Through this qualitative study we aimed to highlight the experiences of those who had conflict-associated wounds which had been affected by AMR bacteria in NWS. By following their trajectory from the time and circumstances of wounding through their treatment and interactions with the healthcare system to the current challenges they face, we hope to draw attention to the situation of this socially and economically marginalised group. For clarity, and as mentioned above, we categorised the findings into 6 themes: i. those related to the mechanism of injury, ii, the impact of the conflict on health system accessibility, iii. experiences of immediate inpatient treatment, iv. the experience of outpatient and home treatment, v. the current impact of the injury on participants and vi. recommendations for improving healthcare access for those with conflict related wounds affected by AMR bacteria. The participants chosen had wounds affected by AMR, since our goal was to explore their experiences and perspectives. Given the methodology, we did not aim to compare to the experiences of those unaffected by AMR.
In general, the most important findings relate to the quality and capacity for both immediate and longer-term care in a devastated health system and the psychosocial and socioeconomic impacts of the injuries, which many of the participants continue to grapple with. The impact of AMR among participants is hard to differentiate from among the experiences of those with comparable conflict-related wounds without AMR, however it is likely that the rate of healing, need for prolonged and more expensive antibiotics, and poorer wound outcomes influenced the experiences of patients in whom AMR bacteria affected their wounds [1, 6]. In addition, when exploring the circumstances of the wound and the impact of the conflict-weakened health system in its ability to respond to those with conflict-associated wounds, there are potential factors which contribute either directly or indirectly to the emergence of AMR organisms. Beyond this, given more prolonged interactions with the health system, the socioeconomic consequences may be greater for those affected by AMR. Future larger scale quantitative research should further explore and quantify this.
In this qualitative study with a relatively small cohort and without an AMR unaffected comparison group, the associations between the type of weapon and the development of AMR cannot be assessed. However, the presence of heavy metals in armed conflicts as a potentiator of AMR through the selection for antibiotics and heavy metal co-resistance mechanisms is increasingly explored . With regards to the development of AMR in such settings, a review by Sahli et al.  of conflict related wound infections in the Middle East noted certain risk factors for AMR in such wounds including excess antimicrobial prescriptions, inadequate prophylaxis at the time of injury, the presence of metal work as well as health system related factors. Additionally, the presence of more severe or complex wounds may lead to the development of AMR. A study from an MSF facility in Raqqa noted that they received a second, larger and more complex array of blast wounded patients when the population returned to the area which has IEDs (improvised explosive devises) and ERWs (explosive remnants of war) .The severity of such wounds in a health system which is unable to manage them effectively, can lead to prolonged infections, recurrent courses of antibiotics and the development of AMR.
Impact of a devastated health system
The health system in NWS has faced significant and ongoing destruction of healthcare including health facilities and ambulances which have adverse effects on access to healthcare [10,11,12]. For acutely injured patients, this often means delays in emergency services reaching them and, due to the targeting and forced displacement of healthcare workers  alongside inadequate training, poor quality of emergency care and transport which can lead to longer term harm. Some participants noted that poor pre-hospital care or transfer to a facility without the required expertise or resources could worsen their condition. Of concern were risks associated with ongoing bombardment or targeting during their transfer to hospital which could take prolonged periods due to check-points and unsafe road conditions . There was little information on pre-hospital care in Syria though Wong et al.  noted in their analysis of attacks on ambulances that the intentional and repeated targeting of ambulances, risks of ‘double-tap’ attacks can lead to delays to care with potential acute and long-term consequences. With regards to risks of AMR, antibiotic prophylaxis is recommended for all severe, acute injuries with open wounds however in NWS, given the poor state of emergency and pre-hospital services, this is unlikely to be provided routinely and even when provided, it is unlikely that patients will receive the right antibiotics at the right doses at the right time. In addition, delays to administration of antibiotics, first debridement or an incorrect intervention e.g., placing internal fixation in an open wound may increase the risks of infection and the subsequent development of AMR  Information on the use of prophylactic antibiotics in this cohort was not available given inadequate patient records and patients would be unaware of what they received at the time of injury or surgery.
