The Global Challenge of Antimicrobial Resistance and Forced Displacement
Antimicrobial resistance (AMR) is one of the most significant global health challenges of our time. While the development of resistant pathogens is a natural evolutionary process, current practices in the overuse and misuse of antibiotics have accelerated this problem. Between 2000 and 2015, antibiotic consumption increased by 65%, mainly driven by the economic growth of low-income and middle-income countries (LMICs). At the same time, the pipeline of new antibiotics is drying up.
Another pressing global challenge is the unprecedented number of people who are forcibly displaced from their homes due to conflict, climate change, and economic collapse. The United Nations has called the past ten years the ‘decade of displacement’, and the most recent data shows that over 100 million people are currently displaced globally due to conflict and persecution. These forcibly displaced populations are often housed within countries with fragile health systems that lack the capacity to effectively diagnose, manage, and treat life-threatening illnesses.
Migrants are exposed to many socioeconomic determinants that contribute to negative health outcomes, including high population concentration, limited healthcare access, and poor sanitary conditions. These factors may also increase the risk of disease transmission and act as drivers for AMR. Access to healthcare services among displaced populations is further challenged by restrictions due to migrant status, language barriers, financial limitations, and discrimination.
This pilot study aimed to identify key barriers to accessing quality-assured and affordable antimicrobials among forcibly displaced persons in Uganda, Yemen, and Colombia. It also investigated their utilisation patterns of antibiotics, knowledge about AMR, and perceptions of the quality of antimicrobials received.
Understanding the Diverse Humanitarian Contexts
Uganda: A Welcoming Asylum Regime with Strained Resources
Uganda hosts one of the largest displaced populations in Africa, with about 1.5 million refugees, mainly from South Sudan and the Democratic Republic of Congo. Most of these refugees are housed in settlements alongside the host community. Uganda has a progressive asylum regime, and refugees have access to the public healthcare system. However, the country’s main challenge is its dependency on financial aid from the UNHCR and other humanitarian organisations to provide equitable healthcare.
Yemen: A Health System in Crisis Amidst Conflict
In Yemen, most of the forcibly displaced people are not refugees from another country, but internally displaced persons (IDPs) – almost all Yemeni citizens. Since the beginning of the conflict in 2014, more than 4 million people have been forced to flee their homes. While the majority of IDPs are hosted within communities, it is estimated that over 1.5 million live in more than 2,300 unplanned and informal settlements. The protracted conflict has led to an economic crisis, with 81% of Yemenis living below the poverty line, and a healthcare crisis, with only 50% of public health facilities being operational.
Colombia: Venezuelan Migrants Lacking Legal Status
Colombia’s situation differs from Uganda and Yemen. Most of the 2.4 million forcibly displaced migrants are Venezuelans who were forced to flee their country due to political turmoil, economic collapse, and a resulting humanitarian crisis. Colombia also has one of the largest internally displaced populations in the world, with 7.5 million reported in 2016. Unlike Uganda or Yemen, there are no camps for displaced people in Colombia, and the displaced population lives alongside the non-displaced local population. The majority of Venezuelan migrants in Colombia lack legal migration status due to reaching the country through informal border crossings and the impossibility of obtaining official documents in Venezuela.
Barriers to Accessing Quality Antimicrobials
The study identified several key barriers that limit forcibly displaced populations from accessing quality-assured and affordable antimicrobials across the three study sites.
Financial Constraints
In Colombia and Uganda, the payment of antimicrobials was perceived as the most significant barrier by the participants. Many migrants and refugees paid out of pocket for their medicines, with limited access to health insurance or free healthcare.
Prescription Requirements
In Yemen and Colombia, the requirement of a prescription to obtain antimicrobials was identified as a major obstacle. This led many participants to seek medicines through informal pathways, such as over-the-counter purchases or sharing with friends and family.
Medication Unavailability
In Uganda and Yemen, the unavailability of certain antimicrobials at healthcare facilities was ranked as one of the top barriers. This issue is not unique to the refugee settlements, as it has been reported in other parts of these countries as well, likely due to challenges in healthcare supply chains.
Time to Reach Healthcare
In Yemen, the time it took to reach the nearest healthcare centre was identified as a significant barrier, confirming previous findings about the limited access to healthcare services in the country due to the ongoing conflict.
Distrust in the Healthcare System
In Colombia, many migrants expressed distrust in the healthcare system, believing that they received lower-quality care and faced hostile behaviour from healthcare workers due to their migrant status. This contributed to their preference for informal pathways to obtain antimicrobials.
Utilisation Patterns and Knowledge Gaps
The study also revealed concerning patterns in the utilisation of antibiotics and a lack of knowledge about AMR among the forcibly displaced populations.
Informal Pathways for Obtaining Antibiotics
Obtaining antimicrobials through informal pathways, either without a doctor’s prescription or through family and friends, was common in Yemen (54%) and Colombia (68%). This practice is concerning, as it increases the risk of using substandard or falsified antibiotics, which can contribute to the development of AMR.
Misuse of Antibiotics
In Yemen and Uganda, a significant proportion of respondents used antibiotics to prevent (45%) or treat (67%) a cold, despite the fact that most colds are caused by viral infections, for which antibiotics are ineffective. This suggests a lack of understanding about the appropriate use of antibiotics.
Low Awareness of AMR
Knowledge of AMR was generally low across all three study sites, with only 17.6% of participants demonstrating an understanding of this critical global health issue. This lack of awareness may lead to the potential misuse of antimicrobials, further driving the development of resistance.
Implications and the Need for Targeted Interventions
The findings of this pilot study highlight the complex and interlinked barriers that forcibly displaced populations face in accessing quality-assured antimicrobials. The use of informal pathways, misuse of antibiotics, and low awareness of AMR are concerning, as they can contribute to the further spread of resistant pathogens.
Addressing these challenges requires a multi-faceted approach that considers the specific contexts and needs of each displaced population. Potential interventions could include:
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Improving Affordability and Accessibility of Antimicrobials: Ensuring that forcibly displaced populations have access to free or affordable, quality-assured antimicrobials through certified healthcare facilities can help mitigate the reliance on informal pathways.
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Strengthening Healthcare Supply Chains: Addressing the issues of medication unavailability in Uganda and Yemen by improving the coordination, management, and funding of healthcare supply chains can enhance the reliability of antimicrobial access.
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Enhancing Health System Capacity: Investing in the capacity of healthcare systems in fragile settings to effectively diagnose, manage, and treat infectious diseases can improve the overall quality of care for displaced populations.
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Promoting AMR Awareness: Targeted educational campaigns and digital interventions (e.g., mobile applications) can help improve the understanding of AMR and the appropriate use of antimicrobials among forcibly displaced communities.
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Strengthening Surveillance and Monitoring: Implementing robust surveillance systems to monitor antimicrobial utilisation patterns and the prevalence of resistant pathogens among displaced populations can inform evidence-based policymaking and intervention strategies.
While this pilot study had a limited sample size and used non-probability sampling in some cases, its findings provide valuable insights into the challenges faced by forcibly displaced populations in accessing quality antimicrobials. Larger-scale assessments and context-specific interventions are needed to address this pressing issue at the intersection of global health security and humanitarian crises.
