda, I met Dr. Zakariya, a dynamic and young Iraqi orthopedic surgeon who endured the Battle of Mosul before joining MSF. Throughout the conflict, Zakariya tirelessly served at Al-Salam public hospital—a six-story facility offering medical and surgical care on the city’s Eastern side, prior to its obliteration by bombing.

One of the most significant casualties of the conflict was Mosul’s healthcare infrastructure. Nine out of thirteen public hospitals in Mosul were decimated during the battle (MSF 2018). The fiercest and final skirmishes of the war unfolded in these hospitals, where Islamic State fighters took refuge with their wounded amid the barrage of aerial bombardments and gunfire. Tens of thousands of injured people required clinical care and repeated surgeries. These patients circulated among the remaining local hospitals, and ad-hoc triage and surgery units provided by military, civilian, and humanitarian entities (Garber et al. 2020).

During this patient surge, Zakariya operated on both fighters and civilians—debriding wounds, installing external fixators to mend open fractures, and performing limb amputations. “There were no breaks. I worked seven days a week and had to trust my instincts,” he explained. Oddly, a perverse form of war telemedicine emerged: Zakariya sent photos, x-rays, and lab results to his senior surgeons, many of whom were either out of town or too fearful to approach the city. Often, he had to improvise, turn to textbooks, or make decisions based on his judgment and limited expertise. For Zakariya, the catastrophe in Mosul was monumental. However, the horror paradoxically pushed him to enhance his surgical skills: “Eight limbs in one day was my record,” he shared with a grim sense of pride.

Today, Zakariya only practices as an orthopedic surgeon part-time. He now plays a crucial role as one of the local doctors managing the antibiotic stewardship program at al-Wahda. In this capacity, he meticulously evaluates incoming patients with wound infections, guaranteeing they receive the correct antibiotic treatment.

Aftermath

Six years post-conflict, antimicrobial resistance persists, now manifesting in traffic and work-related injuries that have supplanted the influx of war-wounded patients. Wound culture results consistently reveal bacteria resistant to a broad spectrum of market-available antibiotics. Most first-line antibiotics are now obsolete, and Methicillin Resistant Staphylococcus aureus (MRSA), a notorious hospital-acquired infection, tops the list of superbugs cultured from patients.

I asked Zakariya, “How are patients contracting these infections?” He attributes the issue to failed hospital sanitation systems and practices, excessive antibiotic use in patients, and a lack of proper lab work to identify culture and sensitivity. “We don’t have sanitation guidelines or protocols in our public hospitals,” he explains. “We administer antibiotics to patients as if we’re engaged in qasf ‘ashwa’I, or ‘indiscriminate shelling’.” Zakariya’s critique of the healthcare system aligns with common narratives of antibiotic stewardship discourses that often frame antimicrobial resistance around the “irrational” use of antibiotics in hospitals and other settings. Yet, this practice in Iraqi hospitals isn’t new and, in fact, has deep roots within Iraq’s complex history of healthcare degradation under decades of war and sanctions.

Throughout the 1990s, Iraqi doctors, grappling with the collapse of sanitation and laboratory infrastructure due to UN-imposed sanctions, began altering wound care practices in response to a surge in hospital infections and a dearth of basic medical supplies. Doctors had to innovate: reusing disposable gloves on multiple patients, economizing surgical stitches, and tolerating overcrowded hospitals (Dewachi 2017). They also normalized what Zakariya characterizes as the “indiscriminate shelling” approach, employing broad-spectrum antibiotics to combat unruly ward infections. Patients typically received a cocktail of three antibiotics to combat all possible infections—a practice passed down from one medical generation to the next, especially during the years of occupation when hospitals were regularly inundated with injuries from counterinsurgency operations and sectarian violence. Throughout these years, infections ran rampant and both US medical authorities—aware of the issue’s extent—and subsequent Iraqi authorities failed to address the rising risks within, and of, Iraqi hospitals.

Another factor driving these infections, as Zakariya and his colleagues now confront, is the degraded urban environment and patients’ exposure to multidrug-resistant bacterial cocktails present in the city’s debris, contaminated water, and open sewage canals linking residential, commercial, and agricultural areas. Within these ecosystems, various microbial communities exchange plasmids and genetic material, mutating into harmful pests and superbugs. “I ask patients involved in accidents if they’ve fallen or were exposed to sewage gutters or roadside garbage piles,” Zakariya explains. “If the answer is yes, then I’m over 95percent certain this patient will have an XDR (an extremely resistant superbug).” Zakariya’s clinical observations resonate with the realities of environmental pathways of antimicrobial resistance among Iraqi patients in Mosul and other Iraqi cities subjected to widespread destruction. His insights corroborate emerging literature increasingly linking environmental antimicrobial resistance with toxic and heavy metal contaminations (Bazzi et al. 2020). The destructive elements of warfare, from the ruin of physical infrastructure such as hospitals, factories, and agricultural sites, to the environmental hazards caused by leakages from these decimated facilities, contribute to a hostile ecosystem. The amalgamation of human and non-human waste blurs the boundaries between the human body and this antagonistic war ecology.

