The United States Central Intelligence Agency (CIA) used a fake vaccination programme to obtain DNA (deoxyribonucleic acid) samples in the search for Osama Bin Laden, which caused distrust and hampered polio eradication and other public health efforts in Pakistan.¹1. Rubenstein L. Unhealthy practice: Medical work in conflict zones is compromised. Foreign Affairs. 2013 Apr 24. Available from: Available from: http://www.foreignaffairs.com/articles/139344/leonard-s-rubenstein/unhealthy-practice [cited 2015 June 23].
http://www.foreignaffairs.com/articles/1... ²2. Polio eradication: the CIA and their unintended victims. Lancet. 2014 May 31;383(9932):1862. http://dx.doi.org/10.1016/S0140-6736(14)60900-4 PMID:24881975
http://dx.doi.org/10.1016/S0140-6736(14)... The Obama administration's vow that the CIA will never again exploit a vaccination programme in its counterterrorism efforts, therefore came as welcome news to global health and humanitarian communities.³3. Monaco L. Letter on vaccine work. DocumentCloud; 2015. Available from: Available from: https://www.documentcloud.org/documents/1164764-monaco-letter-on-vaccine-workers.html [cited 2015 Jun 23].
https://www.documentcloud.org/documents/...

Distrust and suspicion that public health programmes are being used to advance foreign interests have contributed to the increase in murders and violent attacks on vaccination workers.²2. Polio eradication: the CIA and their unintended victims. Lancet. 2014 May 31;383(9932):1862. http://dx.doi.org/10.1016/S0140-6736(14)60900-4 PMID:24881975
http://dx.doi.org/10.1016/S0140-6736(14)... There have been setbacks to polio eradication efforts and other public health objectives.²2. Polio eradication: the CIA and their unintended victims. Lancet. 2014 May 31;383(9932):1862. http://dx.doi.org/10.1016/S0140-6736(14)60900-4 PMID:24881975
http://dx.doi.org/10.1016/S0140-6736(14)... Counterterrorism policies and practices can have unintended health impacts, especially where health programmes are co-opted or undermined, in countries where health systems are strained and population-health indicators are poor.

The reach of counterterrorism laws is long and they have adversely affected humanitarian health activities in many countries where identified terrorist groups are active and health needs are increased.⁴4. Mackintosh K, Duplat P. Study of the impact of donor counter-terrorism measures on principled humanitarian action. New York: United Nations Office for the Coordination of Humanitarian Affairs; 2013. Available from: Available from: https://docs.unocha.org/sites/dms/documents/ct_study_full_report.pdf [cited 2015 Jun 23].
https://docs.unocha.org/sites/dms/docume... Humanitarian actions can be categorized as providing material support to terrorists. Material support has been interpreted to include the provision of medical care (but not medicines), which can render the very activities that are associated with the core ethical commitments of the medical and nursing professions illegal.

Even where specific prohibitions are not in place, such policies have a range of more diffuse effects which can undermine population health. Humanitarian organizations have become more hesitant to rely on local contractors who once provided essential resources like transportation and equipment for fear of making them vulnerable to criminal prosecution or violence.⁴4. Mackintosh K, Duplat P. Study of the impact of donor counter-terrorism measures on principled humanitarian action. New York: United Nations Office for the Coordination of Humanitarian Affairs; 2013. Available from: Available from: https://docs.unocha.org/sites/dms/documents/ct_study_full_report.pdf [cited 2015 Jun 23].
https://docs.unocha.org/sites/dms/docume... Risks of violence have, indeed, increased for health providers where local populations and armed factions perceive them as neither neutral nor impartial, and ultimately untrustworthy.¹1. Rubenstein L. Unhealthy practice: Medical work in conflict zones is compromised. Foreign Affairs. 2013 Apr 24. Available from: Available from: http://www.foreignaffairs.com/articles/139344/leonard-s-rubenstein/unhealthy-practice [cited 2015 June 23].
http://www.foreignaffairs.com/articles/1...

This situation contributes to rising security concerns for health providers and facilities.⁵5. Health care in danger: making the case. Geneva: International Committee of the Red Cross; 2011. The greatest risks, alongside adverse impacts on population health, are incurred by local health workers who may be seen as betraying their own communities, or perceived by other groups to be enemies for having treated members of those communities. Local health workers are typically unable to leave their communities in the face of danger and have access to fewer protections, compared to expatriate humanitarian workers.⁶6. Delaunay S. Condemned to resist. Brussels: Professionals in humanitarian assistance and protection; 2014. Available from: Available from: http://phap.org/articles/condemned-to-resist [cited 2015 Jun 23].
http://phap.org/articles/condemned-to-re...

