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The Terrorism-Disease Nexus: India's Neighborhood Concerns

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  • January-June 2015
    Invited Articles

    The lawyer1 representing the Pakistani clinician2 involved in a US national security plan to confirm Osama Bin Laden’s identity in 2010, was killed in Peshawar last week. The formerly Taliban-linked, then Islamic State (IS) affiliated, and once again Taliban-allied (March 2015) Jamaat-ul-Ahrar group3, has claimed responsibility for the murder as has Jundullah4, a Taliban affiliate associated with Tehrik-i-Taliban Pakistan (TTP) and IS. Now more than ever, we are reminded of the terrorism-disease nexus5.

    While withholding vaccines may not be tantamount to active biological warfare (BW), it could be labelled as passive BW. More importantly, it is terrorism, by any definition. By deliberately disrupting the disease prevention systems like vaccines (oral or injected), and going so far as incentivizing obstructionist behaviors, including, committing violence against healthcare workers, as well as sacrificing children to the disease (in this case, Poliomyeletis or polio for short) and anointing them as martyrs should they succumb to illness or death are intentionally evoking disease or death. This insidious, passive form of BW does not require the need for manipulating pathogens to even mimic the effects of an endemic disease, polio, or to successfully weaponise and disperse polio, rather, by deliberately denying prevention measures, the disease is permitted to run its course unfettered. To date, there are no viable counter-measures to stop polio infection if it has begun. Further, the long lasting impact on the existing government, as represented by its inability to protect its citizens, is immeasurable.

    The effects of preventing access of healthcare workers and supplies to unimmunized children due to assault, and thus denying children a potentially life-saving intervention are no different than actively exposing children to polio as a weapon. The effects can be devastating, even more so when terrorist groups engaging in anti-vaccine practices such as Al Qaeda and Taliban affiliates, Al Shabaab, and Boko Haram are exploiting existing vulnerable national and regional public health infrastructure. In 2014 there were 89 polio-related killings reported6; 80 of those health care workers that were targeted and killed were in Pakistan, with others being from Nigeria.

    Polio has been all but eradicated from the planet. However, its remaining endemic strongholds, Pakistan, Afghanistan, and Nigeria, are also rife with terrorism. In 2014 cases were also documented7 in: Somalia; Equatorial Guinea; Iraq; Cameroon; Syrian Arab Republic; Ethiopia; South Sudan; and Madagascar. The likelihood for cross-border infection, particularly in contiguous nations that border anti-vaccine controlled areas and consequently, into regions with growing allegiances and affiliations with known anti-vaccine terrorist organizations poses a risk to eradication strides made over the last nearly 40 years. If polio is not effectively managed the Centers for Disease Control and Prevention8 (CDC) in the United States suggest that, “… [a] resurgence of polio could paralyze more than 200,000 children worldwide every year within a decade.”

    As we recently have seen with Ebola, any high-consequence infectious disease outbreaks anywhere in the world pose a global threat. The strength of a country’s public health infrastructure is not always the metric by which successful interventions are measured. Attacks against the public health infrastructure are attacks against a nation and its people. Failure of the public health infrastructure, for whatever reasons, is one existential threat that no nation can afford to ignore.

    In so far as the crisis at hand is about power and who is wielding it, there is a need to identify who is best suited to be “in charge” of the evolving anti-vaccine crisis. In Pakistan, where the majority of the cases are, the government must identify the agency and individuals who most clearly possess the highly complex skill sets, training, resources and backgrounds needed to provide overall management of a crisis, not merely the health aspects of the crisis.9

    India’s concerns that this be accomplished sooner rather than later are in part fuelled by the declaration made in India in 2014, that the South-East Asia Regional Office of the World Health Organization (WHO-SEARO) was able to declare the region polio-free10 since January 2011. And for India, Pakistan is only a bus ride away11 and a similar risk also exists for Africa. And, while India has offered its ‘full cooperation’12, to date there has been no reportable progress. However, as the rise in polio cases are parallel to the adoption of anti-vaccine fatwas by Islamist terrorist organizations, incorporating cross-border assistance from the Indian government to the Pakistani government will likely be decided only once Pakistan has made internal management decisions on how to coordinate its response.

    Efforts to issue arrest warrants by local administrators have proven somewhat effective, numbers of vaccine refusals by parents have dropped where punitive measures were put in place.13 However, for a lasting effect, the Pakistani government will need to not only make legislative changes but also enforce them. And, herein lies the heart of the matter. Until there is recognition by the security apparatus in Pakistan, law enforcement or military, that polio is a threat to its national security, and that ensuring vaccination occurs even in terrorist-run strongholds. It is not enough to get security officials to agree that public health or in this case, polio, is a threat, but to agree to treat it as such. By treating polio as a security threat, there should be active participation in threat reduction efforts. Consequently, rather than agreeing to send more health care workers into harm’s way, security forces can administer vaccines.

    Clearly, attacks against public health are a real threat, not just locally or even regionally, but against the entire world. To put the threat of public health to national security in context, consider the fact that more soldiers throughout history have died from infectious disease caught while in combat then all forms of military and enemy action combined. Designating the polio crisis in Pakistan as the result of passive BW or terrorism rather than merely a public health problem due to the endemic nature of polio in Pakistan may alter the agencies and individuals tapped to coordinate and implement the response. Regardless of who or what is the ‘perpetrator’, the impacts on global public health are the same. Until we wake up and truly realize the key and pivotal role that public health and disease prevention, we are indeed placing countries, regions and the world at risk.