Abstract
This Viewpoint calls for a greater understanding of the role that water plays in the transmission of anti-microbial resistance and covid-19 in protracted urban armed conflict, in order to develop a 'pathogen-safe' practice. It argues that dealing with the twin threats is difficult enough in the best of circumstances, and is so little understood in war zones that surgeons and water engineers now question if their practice does more harm than good. Experience suggests that the known transmission routes are complicated by a great number of factors, including the entry of heavy metals through bullets in patients' wounds, hospital over-crowding, mutation in treated water or wastewater, and other threats which endure long after the bombing has stopped. The skeleton research agenda proposes greater sewage surveillance, testing of phages and monitoring of treatment designed to dispel or substantiate these assertions.