Furthermore, the war’s aftermath and the devastation of Iraq’s public hospitals and pharmaceutical industry have given rise to an unregulated drug market that burgeoned post-2003. Iraqi pharmacies increasingly act as gatekeepers to this amalgam of formal and informal therapeutic economies. Over-the-counter antibiotic prescriptions are exceedingly prevalent in these establishments, and even the most potent antibiotics—typically designated for in-hospital treatment—are readily available for procurement and dispensing. Additionally, these pharmacies serve as intermediaries in an informal pharmaceutical economy, trading in substandard medications sourced from suppliers spanning from China to makeshift manufacturers in neighboring Turkey and Syria. Many of these supply chains fall under the control of Iraqi militia leaders and politicians who exploit the country’s rampant corruption for personal profit (Mansour and Sirri 2022)

Where Life, Infrastructure, and Science Meet

Antibiotic resistance has become one of the symptoms of our modern day living—a “biology of history” in infrastructure, produced and sustained through the mass production and usage of antibiotics in therapeutics and animal farming during the past and present centuries (Landecker 2016). However, Iraq tells a different history of biology and infrastructure. Here, inhabitants grapple with a lifeworld of festering wounds—a local biology that resists healing. Amid the ruination of Iraq’s healthcare systems, where hundreds of thousands of such wounds have traversed, antibiotic resistance has become the norm; symptomatic of a multifaceted war biology birthed by infrastructural wounding and dissolution under decades of war and sanctions.
While sanctions may masquerade as a non-warfare approach, their effects create a biological regime that mirrors warfare conditions (Gordon 2012).

In Iraq, a wound transcends personal or societal significance (Dewachi 2015); a wound is an environmental event—registered in both human and nonhuman life. The persistence of such wounds embodies the enduring remnants of empire and foreshadows a global future grappling with the dwindling of the antibiotic era.

As we commemorate the 20th anniversary of the Iraq War, it signifies an opportunity to reflect on this turbulent chapter of history, even as the Iraqi people still grapple with its enduring aftermath. In 2003, the US invaded Iraq under the guise of eliminating the country’s supposed threats of biological weapons and weapons of mass destruction. These weapons were never found. Instead, Iraq became a stage for a large-scale, enduring experiment in war biology, the reach and scope of which lingers in the collapse and reconfiguration of healthcare infrastructure, the quest for care by populations, and widespread environmental degradation. Iraq’s AMR crisis however is not only a legacy of this closing chapter of history. Rather it signals a precarious future looming on a planetary scale as the machinery of empire’s war relocates.

The enormity of the war and its aftermath demands that we delve into the complexity of its consequences and envision new approaches towards accountability and justice. What does it mean to identify and understand the collateral damage of war, or even the collateral of that collateral? The efforts of MSF in Mosul have been instrumental in chronicling the heavy toll of the war and the widespread healthcare crises that persist in the country. Their focus centers on providing care to war injuries, improving antimicrobial stewardship and enhancing laboratory procedures. They also strive to provide technical assistance to the Iraqi Ministry of Health and local hospitals. This work is coming to an end. Confronted by significant obstacles arising from protracted and obscure government procedures, which severely impeded the organization’s capacity to sustain supplies for their projects, MSF made the decision to suspend their critical operations in the city of Mosul.

The suspension of MSF activities in Mosul casts a shadow of uncertainty over the future of AMR surveillance in Iraq. Without their valuable contributions and on-the-ground efforts, AMR surveillance initiatives face significant challenges. That said, MSF’s work in Iraq serves as both a solution and a reflection of the problem’s scale. While it addresses some challenges, it only represents a fraction of the broader issues that persist in various Iraqi cities and healthcare systems. The organization’s efforts also highlight the fleeting nature of such interventions, underscoring the necessity of implementing sustainable, long-term solutions.

To tackle these challenges effectively, it is imperative to allocate significant resources and investments to multidisciplinary investigation teams. These teams should consist of experts from diverse fields, including microbiology, epidemiology, environmental research, and anthropology. By collaborating, these teams can systematically collect evidence elucidating the extensive impact of post-war consequences on both the population and their surroundings. Ideally, the state should play a crucial role in investing in comprehensive research and robust scientific infrastructure. However, this ideal scenario has been hampered by the devastating impact of decades of conflict and the persistent presence of corrupt militia rule in the country. Both research and scientific development have suffered as casualties under these challenging circumstances and lack of accountability.

A friend once told me, musing on the impunity of America’s long wars in Iraq, “Iraq is the place where accountability goes to die!” For the superbugs that thrive in the ruinations of empire, life has just begun.

?w=200″ alt=”” width=”180″ height=”120″ />Omar Dewachi is Associate Professor of medical anthropology at Rutgers University and the co-founder of the Conflict Medicine Program at the American University of Beirut. Trained in clinical medicine and anthropology, Dewachi’s work examines the social, medical, and environmental consequences of war and violence in Iraq and the broader Middle East. He is the author of numerous publications that have appeared in medical, anthropological, and global health journals, including the Lancet. His award-winning book, Ungovernable Life: Mandatory Medicine and Statecraft in Iraq documents the untold history of the rise and fall of Iraq’s healthcare under decades of US-led interventions. His forthcoming manuscript, When Wounds Travel, chronicles close to ten years of ethnographic research and public health work on war and displacement across East of the Mediterranean.  The work documents the wide spread of conflict-related injuries, Multi-Drug Resistant Bacteria, and the reconfigurations of healthcare and humanitarian geographies in Iraq, Syria, and Lebanon under decades of protracted conflicts.

