Thursday, October 2, 2014

Ebola - A Global Terror Vector

This is a copy of an article submitted to the Yale Global Health Review in February, 2014 for publication.  It was never published.  This paper was a self study project undertaken by my daughter.  With the current emerging global Ebola crisis, this information is too important not to release to the web.  YGHR missed the boat on a critical global health issue. 

Joe Mazzarella 
Global Health Risks of Non-state Transnational Terror
Grace Mazzarella
January, 2014

In September of 2000, the United Nations, through its member states, agreed on Millennium Development Goals (MDGs).  The MDGs are a series of goals aimed at making measurable improvements in alleviating worldwide poverty, hunger, disease, illiteracy, environmental degradation, and discrimination against women within a 15 year period.  Since its adoption, the World Health Organization (WHO) has reported that great strides have been in the intervening years.[1]  These gains are the result of concerted governmental and non-governmental programmatic efforts.   Despite this progress, these gains are vulnerable to being undermined by both well-known and less well-known and understood emerging systemic threats.  One of these less well-known and understood threats is the emerging systemic risks associated with the agents and causes of geopolitical conflict.   In the area of global health, the new paradigm of multinational, non-state sponsored terrorism represents a significant and growing risk factor with unique challenges for the world health community.   

Most state efforts to combat terrorism are motivated by a desire to prevent acts of terrorism and their immediate impacts, namely the indiscriminate loss of life and injury to civilians and noncombatant personnel.   While acts of terrorism catch worldwide media attention, terror groups can have significantly greater far reaching and lasting effects through sustained low intensity conflict.  Terror in itself is not the objective for terrorist groups inasmuch as it is to create conditions of increasing civil instability to achieve various ends.  These ends are often political, ethnic and/or religious in nature.  As a consequence, civilian populations are often targeted based upon on their ethnic and religious composition and political alignments.  For the ideological modern terrorist, the objective is to inflict not only death, but to instigate mass displacement and removal of objectionable segments of the civil population.  This, in turn, creates enclaves of control to stage, assemble and support larger operations with the intent of further challenging incumbent government forces, disrupting national systems of civilian and military support, such as commerce and transportation routes and utility infrastructure, and creating successively greater instability within the state.   These strategies and mass displacement effects have been observed in a variety of conflicts including Iraq, Syria and the Sudan.
Focusing on Syria, one needs to only consider the scale of humanitarian tragedy occurring in Syria to understand the scope and nature of this problem.    As of the writing of this Article, the United Nations High Commissioner Refugees (UNHCR), reports that over 2.3 Million refugees have been displaced from their Syrian homes as a result of ongoing civil war, and it is predicated that the refugee population could reach 4 Million if the conflict continues along it present course.[2]  Despite its political characterization, the greater reality is that the Syrian civil war is being fueled by an influx of multinational Islamic fighters, many of which are aligned with known terror groups such as Al-Qaeda and external state sponsors of terrorism like Iran.[3] Beyond the effects of conventional fighting between insurgents and government forces, civilian populations have been brutalized by numerous reported attacks of barbarity designed to terrorize and incite mass civilian departure.  In one of many similar reported incidents, on January 17, 2014, Al-Qaeda insurgents reportedly overran the western-backed Free Syrian Army held town of Jarabulus located in Northern Syria.  Al-Qaeda fighters then initiated an indiscriminate killing spree, murdering men, woman and children.   Among their heinous acts, over hundred men were rounded up and Al-Qaeda fighters began slaughtering them, including beheading their victims and posting heads on spikes.  As a result of this terror, nearly 1,000 civilians fled for the safety in Turkey.[4]   Syria’s civilians, much like in other recent modern terror infused conflicts, are suffering extreme and indiscriminate brutality which is driving mass population displacement.