Delays to immediate, appropriate management of wounds can contribute to AMR through inadequate early debridement or wound management. Such interruptions may be due to attacks against immediate responders or patients and roadblocks or checkpoints which cause delay in arrival or transfer 15 . A 2016 review by Safeguarding Health in Conflict noted that such attacks occurred in 23 countries including on pre-hospital care  in countries such as Afghanistan, Democratic Republic of the Congo, Iraq, Niger, Mali and Yemen [14, 15]. In the Occupied Palestinian Territories, there were 416 instances of violence or interferences on ambulances owned by the Palestinian Red Crescent which resulted in injuries to volunteers, interruption of aid to patients and damage to 108 ambulances in that year . Such attacks may lead to delays to wound management, inadequate prophylaxis which could contribute to AMR. Participants noted this, commenting on health system factors and inadequacy of emergency services or appropriateness of immediate care.
First responders may take patients to the nearest facility rather than the most appropriate given insecurity or a lack of familiarity with what patients may need versus what the health facilities can provide. Participants reported that hospitals were often functioning beyond capacity, particularly in areas which were besieged such as Eastern Ghouta, eastern Aleppo or parts of Homs; this contributed to the scarcity of antibiotics, other required medicines as well as those with the expertise to manage the injuries . Overcrowding and poor infection prevention measures in health facilities can also lead to nosocomial transmission of AMR bacteria  as seen in conflicts in the Middle East; this can lead healthcare facilities to contribute to the AMR burden in these settings.
Poor outpatient wound care and access to required healthcare may also increase the risk of developing wound infections which could become colonised or infected with AMR bacteria; this is of particular concern in those who have metalwork in place as infections can be harder to cure with antibiotics alone due to biofilm formation . The presence of AMR can also increase associated costs for patients due to increased costs of antibiotics as well potentially more protracted wound infections. Despite the frequency with which patients note the socio-economic impact of AMR in their wounds, this topic remains understudied. A review by Kobeissi et al.  noted a paucity of literature on the socioeconomic burden of AMR among populations in conflict-settings, identifying only 8 studies with most studies not having assessed the socioeconomic burden as a primary aim; they were also small studies with the limited statistical power.
The forced exodus of healthcare workers as well as inadequate training can also contribute to poor wound care, inadequate surgical interventions and poor medical care ; the latter may include overprescribing or incorrect prescribing of antimicrobials which can lead to selective pressures resulting in increased AMR . For clinicians, it is essential to differentiate between colonising bacteria versus those which are causing infection to ensure that there judicious antimicrobial prescribing . This is hampered by the poor microbiology support in many areas affected by conflict which can lead to inaccurate antibiotic susceptibility data which can contribute to the problem. A review of bone cultures from war-wounded civilians in MSF’s project between August 2006 and January 2016 in Jordan found that 55% of 1353 bone samples had AMR; patient had originated from Iraq, Yemen, Syria and Gaza . Importantly, they noted that in some patients, osteomyelitis was not suspected, and these patients would otherwise have had internal fixation if the bone cultures had not grown bacteria. In Syria, some efforts to strengthen services through tele-microbiology have been trialled but have yet to be introduces sustainably, particularly where ongoing attacks on health facilities including laboratories occur .