Works Cited

Abou Fayad, Antoine, Anthony Rizk, Samya El Sayed, Malak Kaddoura, Nadine K Jawad, Adel Al-Attar, Omar Dewachi, Vinh Kim Nguyen, and Zahy Abdul Sater. 2023. “Antimicrobial Resistance and the Iraq Wars: Armed Conflict as an Underinvestigated Pathway with Growing Significance.” BMJ Global Health 7 (Suppl 8): e010863. https://doi.org/10.1136/bmjgh-2022-010863.

Bazzi, Wael, Antoine G. Abou Fayad, Aya Nasser, Louis-Patrick Haraoui, Omar Dewachi, Ghassan Abou-Sitta, Vinh-Kim Nguyen, et al. 2020. “Heavy Metal Toxicity in Armed Conflicts Potentiates AMR in A. Baumannii by Selecting for Antibiotic and Heavy Metal Co-Resistance Mechanisms.” Frontiers in Microbiology 11. https://www.frontiersin.org/articles/10.3389/fmicb.2020.00068.

Brown, Collin. 2006. “Superbug Brought Back by Iraq War Casualties.” The Independent. November 8, 2006. https://www.independent.co.uk/life-style/health-and-families/health-news/superbug-brought-back-by-iraq-war-casualties-5331208.html.

Dewachi, Omar. 2015. “When Wounds Travel.” Medicine Anthropology Theory 2 (3). https://doi.org/10.17157/mat.2.3.182.

—. 2017. Ungovernable Life: Mandatory Medicine and Statecraft in Iraq. 1st edition. Stanford University Press.

—. 2019. “Iraqibacter and the Pathologies of Intervention.” MERIP, January. https://www.academia.edu/39768334/Iraqibacter_and_the_Pathologies_of_Intervention.

Fily, Fabien, Jean-Baptiste Ronat, Nada Malou, Rupa Kanapathipillai, Caroline Seguin, Nagham Hussein, Rasheed M. Fakhri, and Céline Langendorf. 2019. “Post-Traumatic Osteomyelitis in Middle East War-Wounded Civilians: Resistance to First-Line Antibiotics in Selected Bacteria over the Decade 2006–2016.” BMC Infectious Diseases 19 (1): 103. https://doi.org/10.1186/s12879-019-3741-9.

Garber, Kent, Adam L. Kushner, Sherry M. Wren, Paul H. Wise, and Paul B. Spiegel. 2020. “Applying Trauma Systems Concepts to Humanitarian Battlefield Care: A Qualitative Analysis of the Mosul Trauma Pathway.” Conflict and Health 14 (1): 5. https://doi.org/10.1186/s13031-019-0249-2.

Gordon, Joy. 2012. Invisible War: The United States and the Iraq Sanctions. Reprint edition. Cambridge, Mass.: Harvard University Press.

Khan, Azmat. 2021. “Hidden Pentagon Records Reveal Patterns of Failure in Deadly Airstrikes.” The New York Times, December 18, 2021, sec. U.S. https://www.nytimes.com/interactive/2021/12/18/us/airstrikes-pentagon-records-civilian-deaths.html.

Landecker, Hannah. 2016. “Antibiotic Resistance and the Biology of History.” Body & Society 22 (4): 19–52. https://doi.org/10.1177/1357034X14561341.

M’Aiber, Sabreen, Karlyn Maamari, Anita Williams, Zakariya Albakry, Ali Qasim Mohammad Taher, Farah Hossain, Said Fliti, Ernestina Repetto, and Krystel Moussally. 2022. “The Challenge of Antibiotic Resistance in Post-War Mosul, Iraq: An Analysis of 20 Months of Microbiological Samples from a Tertiary Orthopaedic Care Centre.” Journal of Global Antimicrobial Resistance 30 (September): 311–18. https://doi.org/10.1016/j.jgar.2022.06.022.

Mansour, Renad, and Omar Sirri. 2022. “Moving Medicine in Iraq: The Political Economy of the Pharmaceutical Trade.” Chatham House – International Affairs Think Tank. June 8, 2022. https://www.chathamhouse.org/2022/06/moving-medicine-iraq-political-economy-pharmaceutical-trade.

MSF. 2018. “Mosul: Hospital Beds Available Still down 70%, a Year after Battle Ended.” 2018. https://prezly.msf.org.uk/mosul-hospital-beds-available-still-down-70-a-year-after-battle-ended.

OCHA. 2020. “Mosul after the Battle: Reparations for Civilian Harm and the Future of Ninewa – Iraq | ReliefWeb.” January 22, 2020. https://reliefweb.int/report/iraq/mosul-after-battle-reparations-civilian-harm-and-future-ninewa.