Omar Dewachi traces the rise of antibiotic resistant bacteria in war-related wounds—which US military doctors labelled Iraqibacter—to the biological legacy of decades of sanctions, war and intervention in Iraq.
In the wake of the US invasion of Iraq in 2003, US military surgeons began reporting on an “invisible enemy” that they called “Iraqibacter.” The moniker referred to Acinetobacter boumannii, a bacterium which was causing serious infections among wounded US military personnel. Subsequent reports in the US media created a major hype about this bacterium, often using the moniker to indicate that it was carried from US field hospitals in Iraq back to the United States along military evacuation lines.[1] In the United States, Iraqibacter was infecting non-military patients as well.
In 2012, the popular PBS science show, NOVA ScienceNOW, dedicated an entire episode to Iraqibacter, entitled Killer Microbe. In ominous terms, the reporter described the rise of this dangerous war pathogen:
"There is a killer on the battle-torn streets of Iraq, but it does not carry a gun. It is attacking injured soldiers…Here is the culprit, it is a bacterium called baumannii, referred to in Iraq as Iraqibacter. It is named for microbiologist Paul Bauman, who researched it in 1968. But even he couldn’t predict what this tiny single-celled organism would one day become. Like most bacteria, it lives in colonies and its constantly reproducing, simply by dividing and dividing again. A single bacterium can give rise to five million trillion in only a day. This bug used to be relatively harmless. Yet somehow it found a way to transform itself into a drug resistant killer."
The major challenge faced by military doctors and scientists was the bacterium’s increasing capacity to develop resistance against the strongest antibiotics while surviving for weeks on hard surfaces of hospital beds, door knobs and medical equipment. The episode delved deeper into the microbiology of this bacterium and explained how this “previously harmless bacteria” has become a major menace in war settings. The bacterium does not cause infection in otherwise healthy individuals—rather it opportunistically preys on patients with weakened immune systems or those with deep tissue damage, such as war wounds. In hospital settings it has a history of appearing in intensive care units where patients are hooked to ventilators for long periods of time.
A. baumannii also has a high tendency to acquire resistance genes from other bacteria that it comes in contact with. Over time, this bacterium has evolved to form biofilms—a phenomenon where bacterial communities stick to each other to survive on hard surfaces and to resist disinfectants. Most importantly, the biofilm allows the bacteria to communicate with each other and exchange genetic matter that helps it develop resistance to a wide range of antibiotics. One of the scientists in the episode explained how examining the genetic makeup of the bacterium shows multiple resistance genes condensed in its DNA structures, illustrating the ability of the bacterium to be a reservoir for resistant genes from its environment.
The NOVA episode, like much of the media coverage and scientific discourse about the bacterium, was littered with War on Terror tropes; the bacterium is described as an “invisible enemy” or “blood insurgent,” and even naming the pathogen Iraqibacter is war-tinged sensationalism. Sporadic outbreaks of resistant strains of this bacterium, in fact, had been reported in US military hospitals and other non-military settings prior to the invasion of Iraq. Moreover, reports from across conflict zones and major treatment centers in the Middle East—from Lebanon to Syria, Gaza and Yemen—have shown this pathogen is one of the main causes of wound infections in those healthcare settings.
Until recently, much of the reporting of A. baumannii in Iraq was done by the US military, which counterintuitively attributed the general increase in such infections among the military to the improved wounded-to-killed ratio from prior wars. Wounds are more likely to “carry organisms of environmental origin into hospital settings.”[2] Others have suggested that the increased resistance of this pathogen is mainly due to contamination of both military and civilian hospitals where injured military personnel and civilians are treated.[3]
The association of Iraqibacter with the US-led war in Iraq, however, is a more complex and contentious story. At the heart of the mystery is not whether the emergence of this bacteria can be attributed to the war, but whether the increased resistance of this bacteria is driven by military activities and interventions. Thus, while the increased reporting on this bacterium during the Iraq war gave rise to its notorious name there has been little attention to what is particularly Iraqi about Iraqibacter, given that it has been found elsewhere in the region.
