Richmond Hill, Ontario, Canada (9 October 2026) – When governance collapses in war, the basic checks on antibiotic use, water quality and infection control collapse with it. A new publication from the United Nations University Institute for Water, Environment and Health (UNU-INWEH) and the Geneva Water Hub warns that these are the conditions under which antimicrobial resistance (AMR) spreads fastest and furthest, with water carrying resistant bacteria between hospitals, communities and farms, and across national boundaries.
The Policy Brief, Antimicrobial Resistance in Water Systems: A One Health Imperative in Fragile and Conflict-Affected Settings, examines how resistant bacteria, resistance genes and antibiotic residues circulate through water across human, animal and environmental interfaces. Written for decision makers in the water, health and humanitarian sectors, the brief sets out practical actions for governments, donors and humanitarian agencies, including in settings where state systems are absent or severely weakened.
AMR, the process by which microorganisms evolve mechanisms to withstand the drugs designed to kill or inhibit them, poses a direct threat to public health, food security and ecosystems. Drug-resistant infections were associated with nearly 5 million deaths worldwide in 2019, and the brief cites UN Environment Programme estimates that the toll could rise to 10 million a year by 2050 if no action is taken. Up to 90% of the antibiotics people consume are excreted into the environment as active substances, and global estimates suggest that up to 80% of wastewater is untreated. In many fragile and conflict-affected settings, the brief reports, that figure approaches 100%.
The publication highlights a risk that routine testing can miss. Water can test negative for standard coliform indicators while still containing antibiotic-resistant bacteria and resistance genes at levels that threaten public health. This pattern was documented in Gaza before the escalation in October 2023, where resistant strains of Pseudomonas and Staphylococcus aureus were found in water samples that had tested negative for Escherichia coli. The publication also reports that, even before October 2023, more than 100 million litres of mostly untreated wastewater were discharged into the sea from Gaza every day because of damaged treatment facilities.
“In Gaza, water samples that passed the standard test for faecal contamination still carried resistant bacteria,” said Reem Abu-Shomar, Research Fellow, Water, Peace and Public Health at UNU-INWEH and a lead author of the publication. “When the only test available says the water is safe, people drink it. In places where laboratory capacity for resistance testing is extremely limited, we cannot assume resistance is absent simply because no one has looked for it.”
The publication names Gaza, Syria and Sudan among the settings where weak regulatory enforcement and often non-functional infrastructure amplify these pressures, while flooding in South Sudan and water scarcity in Yemen further accelerate the environmental spread of resistant pathogens. In Gaza, the authors describe damaged water and sanitation systems, overcrowding and the unregulated use of antibiotics, driven by the collapse of healthcare and pharmacy oversight, as a perfect storm for AMR. Across conflict settings, the resulting preventable illness and deaths, from sepsis and diarrhoea for example, often go unrecorded in conflict mortality counts, leaving AMR largely invisible in mortality estimates.
The authors recall that international humanitarian law prohibits parties to armed conflict from attacking objects indispensable to the survival of the civilian population, including water supply infrastructure. They state that humanitarian water, sanitation and hygiene programmes must document infrastructure damage to support legal accountability and post-conflict reconstruction planning.
Under a One Health approach, which recognises the interdependence of human, animal and environmental health, the brief sets out three mutually reinforcing actions: enhancing water, sanitation and hygiene infrastructure, including decentralised or mobile treatment where centralised systems are inoperable; integrated AMR surveillance in water and the environment; and antimicrobial stewardship combined with treatment of antibiotic-containing waste before it is discharged. It recommends that donors, multilateral development banks and UN agencies establish earmarked funding lines for AMR and water, sanitation and hygiene within existing humanitarian response plans and national AMR action plans.
“None of this has to wait for a state-of-the-art laboratory,” said Abu-Shomar. “A university lab can test a few water samples each month, health workers can document their prescriptions, chlorine can be added to water trucks. These are small-scale fixes, but in prolonged crises they can have a major impact.”
“Treating water and sanitation as essential health interventions is not optional in conflict settings,” said Professor Kaveh Madani, Director of UNU-INWEH. “When water systems are destroyed, the conditions that allow AMR to spread reach far beyond the immediate conflict zone. Resistant bacteria from hospital wastewater can enter rivers and end up in irrigation systems or wells, and from there in the food supply. AMR knows no borders, and neither does water. Protecting these systems protects us all.”
Key Findings at a Glance
- Drug-resistant infections were associated with nearly 5 million deaths worldwide in 2019; this could rise to 10 million a year by 2050 without action.
- In Gaza, before October 2023, resistant bacteria were found in water samples that had tested negative for E. coli, and more than 100 million litres of mostly untreated wastewater entered the sea every day.
- Surveillance can start small: monthly sampling of drinking water and wastewater outflow over one year at a high-risk site such as a hospital or camp for internally displaced people, using basic methods and existing public or NGO laboratories, can provide a useful risk map.
Publication Details
Geneva Water Hub and United Nations University Institute for Water, Environment and Health (UNU-INWEH). (2026). Antimicrobial Resistance in Water Systems: A One Health Imperative in Fragile and Conflict-Affected Settings. DOI: 10.53328/INP26RAS001. ISBN: 978-92-808-6147-1. https://www.genevawaterhub.org/resources/antimicrobial-resistants-water-systems-one-health-imperative-fragile-and-conflict
Lead authors and coordinators: Reem Abu-Shomar (UNU-INWEH), Imane Messaoudi-Mattei (Geneva Water Hub) and Mark Zeitoun (Geneva Water Hub). The Policy Brief was developed within the framework of the JI RISE project, led by Imperial College London and funded by Community Jameel through the Jameel Institute.
Available for Interview
Interview requests should be submitted to media.inweh@unu.edu
Reem Abu-Shomar, Research Fellow, Water, Peace and Public Health, UNU-INWEH
Media Contacts
Marjan Asadullah, Communications Assistant, UNU-INWEH, marjan.asadullah@unu.edu
About UNU-INWEH
Marking its 30th anniversary of operation in 2026, the United Nations University Institute for Water, Environment and Health (UNU-INWEH) is one of 13 institutions that make up the United Nations University (UNU), the academic arm of the UN. Known as ‘The UN’s Think Tank on Water’, UNU-INWEH addresses critical water, environmental, and health challenges around the world. Through research, training, capacity development, and knowledge dissemination, the institute contributes to solving pressing global sustainability and human security issues of concern to the UN and its Member States. Headquartered in Richmond Hill, Ontario, UNU-INWEH has been hosted and supported by the Government of Canada since 1996. With a global mandate and extensive partnerships across UN entities, international organizations, and governments, UNU-INWEH operates through its UNU Hubs in Calgary, Hamburg, New York, Lund, and Pretoria, and an international network of affiliates.
About the Geneva Water Hub
The Geneva Water Hub (GWH) is a Center of Competence on Water for Peace based out of the University of Geneva and the Geneva Graduate Institute. Established in 2015 by the Swiss Agency for Development and Cooperation (SDC), the GWH pursues the roadmap laid out in the report of the Global High-Level Panel on Water and Peace “A Matter of Survival”. The GWH’s mission is to advance the use of water for peace in humanitarian, development, and peacebuilding efforts. Our experience has shown that when water is shared equitably, and spared from war and pollution, peace can prevail.