Socioeconomic factors and poor living conditions were noted by almost all participants, relating to access to employment as well as inability to afford essential treatments or services for their clinical needs. Resource and transport constraints also affected their ability to travel to health facilities for medical care or physiotherapy. Poverty in Syria has reached more than 80% of the population with high rates of unemployment, particularly after the COVID-19 pandemic. For some, who may be the head of the household, unemployment could also push their families further into poverty leading them to need to either reliable on handouts or charities and to make difficult decisions to prioritise food and shelter over their own medical needs. These impacts among patients with conflict-associated wounds remain understudied however Dewachi’s ethnographic exploration of such wounds explores the as a ‘social wound’ with intersections in social experiences for those who also carry physical wounds . In NWS where this study was conducted, around 1.4 million IDPs reside in tented settlements with others living in inadequate shelters. For participants who had significant disabilities, they lacked the ongoing physiotherapy, equipment and adjustments to shelter that would have allowed them a better quality of life. The lack of adaptations and costs of transport also affected their ability to keep outpatient appointments. Such factors are unlikely to be related directly to AMR in itself but to the severity of their injury and resulting disability.
Addressing the needs of those with conflict wounds affected by AMR
The complex needs of those with life-altering conflict related wounds, particularly those with AMR require expertise which takes a holistic, patient-centred approach to ensure effective management. Levesque et al.  conceptual framework of access to healthcare provides a useful way in which to explore the health system needs of those with AMR affected conflict wounds. Such patients require a multi-disciplinary approach which considers both the medical needs as well the psychosocial needs of such patients and their abilities to perceive, seek, reach, pay for or engage with services .
Prior to Syria’s conflict, surgeons and physicians lacked expertise in the care of war related injuries and had to develop such skills during the conflict. With regards to AMR, significant challenges remain with regards to expertise, laboratory back up as well as the availability of required medications to effectively manage AMR affected wounds, particularly for those which have metalwork in place . Though some efforts to address resources and expertise gaps have been made, the ongoing conflict, high population needs and challenges relating to cross-border aid have impeded efforts to strengthen the health system in the area. It is essential that humanitarian organisations, policy makers and funders take into account the needs of patients with conflict injuries and strengthen resources for investigation and management of AMR.
Participants stressed the need for both physical and psychosocial support but all emphasised that opportunities for employment so that they can support themselves and their families were essential. In NWS, given the inadequacy of the humanitarian response compared to the increasing needs of the population, the needs of those with disabilities are often overlooked. Initiatives in areas under government control are also sparse but some promising projects which seek to support those with disabilities with free physiotherapy, artificial limbs and other aids has been in Hanano Primary Health Care centre in Aleppo since 2018; it provides services to 3500 community members per month . However, without active policies which support inclusion and reduce discrimination faced by those who have significant disabilities as a result of their injuries, livelihood and economic opportunities will be unavailable to them both immediately or in the early reconstruction phase. However, with high unemployment across Syria and limited social policies to support marginalised populations, those with disabilities are often overlooked in health system and humanitarian planning .
Policies focused on long-term inclusion are essential due to permanent nature of many of the disabilities among this population though the interplay between disability and AMR (including socioeconomic and clinical outcomes) is poorly characterised in the literature, even outside of Syria. A December 2020 HNAP (Humanitarian Needs Assessment Program) factsheet on disability in Syria estimates that 30% of those over the age of 12 years have a disability of which around 18% relate to mobility with socio-economic and psychosocial impacts  It is also estimated that 1.4% of all years lived with disability relate to violence and conflict with rates of disability close related to violence and conflict . Data from Vietnam suggests a positive association with bombing on disability more than 30 years after the conflict ended, suggesting a long-term impact of conflict on individuals as well as the health system .
The particular needs of women who have conflict associated wounds affected by AMR are important to understand. However, only two of the participants were women (and of the 25 initially screened) and both agreed to participate. Of note, their interviews lasted twice as long on average as the interviews with men. The disparities in numbers of women may related to the greater number of men involved in combat compared to women or to the ability of injured women to access specialist facilities due to increased reliance on other family members. Gender related factors were important in terms of access to services, availability of women healthcare staff and sociocultural impacts and suggest an intersectionality of vulnerabilities, additional to that of men participants. One of the women participants also highlighted the religious and gendered needs which affected her care and caused her distress at the time of her wound changes due to a lack of women medical workers where she resided. Based on a sample of two men, we are unable to extrapolate more from this however further work which explores the gendered elements of this cohort is needed.