Intelligence officials may attempt to use health organizations and workers to gather intelligence. The United States military has also used health care in the context of counterinsurgency operations.⁷7. Williamson J. Using humanitarian aid to 'win hearts and minds': a costly failure? Rev Int Croix Rouge. 2011 Dec;93(884):1035-61. These counterterrorism policies and practices can threaten people's health by creating the conditions for distrust and by deterring people from seeking care. For humanitarian health workers, the principles of impartiality and independence, which lie at the centre of humanitarian work, are undermined. This can lead to moral distress for health workers concerning accountability to intended beneficiaries of services and to funders, responsibility to patients and the law, complicity with perceived wrongs and compromise of professional and personal ethical commitments.⁶6. Delaunay S. Condemned to resist. Brussels: Professionals in humanitarian assistance and protection; 2014. Available from: Available from: http://phap.org/articles/condemned-to-resist [cited 2015 Jun 23].
http://phap.org/articles/condemned-to-re... ⁸8. Lepora C, Goodin RE. On complicity and compromise. Oxford: Oxford University Press; 2013. http://dx.doi.org/10.1093/acprof:oso/9780199677900.001.0001
http://dx.doi.org/10.1093/acprof:oso/978...

Several ethical values and principles are at stake, including: trust, solidarity, proportionality and accountability. Trust is an essential aspect of all human social interaction, but is especially important in global health work, where health workers employed in a particular public health programme have not previously worked with the local population. Solidarity, although traditionally interpreted as a principle and practice embraced within the confines of community, is now global in scope. Solidarity involves cultivating bonds with others, trying to imagine their plight and standing with them in fighting injustice. In advancing their counterterrorism agenda, strategists and policy-makers should not threaten solidarity in global health action. Indeed, we have witnessed solidarity around the moral imperative to detach counterterrorism measures from health programmes and interventions.²2. Polio eradication: the CIA and their unintended victims. Lancet. 2014 May 31;383(9932):1862. http://dx.doi.org/10.1016/S0140-6736(14)60900-4 PMID:24881975
http://dx.doi.org/10.1016/S0140-6736(14)... ³3. Monaco L. Letter on vaccine work. DocumentCloud; 2015. Available from: Available from: https://www.documentcloud.org/documents/1164764-monaco-letter-on-vaccine-workers.html [cited 2015 Jun 23].
https://www.documentcloud.org/documents/...

The principle of proportionality states that there should be a balance between the risks of harm and the potential benefits of a given intervention. In this context there is no evidence that population-health impacts are considered by security advisers, an oversight we find ethically unjustifiable given the potential for harm resulting from decisions on the methods used to combat terrorism. This omission also violates obligations to respect and protect health care, established under international humanitarian law⁹9. Protocol additional to the Geneva Conventions of 12 August 1949, and relating to the protection of victims of international armed conflicts, 8 June 1977. Geneva: ICRC; 2015. Available from: Available from: https://www.icrc.org/ihl/intro/470 [cited 2015 Aug 13].
https://www.icrc.org/ihl/intro/470... and human rights law.¹⁰10. Right of everyone to the enjoyment of the highest attainable standard of physical and mental health. A/68/297 New York: United Nations; 2013. Available from: Available from: http://www.wma.net/en/20activities/20humanrights/20distress/A_-Grover-Report-UN-GA-October-2013.pdf [cited 2014 Jun 23].
http://www.wma.net/en/20activities/20hum...

Those focused on fighting terrorism have the responsibility of weighing the potential health consequences for people living in areas targeted by counterterrorism efforts. To the extent that counterterrorism operations, laws, and policies damage population health - especially where these effects are foreseeable and preventable - such responsibilities are clearly established in ethics and international law.

New mechanisms to ensure that counterterrorism activities do not contravene international law or ethical values and principles will require careful design. Apart from the ethical and legal grounds, there are good practical reasons to design more effective counterterrorism measures. Preventable harms to population health contribute to mistrust and instability and undermine the stated objectives of the intelligence services.

Acknowledgements

This paper is based on the outcomes of a workshop funded by Fondation Brocher. MH is also affiliated with the Biomedical Ethics Unit, McGill University, Montreal, Canada; DM is also Scientific Coordinator, ICMM Center of Reference for Education on International Humanitarian Law and Ethics, Zurich, Switzerland; LR is also affiliated with the Berman Institute of Bioethics, Johns Hopkins University, Baltimore, USA. VW is also affiliated with the Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland

References

Publication Dates

History