Drawing upon a more environmental approach and focusing on war ecologies, the rise of Iraqibacter can be explored, and possibly explained, as less a matter of an inherent link to Iraq itself than an outcome of the wars that have taken place in Iraq over the past few decades. Asking what is particularly Iraqi about Iraqibacter may also encourage greater attention to the environmental degradation of decades of sanctions, bombing campaigns and military interventions that have transformed innocuous bacteria into dangerous drug-resistant strains.
I first came to know about A. baumannii’s infections during my ethnographic research on conflict-related injuries in the wake of the 2011 Arab Uprisings. In 2012, I began an ethnographic project documenting the experiences of wounded Iraqi patients travelling to Lebanon to seek healthcare in Beirut’s high-tech public and private hospitals. Patients there sought various forms of medical and surgical care, including treatment for cancer and reconstructive surgery. Some patients were moving back and forth between Iraq and Beirut, flying in as frequently as once a month to receive chemotherapy or undergo staged reconstructive surgeries for injuries they had incurred in Iraq. Patients and their families were on a quest for quality healthcare that was either unavailable or untrustworthy in Iraq’s war-torn healthcare infrastructure.[4]
These journeys were part of a broader phenomenon of medically-driven travel, delineating a sort of “therapeutic geography” of war linking zones of fighting in Iraq, Gaza, Syria, Libya and Yemen with humanitarian hospitals and medical hubs across the region in Lebanon, Jordan, Turkey, Iran and India.[5]
But in one Beirut hospital in particular, Iraqi cases seemed to present a significant clinical challenge to local doctors. “We see many tough cases from Iraq,” explained one of the surgeons at the hospital, whose workload has been transformed by the influx of wounded Iraqi patients. “Many are presenting with very aggressive types of wound infections. We are struggling with high rates of multi-drug resistance bacteria among those who are injured in suicide bombings and the ISIS war. These bugs could be transmitted to other patients, and we often put Iraqis in quarantine before admitting them into the regular wards.”
In this Beirut hospital, patient records revealed that at least half of the wounded Iraqi cases treated at the hospital had multidrug-resistance infections, with the majority caused by A. baumannii. Many cases of people injured in the ongoing civil war in Syria treated at the same hospital showed similar infection profiles, though at slightly lower rates for A. baumannii. Communications with different regional hospitals and humanitarian organizations revealed a wide spread of this pathogen in Syria,[6] Gaza,[7] Yemen[8] and Libya—all zones of intervention and war.[9] The scope of the problem reflected the difficulty of treating large numbers of war-injured patients in civilian and humanitarian hospitals across the region and the scramble of these hospitals to deal with an endemic problem of colonization by drug-resistant bugs—a problem with long-lasting public health and financial burdens on patients and health systems.
Medical explanations of the general global rise of drug resistance, including A. baumannii, often attribute it to the lack of infection control in hospitals and the ungoverned use of antibiotics—problems that often worsen during wartime. But, such an explanation fails to consider the complex context of war and its contribution to the changing ecologies of antibiotic resistance.
On the other hand, Iraqis I interviewed expressed ambivalence about the cause of such stubborn infections, attributing them to a wide range of problems including “pollution,” “insecurity,” “corruption,” “the United States,” “sectarianism,” “stress,” “Saddam” and so on. Their narratives, though general and confusing, consistently pointed to the broader political, environmental and social entanglements of these ailments in a toxic history and ecology shaping the conditions of their everyday survival.[10]
Driven by intuition, speculation and emerging ethnographic evidence about the experiences of war and injury in the region, the mystery of Iraqibacter and its increasing drug resistance in war settings is open to a number of historical and environmental hypotheses. Such theories are based on an understanding of the history of war interventions and their microbiological and environmental legacies. This type of analysis draws upon historian of science Hannah Landecker’s notion of the “biology of history” in researching the rise of antibiotic resistance in today’s post-industrial life.[11] Through understanding the biology of history, defined as the physical registration of human history in bacterial life, Landecker shows how the mass production of antibiotics on an industrial scale has shaped the biological evolution of today’s bacteria and the scale of antibiotic resistance that exists today globally. She argues that the industrial scale production of individual therapies targeting single pathogens, as well as the extensive use of antibiotics in animal farming, are “environmental events” affecting the evolution of bacteria far beyond our unregulated use of antibiotics in individual bodies.
