While antibiotic misuse and overuse has often been the focus of antimicrobial resistance (AMR) science and policy, clinical microbiology in the Middle East is turning to evaluating war and conflict as drivers to antimicrobial resistance.

War has been implicated in the emergence of antimicrobial resistance as far back at the 1940s and these conditions have since persisted and intensified, with contemporary conflicts pressuring microbes with selective environments that contain unique combinations and concentrations of toxic heavy metals and antibiotics and providing niches and dissemination routes.

Iraq experienced a sequence of conflicts since the 1980s, and reports point to a progressive deterioration of Iraq’s national healthcare system, lack or limitation in trained staff, infection prevention and control, access to antibiotics as well as sanitation control and debridement of highly contaminated wounds from explosives or burns, as well as inappropriate diagnoses and drug regimens, all potential contributors to the rising rates of AMR in Iraq.

AMR co-selection from heavy metals is becoming more strongly implicated due to conflict-driven environmental contamination, as with lead, mercury, chromium, copper, lead nickel and zinc used to coat bullets, missiles, gun barrels and military vehicles, while antimony, barium and boron are used as weapon-priming compounds.

The rise of AMR in Iraq, with indications of regional and global spread, remains direly understudied, where clinical, microbiological, historical, ethnographic and environmental research is needed to conclusively establish the roles that war and conflict play in the rise of multidrug-resistant organisms.

Understanding the link between AMR and conflict is essential for a global response to AMR, especially with little indication that global conflict will abate in years to come.