policy and politics
Counterterrorism, Ethics, and Global Health by Lisa Eckenwiler and Matthew Hunt
T
he surge in murders of polio vaccination workers in Pakistan out of suspicion that they represent foreign interests and agents— suspicion reinforced by the covert operation that led to Osama bin Laden’s killing—serves as a poignant example of health-related moral hazards that can arise in the pursuit of national security objectives. The anxiety and psychological trauma, physical injury, and death in civilian populations living under the drones operating in Waziristan and other Pakistani border areas are still others. Then, too, we might consider the arrest and prosecution under counterterror laws of Bahraini doctors who treated antigovernment protestors. The intersection of national security, foreign policy, and health has been explored in a number of arenas, but thus far, little attention has been devoted to the ethical issues surrounding the global health impact of current counterterrorism policy and practice. In this essay, we’ll review a range of harms to population health traceable to counterterrorism operations, identify concerns involving moral agency and responsibility—specifically of humanitarian health workers, military medical personnel, and national security officials and operatives1—and highlight two interrelated policy issues: the need for a conception of national security that incorporates a cosmopolitan concern for health, and the need for shared health governance, including governance of activities affecting health.
12 HASTI N G S C E N T E R R E P ORT
Harms to Health
W
hile estimates vary dramatically depending on who is counting, deaths from the so-called targeted killings carried out by drones operated primarily by U.S. national security agencies are a most obvious health consequence of counterterror operations. Sources suggest that the number of noncombatant deaths stands at over four hundred.2 Many people living in the areas patrolled and targeted by drones also sustain grave and disabling physical injuries and suffer from heightened anxiety and trauma-related illnesses.3 Evidence points, moreover, to serious adverse effects on the health of some military personnel who operate drones, including anxiety, depression, post-traumatic stress, and emotional exhaustion.4 Drone patrols and strikes have also been associated with the dispersion of civilian populations (and with them, doctors and other health workers), thereby contributing to the burgeoning numbers of internally displaced persons and refugees with heightened health vulnerabilities. Neighboring countries and their health care systems, in turn, become strained as they struggle to absorb and provide for the highly variable needs both of displaced populations and of local communities.5 A rise in the killing of health workers can also be linked to counterterror efforts. At least thirty-one polio vaccination workers have been killed since July 2012 in Pakistan alone, while others, as well as security personnel trying to protect them, have been wounded. By
the lights of many, the covert operation involving a vaccination program in the location and killing of Osama bin Laden has contributed to fear and distrust among populations in need of health services and has threatened supply chains, setting back program successes there and in the broader region.6 This operation and its aftermath exemplify a broader trend seen in the war on terror toward the militarization of health care, defined as the “targeting and implication of medicine in warfare.”7 Counterterrorism frameworks promulgated by the United States and adopted by other countries are also implicated in undermining population health. Policies that prohibit a wide range of activities regarded as providing material support to terrorists have adversely affected health program funding and ground operations in some countries.8 Even where specific prohibitions are not in place, such policies may still have a range of more diffuse effects. For instance, contractors who once provided essential support (such as transportation and equipment) have become more hesitant, and security risks increase for humanitarian health providers where local populations and armed factions perceive them as not providing care impartially. These harms to health are properly considered only in the broader context of global health inequities. Populations in places like Afghanistan, Pakistan, Somalia, and Yemen—already vulnerable by global health standards—are more precariously positioned as a result of the war on terror. Moral Agency and Responsibilities
C
ounterterrorism officials and military operatives must, by the nature of their work, make judgments about the justifiability of their operations. Also inherent to their work is deception. Setting aside the matter of whether deception is justifiable in general in the service of state protection, deception that involves the use of a health program and health workers as instruments of national security warrants more ethiMay-June 2014
cal argument at best and, for reasons noted above, perhaps outright condemnation and future prohibition. U.S. officials have also been criticized for allegedly failing to give an accurate accounting of the deaths attributable to drone strikes and, more broadly, for a lack of transparency. Even if we accept that some degree of secrecy is essential for national security, the failure to provide accurate information merits more explicit justification, given the implications for efforts to meet health needs. A central question here is how we ought to understand the unique moral agency and ethical responsibilities of counterterrorism officials related to harms arising beyond the bounds of their security-centered mandate yet traceable to their interventions. What might be called the “liability model” assigns responsibility when a harm can be linked to a given perpetrator—say, an unintended death from a drone strike sponsored by the Central Intelligence Agency, assuming the CIA acknowledges the strike and related death. Alternatively, an account that sees harms as sometimes unintended, slow to unfurl, and not always directly traceable to a clearly identifiable agent assigns responsibility more generously, to all those who contribute to creating the harms. Such an account would include concerns like diminished trust in health and medical workers and programs, and the deepening of global health inequities within its scope. Among the main problems facing humanitarian and local health workers alike are the counterterrorism frameworks noted earlier that treat them as tools in the war on terror. Such frameworks threaten their professional autonomy and their commitment to neutrality and independence. Humanitarian and health workers struggle to provide care for populations that may perceive them as untrustworthy and avoid them entirely. Under these conditions, the workers are compelled to manage profound moral distress and sometimes fear. At the same time, these May-June 2014
