"When health systems are fragile and patients don't get good initial treatment for their injuries, they frequently end up living with a chronic injury," DWB's Murphy explained. These injuries are susceptible to infection, which could be avoided if better initial treatment were available, he said. DWB's Iraqi patients in Amman have undergone an average of four previous operations, with 19 months on average between injury and DWB admission.
But better initial treatment is not always feasible in conflict zones. In Syria, 60 percent of hospitals have been damaged or destroyed since the start of the war. Before 1991, Iraq had a high-performing healthcare system, but a decade of sanctions topped off with the U.S.-led invasion in 2003 left that in shambles, too.
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The shades were drawn, the flatscreen TV black and silent in Talal's room. Under hospital protocol, the door remained shut. Talal was gaunt, his cheeks hollow, as if someone had vacuumed out the flesh from within. His right knee was bulky with bandages and framed with a transarticular external fixator—a cube-like brace of thin metal bars—while the skin on his swollen right calf and foot alternated purple and yellow. He couldn't wiggle his toes.
According to medical records, the 38-year-old Libyan was shot in his right leg at the end of August. He entered the Arab Medical Center on September 3 with a fractured right femur and an open infection, which was found to be resistant to 17 different antibiotics from several different drug classes, and responded to just two. Talal is now on one of them, tigecycline, which costs $143.80 a day (102 Jordanian dinars for two vials daily). Mayes al-Ahmad, an infection-control nurse, expected Talal to stay on tigecycline for three weeks—that's more than $3,000 for the medicine alone—after which the hospital will conduct more tests.
"If the infection is multi-drug-resistant, the cost is of course higher," al-Ahmad noted, because of the necessities of isolation, increased testing, longer hospital stays, and more expensive drugs. And it's not just about the money. Caring for patients with resistant infections also requires more human resources, like highly skilled staff. A nurse who has worked in infection control at three hospitals in Jordan in the past six years, al-Ahmad said resistance "has grown worse with the arrival of foreigners," especially from countries at war.
Talal, meanwhile, was tired and in pain. "Zift," he stated, conveying how he felt. Terrible. His shrunken torso disappeared within his brown and black striped tunic, and he lay down every few minutes, as if sitting upright was too exhausting.
Even with al-Ahmad's anecdotal evidence, Bakri's internal data, and DWB's analysis of patients bearing extraordinarily complex wounds, it's hard to glean precisely the impact on Jordan from antibiotic resistance. "You've got no idea of the levels of resistance coming in," said Tim Walsh, a medical microbiology and antimicrobial resistance professor at Cardiff University in Wales, while in Jordan, data on resistance are "almost nonexistent." Indeed, Ministry of Health surveillance of resistance is limited to select units in four public hospitals, though it has revealed high levels of bacterial resistance to both first-line and last-resort antibiotics.
Bakri said the university hospital had not conducted cost-impact studies, while Jarour, the health ministry official, couldn't say what antibiotic resistance might cost Jordan in the long run. But both were certain they'd see higher healthcare costs, worsening morbidity rates, and above all, more deaths. As Bakri stated frankly, "It's going to be a disaster."