But Syria is not unique.  In many of today’s conflicts around the globe, terrorist organizations operate to destabilize government institutions by sowing fear and insecurity among the populace, and eroding the will and capacity of government institutions to carry-out the delivery of basic services.[5]  Whether one begets the other is open for debate, however it is generally recognized that terror groups tend to coalesce and root themselves in places where governments are politically weak and have failing civil institutions.  Cases on point include Iraq, Afghanistan, Pakistan, South Sudan, Somalia, Libya, Algeria, Nigeria, the Palestinian Territories, Lebanon, Indonesia and Yemen, among others.[6]  In fact, the number of displaced person has risen year over year and reached its highest since 1994 with an estimated 45 Million refugees, and the UNHCR reports that vast percentage of refugees are arising within the aforementioned countries.[7] As non-state actors foment civil unrest and spread terror, large civilian displacement becomes a major pandemic disease vector that has broad regional and global implications.
By way of example, the Syrian war has given rise to an outbreak of polio, a disease that has been effectively eradicated from most of the global community, save a few, through decades of vaccination efforts.  Prior to the conflict, the last reported case of polio in Syria was reported in 1995.  In November of 2013, the WHO raised an alarm with an outbreak of up to 37 confirmed cases of polio. [8]    As result, a massive immunization effort has been launched to stem the outbreak.  Nonetheless, this in turn has raised fears that there is high risk of a polio outbreak in Europe given that large numbers of Syrian refuges may begin to migrate from temporary camps in neighboring countries to Europe as they search for better living conditions.[9]
Other places where polio has gained a foothold through disease importation include the African horn nation of Somalia, which is home to a nominally functioning government and numerous terror camps.  Other countries of polio importation, as reported by the WHO, include several African countries with terror based insurgencies such as Niger, Mali and the Congo.[10]  Meanwhile, the countries of Afghanistan, Pakistan and Nigeria remain polio endemic.  All of these locations share another common thread besides polio.  They are each suffering from ongoing conflict spurred by endemic terror groups operating within their borders are main drivers of forcible displacement.
 Overall, the Syrian conflict serves as a powerful example of the role that non-sate terror organizations play in breeding conditions for global health emergencies and potential pandemics.  While the twentieth century was occasioned by state conflicts, the twenty-first century has given rise to a new form of non-state entity conflict that is transnational in nature.  Hallmarked by internal destabilization, these forces operate to sow political instability and fear among the populace and ignite civil strife.   Unlike traditional sovereign conflicts, the ability for world organizations to reach into and operate in these conflict areas to stem global health emergencies is often hampered due to non-existent diplomatic functions and no reliable or formal command and control leadership capable of brokering necessary conditions of security and safety for non-combatant relief workers.   In Syria, the effort to provide humanitarian relief has been thwarted in many cases and nation-states have been unable to provide consistent meaningful humanitarian aid.[11]
In the emerging reality of geopolitical conflicts characterized by non-state terror groups, it is possible that global health emergencies may be exploited as another tactic to create large scale destabilization and fear.  In this vein, while seemingly remote, it is not unreasonable to assume that terror groups could seek to spread highly contagious diseases in target populations through one or more terrorist cells.  In essence, the dynamics of population displacement, nonfunctional health delivery systems, and access to contagious diseases becomes a vehicle for biological warfare, or coined another way its own weapon of mass destruction (WMD).  While polio would be an unlikely candidate due to mass vaccination, infectious diseases such as the hemorrhagic Ebola or Marburg viruses could be used to create a large scale pandemic with a small team of sickly volunteers. Further, proximate access to and vectors for movement by a multinational terror organization are present because they are coincident with terror endemic areas, notably the Sudan, Uganda (bordering South Sudan) and Democratic Republic of Congo.[12]  These viruses can be opportunistically identified in the population and then intentionally passed from a host to willing conspirators. Placing “ground zero” patients inside of highly dense refugee camps along and infecting several disparate international targets has the potential to create global impacts that could overwhelm response systems and resources.  This tactic, albeit crude by today’s standards, has a historical precedent within North America when British forces used infected blankets of small pox to eradicate Native Indians during the French Indian Wars.[13]
More generally, non-state controlled areas with largely collapsed or inoperative healthcare systems and large refugee populations present conditions for pandemic outbreaks that can impact local, regional and global security.   This risk requires collaboration and attention among not only world health authorities but political and policy leaders, security experts and institutions of research and higher learning in order to create the necessary programs to monitor, identify, respond to and mitigate these hazards.    As the world community makes progress towards its MDGs, it is important that it recognize emerging changes in geopolitical dynamics and be prepared to adapt its programs and strategies to counter their associated risks. 

[1] United Nations, The Millennium Development Goals Report 2013, 1 July 2013, ISBN 978-92-1-101284-2, available at:
[2] Syria Regional Refugee Response, UNHCR Interagency Information Sharing Portal –Regional Overview, Web. 20 Jan. 2014 (
[3]  Laub, Zachary, and Masters. "Al-Qaeda in Iraq (a.k.a. Islamic State in Iraq and Greater Syria)." Council on Foreign Relations, March 2013.
[4] Hunter, Isabel, Al-Qaeda slaughters on Syria's killing fields, AL Jazeera Online (January 21, 2014) (
[5] Audrey Cronin, Ending Terrorism – Lessons for Defeating Al Qaeda, International Institute for Strategic Studies (Adelphi Paper 393, 2008), Ch. 1.
[6] National Counter Terrorism Center, Counterterrorism Calendar 2014 – Interactive Map, Web, accessed January 22, 2014 (
[7] UNHCR-Global Trends Report 2012, Displacement-The New 21st Century Challenge, June 19, 2013 (
[8] Global Alert and Response, World Disease News, Polio in the Syrian Arab Republic – update, World Health Organization (November 23, 2013), Web (
[9] Eichner &Brockmann, Polio emergence in Syria and Israel endangers Europe, The Lancet,  Volume 382, Issue 9907, Page 1777, 30 November 2013 (Elsevier Ltd, pub. online November 8, 2013,
[10] Polio Global Eradication Initiative Annual Report 2012, World Health Organization (WHO, Geneva, March 2013). (
[11] Blanchard, Humud & Nikitin, Armed Conflict in Syria: Overview and US Response, Congressional Research Service, Rel. RL33487, January 14, 2014 (avail., 10. “As with humanitarian assistance, U.S. efforts to support local security and service delivery efforts to date have been hindered by a lack of regular access to areas in need. According to Administration officials, border closures, ongoing fighting, and risks from extremist groups have presented unique challenges.”
[12] CDC, Known Cases and Outbreaks of Ebola Hemorrhagic Fever in Chronological Order, Web, accessed January 23, 2014, and CDC, Known Cases and Outbreaks of Marburg Hemorrhagic Fever, in Chronological Order, Web, accessed January 23, 2014. (
[13] F. Fenner et al., The History of Small Pox and its Spread Around the World, (Geneva, WHO, 1988): 239.] See, also, Sheldon J. Watts, Epidemics and History: Disease, Power and Imperialism (Yale University Press, 1999) for a comprehensive exposition on the geopolitical impacts and epidemics in the Western world.