frameworks have led some international organizations to rely more on local health organizations and personnel, raising novel issues of accountability and responsibility.9 As the global war on terror has evolved—or devolved—the military’s effort to “win hearts and minds” through such strategies as providing medical care to local populations has situated military medical personnel in the midst of ethical controversy. Deploying health services for the sake of advancing strategic aims seems to violate obligations at the core of health professionals’ identity, including the obligations to respect patients as ends in themselves, to avoid treating them as instruments for other purposes, and to serve their particular health interests rather than the state’s interests. Where the provision of health care and the gathering of intelligence are combined, confidentiality is threatened. We might also raise questions about the distribution of resources and wonder whether intelligencegathering or other military-security– related activities are defensible uses of health professionals’ time. Policy Questions
G
iven these unintended but foreseeable outcomes, any state-centered conceptualization of security that ignores health as an important element—especially in a global context of deepening health inequities—is ethically suspect and might be construed as violating existing international obligations. It also fails the test of prudence. The most pressing policy issue is how to integrate concern for health, including global health, in efforts to prevent terrorism. Already, infectious diseases and disasters have demonstrated the necessity of broadening our conception of the relationship between health, national security, and foreign policy beyond nationalist self-interest and collaborating under a transnational conception of public health. The grave implications of counterterrorism policies and operations also reveal
the need to develop more shared and integrated governance over health. Identifying threats to global health posed by counterterrorism strategies, analyzing them in relation to anticipated gains, and determining the proper assignment of responsibilities for harms done to health and health systems are morally pressing tasks that existing structures and processes lack the capacity to carry out. 1. The participation of doctors in interrogation, force-feeding, or torture and the participation of medical professionals in developing weapons fall outside the scope of our interests here. 2. C. Woods, “Leaked Pakistani Report Confirms High Civilian Death Toll in CIA Drone Strikes,” The Bureau of Investigative Journalism, July 22, 2013; B. Emmerson, Report of the Special Rapporteur on the Promotion and Protection of Human Rights and Fundamental Freedoms while Countering Terrorism, United Nations Human Rights, March 10, 2014. 3. International Human Rights and Conflict Resolution Clinic, Stanford School of Law, and Global Justice Clinic, New York University School of Law, Living under Drones: Death, Injury, and Trauma to Civilians from US Drone Practices in Pakistan, 2012, http://livingunderdrones.org. 4. W. Chappelle, A. Salinas, and K. McDonald, “Psychological Health Screening of Remotely Piloted Aircraft (RPA) Operators and Supporting Units,” ftp.rta.nato.int/ public/PubFullText/RTO/...MP.../MPHFM-205-19.doc?. 5. O. Dewachi et al., “Changing Therapeutic Geographies of the Iraqi and Syrian Wars,” Lancet 383 (2014): 449-57. 6. L. Garrett and M. Builder, “The Taliban Are Winning the War on Polio,” Foreign Policy, February 12, 2014; Médecins Sans Frontières, “Alleged Fake CIA Vaccination Campaign Undermines Medical Care, http://www.doctorswithoutborders. org/press/release.cfm?id=5439. 7. Dewachi et al., “Changing Therapeutic Geographies,” 450. 8. S. Pantuliano et al., Counter-terrorism and Humanitarian Action: Tensions, Impact and Ways Forward (London: Overseas Development Group, 2011). 9. S. Delaunay, “Condemned to Resist,” Professionals in Humanitarian Assistance and Protection Newsletter, February 10, 2014. DOI: 10.1002/hast.308 This column appears by arrangement with the American Society for Bioethics and Humanities. H AS TI N GS C EN TE R RE P O RT
13
Counterterrorism, Ethics, and Global Health by Lisa Eckenwiler and Matthew Hunt
T
he surge in murders of polio vaccination workers in Pakistan out of suspicion that they represent foreign interests and agents— suspicion reinforced by the covert operation that led to Osama bin Laden’s killing—serves as a poignant example of health-related moral hazards that can arise in the pursuit of national security objectives. The anxiety and psychological trauma, physical injury, and death in civilian populations living under the drones operating in Waziristan and other Pakistani border areas are still others. Then, too, we might consider the arrest and prosecution under counterterror laws of Bahraini doctors who treated antigovernment protestors. The intersection of national security, foreign policy, and health has been explored in a number of arenas, but thus far, little attention has been devoted to the ethical issues surrounding the global health impact of current counterterrorism policy and practice. In this essay, we’ll review a range of harms to population health traceable to counterterrorism operations, identify concerns involving moral agency and responsibility—specifically of humanitarian health workers, military medical personnel, and national security officials and operatives1—and highlight two interrelated policy issues: the need for a conception of national security that incorporates a cosmopolitan concern for health, and the need for shared health governance, including governance of activities affecting health.
