LEBANON - While the visible scars of war are etched into Lebanon’s skyline, an invisible transformation is taking place in its soil and water. Lebanon’s antimicrobial resistance (AMR) crisis and the inability of hospitals and the medical sector to control it fall beyond clinical failure.

Its roots lie deep in the collapse of other safeguards, like agricultural, environmental, and industrial sectors. Therefore, there is an urgent need for an approach that integrates humans, animals, and the environment, also known as the “One Health” approach.

With the recent wars in Lebanon and the damage to the water, sanitation, and hygiene (WASH) infrastructure, as well as disrupted agricultural and farming oversight, there would be an unchecked emergence and spread of superbugs.

The path to recovery then must integrate ecological restoration and biosafety across all fields as core components of national health security. 

What is VUCA?

The fog of war is often described as VUCA: volatile, uncertain, complex, and ambiguous. In such settings, priorities shift from long-term stability to immediate survival, and regulatory oversight across health, agriculture, food safety, and environmental protection is often abandoned.

The consequences extend beyond AMR alone, with growing risks of zoonotic infections such as rabies, leptospirosis, and brucellosis, as well as foodborne, waterborne, and respiratory threats among displaced and overcrowded populations.

Experiences from Ukraine, Syria, and Sudan show that conflict-driven collapse of civil infrastructure can amplify infectious, environmental, and mental health harms in ways highly relevant to Lebanon.

The Center for Disease Control and Prevention (CDC) defines One Health as the intersection of human health, animal health and the shared environment.9 It tackles issues such as antimicrobial resistant organisms, vector-borne diseases, food-borne illnesses, diseases in animal meat, the human-animal bond and water contamination. In Lebanon, this intersection has become a collision force that requires a statewide intervention. 

Lebanon's Hidden AMR Crisis

Upon looking at the current state of Lebanon, it is easy to spot the war-led destruction and infrastructural damage. However, looking deeper, one could find subtle everyday processes that contribute to superbug emergence.

The ghost of economic collapse exerts continuous pressure on many of the productive fields, where product failure or infection/pest spread threatens the irreversible downfall of a business or sector.

With the absence of oversight, these sectors, especially agriculture, overuse pesticides and antibiotics to protect crops from damage to ensure productivity and economic safety for continuity.

A Microbiological Shift

Hospital infection control is hard in conflict zones, where water can easily get contaminated, and disinfection supplies are in shortage, superbugs spread easily, especially with a wounded or sick patient population with high turnover. However, per a One Health approach, hospitals are the last line of defense against AMR.

During conflict, people focus on requirements for survival, and often disregard preventive health, surveillance, animal health and plant health. This situation has created a One Health catastrophe, where the degradation of water systems and animal health oversight has turned the environment into a reservoir for untreatable infections. 

Rebuilding One Health

In times of economic and kinetic crisis, oversight in the food chain vanishes. Governmental infrastructure degrades to the minimum necessary activities, focusing on electricity, water, and roads. The unregulated use of antibiotics in livestock and the contamination of agricultural products make the One Health link in Lebanon literal.

What happens on the farm and in the field will end up eventually in the intensive care unit. Additionally, the loss of clean water for irrigation means we are effectively watering our crops with resistance. 

We cannot fight what we cannot see. Therefore, a key step in the fight against AMR is determining where the problem starts. A One Health approach requires breaking down data silos between botanists, veterinarians, environmental scientists, and medical doctors, with oversight from the Ministry of Public Health (MoPH).

 We need a surveillance system that tracks resistance from the sewer to the surgery center to predict the next outbreak before it hits the wards.

Ideally, it would be passive, optimizing technological advances, leaving human cognition to solve more pressing issues while data regarding health risks is made available by integrated software or artificial intelligence. Otherwise, the detection of one superbug likely means there are hundreds of others roaming around, as source control is not achieved.

A Multi-Level Strategy

Solving AMR in Lebanon requires work before reaching hospitals and inside hospitals. In the environment, promoting political stability, fixing infrastructure, especially water piping, water treatment, sewer maintenance, regulating insecticide and pesticide use, regulating livestock antibiotic use and improving access to new antimicrobials for hospitals is of utmost importance. 

In the community, it requires increased surveillance and governmental measures targeting food-borne illnesses and regulating pet health, mandating vaccines and managing stray or adopted pets, as well as regulating public access to antimicrobials. 

Inside hospitals, the most effective approach is strengthening and implementing infection control measures, like hand hygiene, enhanced environmental decontamination, patient isolation, hospital water treatment and enforcing semi-sterile and sterile areas in operating rooms, each of which faces its own challenges during conflict.

Triage in emergency departments remains important, especially in regard to assessment of isolation needs before exposure of patients to superbugs happens. 

Targeting antimicrobial resistance in Lebanon goes far beyond what doctors can manage with their patients. It is mostly a multidisciplinary process fueled by natural or man-made disasters, decreased regulatory oversight, obsolete laws, economic instability, and decreased enforcement of infection control measures.

It is possible to mitigate AMR in Lebanon, but it requires a policy update and enforcement rather than framing it as a healthcare sector responsibility only. It is a problem too big for doctors to be able to prescribe their way out of it. 

Hilal Abdessamad, MD, MS, is an Infectious Disease Fellow and public health advocate.
Brian K. White , MD, MS, is an Infectious Diseases Physician