Landecker thus invites us to think more dialectically about the “materiality of history and historicity of matter” to consider the dynamic entanglements between human activities and the development of antibiotic resistance both locally and globally. In the biology of history, bacteria are an archive of changing human ecology. Information captured through the genetic analysis of historical and contemporary samples of bacteria and soil might give us insights into the historical developments of antibiotic resistance.
What could such an archival project of A. baumannii samples from different war zones look like? What would it reveal about the history of political and environmental events and processes that have shaped the antibiotic resistance of Iraqibacter? While such an analysis to document the biology of war does not exist yet, there are a number of theories that can be considered based on an understanding of the historical context of war and interventions in Iraq and the potential ways toxic legacies of war drive the rise of antibiotic resistance.
Since 1980, Iraq has experienced the full spectrum of militarization which may have significantly impacted the rise of antibiotic resistance. The first conflagration, the Iran-Iraq war (1980–1988), is considered one of the longest conventional wars of the twentieth century. Fought along the borders of both countries, it left close to 1.5 million (mostly military personnel) dead and injured. Treatment in both countries took place in relatively advanced military hospitals, where antibiotic resistance was mostly under control.
Unlike the Iran-Iraq war, which was waged largely on battlefields, the First Gulf War (1990–1991) and sanctions regime on Iraq (1990–2003) destroyed the national infrastructure and undermined the country’s once advanced healthcare system.[12] The massive US bombing campaign in 1991 targeted the country’s vital networks of electricity, water sanitation and communication and left the provision of healthcare severely challenged. The restrictive 12-year sanctions regime which followed drove healthcare workers abroad, cut off a range of basic medical supplies, including a wide range of first-line antibiotics used to treat common infections, and contributed to skyrocketing child and maternal mortality rates.[13]
The 2003 invasion and occupation of Iraq was a direct assault on the entire country that brought carnage to Iraqi cities and triggered unprecedented political violence, death and war wounds. For nearly a decade, counterinsurgency warfare and resistance operations transformed the country’s urban landscape and neighborhoods into a war zone characterized by communitarian political violence, where the health infrastructure was severely compromised. It is estimated that hundreds of thousands of Iraqis have been killed and injured as a result of both military operations and terrorist attacks.[14] In their pursuit of spectacular demonstrations of violence and injury, suicide bombings specifically targeted markets, mosques and busy roads—all densely-populated public spaces where projectile debris and the proximity of the wounded aid the contamination of such wounds.
To understand the links and interactions of biology and the history of Iraq’s war ecologies, it is important to note that according to available literature from the 1980s and based on interviews and conversations with Iraqi microbiologists, drug resistant A. baumannii was not a known pathogen during the Iran-Iraq War. Problems attributed to antibiotic resistance came from other bacteria such as Pseudomonas and Staphylococcus, which presented clinical problems for both military and civilian physicians. One of the earliest reports of A. baumannii in the Middle East during the 1980s came from Lebanon, where microbiologists at the American University of Beirut reported a hospital epidemic of the bacterium after treating patients injured by Israeli bombardments in the mountains in 1986.[15] It was not until a decade later that the pathogen was reported again among Kuwaiti patients in a Saudi Intensive Care Unit (ICU) in 1994–1995. Outbreaks were also reported following the Marmara earthquake in Turkey in 1999 and in a Saudi neonatal ICU in 2002.
But the absence of reports about A. baumannii in Iraq during the 1990’s does not necessarily signify the absence of this pathogen, only that there was no active documentation of drug resistance during that period. Many laboratory consumables were unavailable or expired, rendering accurate microbiological cultures unreliable, while treatment tools such as surgical sutures and disposable gloves were often reused. These conditions translated into not only a loss of information about pathogens but also a rapid deterioration of infection control as surveillance and sanitation systems collapsed.
In response to the everyday shortages and the deterioration of health facilities in Iraq under the sanctions regime, Iraqi doctors became accustomed to using broad-spectrum antibiotics as a preventative strategy for surgical procedures in hospitals to address the rising problem of infections in the wards. This practice meant that doctors prescribed three antibiotics for every case in order to cover the range of possible bacterial and microbial infections.