12 HASTI N G S C E N T E R R E P ORT
Harms to Health
W
hile estimates vary dramatically depending on who is counting, deaths from the so-called targeted killings carried out by drones operated primarily by U.S. national security agencies are a most obvious health consequence of counterterror operations. Sources suggest that the number of noncombatant deaths stands at over four hundred.2 Many people living in the areas patrolled and targeted by drones also sustain grave and disabling physical injuries and suffer from heightened anxiety and trauma-related illnesses.3 Evidence points, moreover, to serious adverse effects on the health of some military personnel who operate drones, including anxiety, depression, post-traumatic stress, and emotional exhaustion.4 Drone patrols and strikes have also been associated with the dispersion of civilian populations (and with them, doctors and other health workers), thereby contributing to the burgeoning numbers of internally displaced persons and refugees with heightened health vulnerabilities. Neighboring countries and their health care systems, in turn, become strained as they struggle to absorb and provide for the highly variable needs both of displaced populations and of local communities.5 A rise in the killing of health workers can also be linked to counterterror efforts. At least thirty-one polio vaccination workers have been killed since July 2012 in Pakistan alone, while others, as well as security personnel trying to protect them, have been wounded. By
the lights of many, the covert operation involving a vaccination program in the location and killing of Osama bin Laden has contributed to fear and distrust among populations in need of health services and has threatened supply chains, setting back program successes there and in the broader region.6 This operation and its aftermath exemplify a broader trend seen in the war on terror toward the militarization of health care, defined as the “targeting and implication of medicine in warfare.”7 Counterterrorism frameworks promulgated by the United States and adopted by other countries are also implicated in undermining population health. Policies that prohibit a wide range of activities regarded as providing material support to terrorists have adversely affected health program funding and ground operations in some countries.8 Even where specific prohibitions are not in place, such policies may still have a range of more diffuse effects. For instance, contractors who once provided essential support (such as transportation and equipment) have become more hesitant, and security risks increase for humanitarian health providers where local populations and armed factions perceive them as not providing care impartially. These harms to health are properly considered only in the broader context of global health inequities. Populations in places like Afghanistan, Pakistan, Somalia, and Yemen—already vulnerable by global health standards—are more precariously positioned as a result of the war on terror. Moral Agency and Responsibilities
C
ounterterrorism officials and military operatives must, by the nature of their work, make judgments about the justifiability of their operations. Also inherent to their work is deception. Setting aside the matter of whether deception is justifiable in general in the service of state protection, deception that involves the use of a health program and health workers as instruments of national security warrants more ethiMay-June 2014
cal argument at best and, for reasons noted above, perhaps outright condemnation and future prohibition. U.S. officials have also been criticized for allegedly failing to give an accurate accounting of the deaths attributable to drone strikes and, more broadly, for a lack of transparency. Even if we accept that some degree of secrecy is essential for national security, the failure to provide accurate information merits more explicit justification, given the implications for efforts to meet health needs. A central question here is how we ought to understand the unique moral agency and ethical responsibilities of counterterrorism officials related to harms arising beyond the bounds of their security-centered mandate yet traceable to their interventions. What might be called the “liability model” assigns responsibility when a harm can be linked to a given perpetrator—say, an unintended death from a drone strike sponsored by the Central Intelligence Agency, assuming the CIA acknowledges the strike and related death. Alternatively, an account that sees harms as sometimes unintended, slow to unfurl, and not always directly traceable to a clearly identifiable agent assigns responsibility more generously, to all those who contribute to creating the harms. Such an account would include concerns like diminished trust in health and medical workers and programs, and the deepening of global health inequities within its scope. Among the main problems facing humanitarian and local health workers alike are the counterterrorism frameworks noted earlier that treat them as tools in the war on terror. Such frameworks threaten their professional autonomy and their commitment to neutrality and independence. Humanitarian and health workers struggle to provide care for populations that may perceive them as untrustworthy and avoid them entirely. Under these conditions, the workers are compelled to manage profound moral distress and sometimes fear. At the same time, these May-June 2014
