Lebanese infectiologist and professor Souha Kanj was among the first to make an overview of antibiotic resistance in Arab countries. She is internationally renowned in her field and will receive an honorary doctorate from Radboud University this week. After having had a career in the US, she now works in Lebanon again. ‘I am much more needed here.’

‘Like everywhere else, the coronavirus pandemic worries us in Lebanon,’ says Souha Kanj, professor of infectious diseases at the American University of Beirut Medical Center. ‘In the spring we had few infections, but now we are at more than 1,000 cases a day.’ That is comparable per capita to the Netherlands. ‘Government hospitals are filling up, and private hospitals are also having a hard time.’

Yet, the coronavirus is only in third place on the list of the biggest problems facing Lebanon, Kanj sighs in an interview via Zoom. A greater problem is posed by the economic and political crisis in this country, which until recently was relatively prosperous. Government debt is heading towards 100% of gross national income, unemployment rates are skyrocketing, and government after government turns out to be corrupt. People are standing in long queues in front of the banks, because they want to withdraw their inflation-prone Lebanese pounds.

Explosion

But as far as Kanj is concerned, the explosion of 2,750 tons of ammonium nitrate on August 4 in the port of her hometown Beirut stands out above everything else. It was the biggest non-nuclear explosion of the 21st century. ‘300,000 people were left homeless, almost 200 people were killed and thousands injured.’ Her colleague Imad Uthman compared the explosion to the attacks of September 11, 2001. Never before had the Lebanese health-care system experienced such a flood of injuries, not even during the civil wars and armed conflicts with neighboring countries Syria and Israel, he told the British Royal College of Physicians.

How can people work under those circumstances? In Kanj’s case, that means fighting antibiotic resistance. She is one of the world’s experts in this field and a figurehead for infection control in the Middle East. The fact that she is a woman makes her even more of a role model. She completed her medical education at the prestigious Duke University in the United States, where her children were also born and raised, but eventually returned to her native Lebanon. On Wednesday she will receive an honorary doctorate from Radboud University.

Nijmegen is not unknown to you.

‘Indeed. Two years ago I was already a visiting scholar at the Radboud University Medical Center, via the Valkhof chair. And before that I had a lot of contact with Jos Van der Meer, Andreas Voss and Heiman Wertheim, among others, because we work in the same field. I only found out later that they are all associated with Radboud University (laughs). But I am humbled by this honorary doctorate. I went through the list of awards from the past few years last weekend: Angela Merkel, philosopher Daniel Dennett- those are big names.’

The situation in your country is extremely worrying. How do you cope?

‘My children, all three of whom live in the US, ask almost every day: what are you still doing there, come over here! I’m staying in Lebanon, however. My children are all adults now and have good jobs, and they can manage just fine without my husband and me. I am much more needed here, and I also feel loyal to this country, despite everything. In the US there are more than enough people with my expertise, as opposed to here. Every change I can make here in the field of infectious diseases and antibiotic resistance, however small, is welcome. And: everything is relative. The other day, I read that some children in Haiti are eating ‘dirt cookies’, because of the lack of real food. Luckily, the situation here is not that desperate.’

How big is the problem of antibiotic resistance?

‘That cannot be underestimated. Europe, and certainly the Netherlands, is one of the few places where things are going well. You have strict rules on the use of antibiotics. But in the rest of the world the situation is dire. Experts estimate that by 2050, ten million people a year will die of infections from resistant bacteria and fungi. That’s ten times the number of deaths from Covid-19. Last week I discussed the case of a patient who had a bacterial infection that did not respond to any antibiotics.’

What are the reasons for this?

‘It has to do with a number of things. First of all, many countries have no rules at all for antibiotic use. People are not sufficiently aware of the risks. For example, here in the Middle East you can buy antibiotics from the drugstore without a doctor’s prescription. Sometimes these are also of suboptimal quality, or they are taken for too short a period of time. Then, instead of killing the bacteria, you increase the chance that they become resistant. The overuse of antibiotics and anti-fungal agents in animal feed and agriculture also induces resistance.

‘In addition, people don’t adhere to hygiene rules, such as washing their hands thoroughly or coughing etiquette. This increases the risk of infectious disease outbreaks. Consider, for example, the pilgrimages to Mecca, where people from all over the world are close together every year. Or think of the living conditions of refugees in our region. Lebanon has 1.5 million Syrian refugees, aside 4.5 million Libanese inhabitants.’

Resistance

Kanj tries to combat all these problems in several ways, among them medical scientific research. She was among the first researchers to chart the magnitude of the problems surrounding antibiotic resistance in the Arab countries of the Middle East. She is also exploring other options for tackling bacteria, such as so-called phages, antibacterial viruses. She also developed infection prevention monitoring and education programs for health-care workers, and private organisations in the Arab world. Thanks to her efforts, Lebanon has signed the WHO pledge for hand hygiene.

All attention is now focused on the coronavirus pandemic. How does that affect your work?

‘The virus has only made the resistance problem worse, in several ways. For example, our financial resources have become more limited because a lot of money has been diverted to fighting the pandemic. This also delays the lab research, apart from all global coronavirus measures.

‘I always make it clear: I am not here to compete’

‘What I find even more worrying is that antibiotic use has increased unnecessarily. In a recent global study, it was found that more than 70% of Covid-infected patients admitted to the hospitals received antibiotics. However, according to our calculations, only 3.5% actually needed them. Fortunately, many international health organisations have now established stricter guidelines. I am very hopeful that this will help, because most doctors follow those guidelines.’

Does being a woman make your job in the Middle East more difficult?

(Laughs) ‘Well, not just in the Middle East. I encountered quite a lot of resistance when, as a female doctor, I ended up in higher positions – even from direct colleagues. They perceived me as a threat. Women have a long way to go, especially in the medical world. In some of the Arab countries, female students and doctors even literally sit in the back of the room at meetings, instead of at the table, and don’t have the courage to speak up.’

How did you manage yourself?

‘I make it clear, everywhere and always: I am not here to compete with you, we are a team. Moreover, I have never cared much about misogynistic comments. I owe that to my father. We were five girls and one boy at home, but he treated the girls like the boy. Whatever he was allowed to do, I could do as well. The way you are raised is so important.

‘I also try to put my father’s lessons into practice: in the end you need to practice what you preach. I hire people based on their qualities; their gender is not part of the equation. And I always try to see the individual person. At Duke University, I was allowed into the residency programme because someone believed in me. He offered me the opportunity, even though I didn’t formally meet all the selection criteria. I can tell you that this motivated me to prove that I was worthy of the choice. I owe my success to my mentors I had at Duke University.’

Souha Kanj’s lecture during the Dies can be followed via a livestream. This also applies to the other activities that take place that day in honour of the university’s 97th birthday. Wednesday evening at 20.00h, Radboud Reflects will interview Kanj during a lecture for the public at Radboud Reflects.