For 12 years, the collapse of infection control at hospitals and the responsive overuse of antibiotics were further complicated by the continuous interruptions of antibiotic supplies and access under the UN economic embargo.[16] Certain antibiotics would be available one day and disappear another. Doctors switched antibiotics regularly, not according to treatment protocols but according to availability. Patients and their families begged relatives abroad to mail back supplies, or otherwise scrambled to locate scarce antibiotics spread across the country’s pharmacies stocked with counterfeit and expired medications. It was antibiotic anarchy, where the present-day ecology of antibiotic resistance in Iraq was a distant concern.
Could Iraqibacter be a byproduct of the antibiotic anarchy brought on by the Gulf War and sanctions? In the Iraqi context there have been no studies thus far documenting the extent of antibiotic resistance, yet stubborn infections continue to define clinical practice in hospitals, especially among wounded patients. At the same time, since 2003 and the lifting of the international embargo, a large variety of antibiotics have been reintroduced. Doctors and pharmacists explain that patients are often given third and fourth generation antibiotics as a first resort, often because there is a dread among patients that the first-line antibiotics—such as amoxicillin—have no effect. As one pharmacist put it when referencing patients’ persistent refusal to accept such medicines, “Even our bacteria are resistant.”
In addition to the antibiotic anarchy theory, another hypothesis links the rise of antibiotic resistance in war settings to the toxic environmental legacies of war, which are considerable in the case of Iraq. Scientific literature over the last two decades has shown links between heavy metal contaminants and the rapid development of resistance in bacteria. The environmental concentrations of such metals can increase dramatically in war zones, where large-scale infrastructure is pulverized and the explosion of large amounts of munitions leave a legacy of toxicity. Studies of contaminations in industrial and agricultural settings have shown how A. baumannii can become resistant to antibiotics after exposure to heavy metal contaminations in soil and water.[17] In scientific terms this is known as cross-resistance—where an organism develops tolerance to one substance as a result of exposure to a different substance.
Heavy metals exist naturally in the environment and each locality has its unique geo-history of heavy metal signatures. War introduces new elements to these ecosystems—from weapons, bomb-damaged infrastructure, oil fires and spills, the destruction of industrial facilities as well as hospitals, farms and so on. This process could explain the tendency of antibiotic resistance to arise alongside natural or human-made disasters marked by the destruction of the lived environment and failures of reconstruction which allow contaminants to linger. Despite this symbiosis of resistance and destruction, studies have not yet been devised to catalogue the scale and extent of environmental contamination-driven antibiotic resistance in war settings.
The moniker Iraqibacter has been used to describe an antibiotic resistant “superbug” that is linked to US military casualties in Iraq and its movement back to the United States. Despite the racial overtones of linking a bacterium to Iraq, asking what is “Iraqi” about Iraqibacter unravels links between decades of war and interventions and the increasing prevalence of antibiotic resistance in Iraq and other conflict zones in the region.
From bombing campaigns, to sanctions, to full scale invasion, to the so-called War on Terror, Iraq has been at the forefront of Western interventions over decades which have changed the very ecosystem in which people live. In such a context, Iraqibacter may be the culmination of many things: the decades of militarization and wounding, the collapse of infection control and infrastructure, the movement of the injured across the region to seek healthcare, the overuse and misuse of antibiotics driven by sanctions, the proliferation of poor-quality drugs and counterfeit medicines and the destruction and contamination of the natural and lived environment. All define a toxic legacy of decades of war that are endured in the wounds and bodies of Iraqis and their care projects.
Given the potential links between decades of militarization and the changing ecologies of wounds and antibiotic resistance, there is a need to expand our analytical perspectives to rethink what an archive of war history would include. Part of such history could be inscribed in the genetic life of bacteria—something that modern-day gene sequencing technologies could help us identify. What would it look like if we plot genetic kinship trees of bacteria onto a history of political events and changing healthcare practices? Understanding the links between history and biology will require a major scientific and research endeavor that brings together laboratory and environmental scientists and clinicians with historians and anthropologists to trace the historical splicing of resistance in the genetic makeup of the bacteria. Unravelling the genetic life of bacteria in time and space would just begin to link the microbiological biographies with the biographies and ecologies of war and intervention.