frameworks have led some international organizations to rely more on local health organizations and personnel, raising novel issues of accountability and responsibility.9 As the global war on terror has evolved—or devolved—the military’s effort to “win hearts and minds” through such strategies as providing medical care to local populations has situated military medical personnel in the midst of ethical controversy. Deploying health services for the sake of advancing strategic aims seems to violate obligations at the core of health professionals’ identity, including the obligations to respect patients as ends in themselves, to avoid treating them as instruments for other purposes, and to serve their particular health interests rather than the state’s interests. Where the provision of health care and the gathering of intelligence are combined, confidentiality is threatened. We might also raise questions about the distribution of resources and wonder whether intelligencegathering or other military-security– related activities are defensible uses of health professionals’ time. Policy Questions
G
iven these unintended but foreseeable outcomes, any state-centered conceptualization of security that ignores health as an important element—especially in a global context of deepening health inequities—is ethically suspect and might be construed as violating existing international obligations. It also fails the test of prudence. The most pressing policy issue is how to integrate concern for health, including global health, in efforts to prevent terrorism. Already, infectious diseases and disasters have demonstrated the necessity of broadening our conception of the relationship between health, national security, and foreign policy beyond nationalist self-interest and collaborating under a transnational conception of public health. The grave implications of counterterrorism policies and operations also reveal
the need to develop more shared and integrated governance over health. Identifying threats to global health posed by counterterrorism strategies, analyzing them in relation to anticipated gains, and determining the proper assignment of responsibilities for harms done to health and health systems are morally pressing tasks that existing structures and processes lack the capacity to carry out. 1. The participation of doctors in interrogation, force-feeding, or torture and the participation of medical professionals in developing weapons fall outside the scope of our interests here. 2. C. Woods, “Leaked Pakistani Report Confirms High Civilian Death Toll in CIA Drone Strikes,” The Bureau of Investigative Journalism, July 22, 2013; B. Emmerson, Report of the Special Rapporteur on the Promotion and Protection of Human Rights and Fundamental Freedoms while Countering Terrorism, United Nations Human Rights, March 10, 2014. 3. International Human Rights and Conflict Resolution Clinic, Stanford School of Law, and Global Justice Clinic, New York University School of Law, Living under Drones: Death, Injury, and Trauma to Civilians from US Drone Practices in Pakistan, 2012, http://livingunderdrones.org. 4. W. Chappelle, A. Salinas, and K. McDonald, “Psychological Health Screening of Remotely Piloted Aircraft (RPA) Operators and Supporting Units,” ftp.rta.nato.int/ public/PubFullText/RTO/...MP.../MPHFM-205-19.doc?. 5. O. Dewachi et al., “Changing Therapeutic Geographies of the Iraqi and Syrian Wars,” Lancet 383 (2014): 449-57. 6. L. Garrett and M. Builder, “The Taliban Are Winning the War on Polio,” Foreign Policy, February 12, 2014; Médecins Sans Frontières, “Alleged Fake CIA Vaccination Campaign Undermines Medical Care, http://www.doctorswithoutborders. org/press/release.cfm?id=5439. 7. Dewachi et al., “Changing Therapeutic Geographies,” 450. 8. S. Pantuliano et al., Counter-terrorism and Humanitarian Action: Tensions, Impact and Ways Forward (London: Overseas Development Group, 2011). 9. S. Delaunay, “Condemned to Resist,” Professionals in Humanitarian Assistance and Protection Newsletter, February 10, 2014. DOI: 10.1002/hast.308 This column appears by arrangement with the American Society for Bioethics and Humanities. H AS TI N GS C EN TE R RE P O RT
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