Iraqibacter is a true pathology of intervention. It stands as an archive of a cruel history, the manifestation of which runs deep through the wounds of Iraqis and the genetic make-up of their environments. ■
[1] See for example: Steven Silberman, “The invisible Enemy,” Wired Magazine, February 1, 2007.
[2] Robert E. Black, Laura B. Sivitz and Abigail E. Mitchell, Gulf War and Health: Volume 5: Infectious Diseases, Institute of Medicine, Board on Population Health and Public Health Practice (National Academies Press, 2006).
[3] Callie Camp and Owatha L. Tatum, “A Review of Acinetobacter Baumannii as a Highly Successful Pathogen in Times of War,” Laboratory Medicine 41/11 (November, 2010).
[4] Omar Dewachi, Anthony Rizk, and Neil V. Singh, “(Dis)Connectivities in Wartime: The Therapeutic Geographies of Iraqi Healthcare-Seeking in Lebanon,” Global Public Health 13/3 (2018).
[5] Omar Dewachi, Mac Skelton, Vinh-Kim Nguyen, Fouad M Fouad, Ghassan Abu Sitta, Zeina Maasri and Rita Giacaman, “Changing Therapeutic Geographies of the Iraqi and Syrian Wars,” The Lancet 383/9915 (February 2014).
[6] Aula Abbara, Timothy M. Rawson, Nabil Karah, Wael El-Amin, James Hatcher, Bachir Tajaldin, Osman Dar, et al., “A Summary and Appraisal of Existing Evidence of Antimicrobial Resistance in the Syrian Conflict,” International Journal of Infectious Diseases: IJID: Official Publication of the International Society for Infectious Diseases 75 (October 2018).
[7] Rupa Kanapathipillai, Nada Malou, Kate Baldwin, Pascale Marty, Camille Rodaix, Clair Mills, Patrick Herard and Malika Saim, “Antibiotic Resistance in Palestine: An Emerging Part of a Larger Crisis,” British Medical Journal (BMJ) 363 (October 15, 2018).
[8] Sam Loewenberg, “Yemen: A Deadly Mixture of Drug Resistance and War,” The Bureau of Investigative Journalism, April 15, 2018.
[9] Benedikt Lohr, Yvonne Pfeifer, Ursel Heudorf, Christoph Rangger, Douglas E. Norris, and Klaus-Peter Hunfeld, “High Prevalence of Multidrug-Resistant Bacteria in Libyan War Casualties Admitted to a Tertiary Care Hospital Germany,” Microbial Drug Resistance 24/5 (October 2017).
[10] Omar Dewachi, “The Toxicity of Everyday Survival in Iraq,” Jadaliyya, August 13, 2013.
[11] Hannah Landecker, “Antibiotic Resistance and the Biology of History,” Body & Society 22/4 (December 2016).
[12] Omar Dewachi, Ungovernable Life: Mandatory Medicine and Statecraft in Iraq (Stanford: Stanford University Press, 2017).
[13] Alberto Ascherio, Robert Chase, Tim Coté, Godelieave Dehaes, Eric Hoskins, Jilali Laaouej, Megan Passey, et al., “Effect of the Gulf War on Infant and Child Mortality in Iraq,” New England Journal of Medicine 327/13 (September 1992).
[14] Gilbert Burnham, Riyadh Lafta, Shanon Doocy and Les Roberts, “Mortality after the 2003 Invasion of Iraq: A Cross-Sectional Cluster Sample Survey,” The Lancet 368/9545 (2006).
[15] Ghassan M. Matar, E. Gay, R. C. Cooksey, J. A. Elliott, W. M. Heneine, M. M. Uwaydah, R. M. Matossian and F. C. Tenover, “Identification of an Epidemic Strain of Acinetobacter Baumannii Using Electrophoretic Typing Methods,” European Journal of Epidemiology 8/1 (January 1992).
[16] Joy Gordon, Invisible War: The United States and the Iraq Sanctions (Cambridge, MA: Harvard University Press, 2012).
[17] Mohamed Helal El-Sayed, “Multiple Heavy Metal and Antibiotic Resistance of Acinetobacter Baumannii Strain HAF—13 Isolated from Industrial Effluents,” American Journal of Microbiological Research 4/1 (February 2016).
