Biological Warfare and Syria Annie Sparrow

Biological warfare is generally understood as the deliberate wartime introduction of a lethal pathogen with the intent to kill or maim. Syria under President Bashar al-Assad is pursuing a sinister variation—one with long and dangerous historical precedents. Assad’s government has allowed pathogens normally controlled by public health measures—such as clean water, sanitation, waste disposal, vaccination, and infection control—to emerge as biological weapons through the deliberate destruction and withholding of those measures. The conflict has in effect reversed public health advances to achieve levels of disease not seen since the Napoleonic era.

Warfare was long synonymous with conditions preferred by germs—soldiers were packed into trenches without sanitation or clean water, exposed to the environment, and surrounded by vermin. Poor nutrition didn’t help, and penicillin wasn’t an option until the 1940s. During the Napoleonic wars, eight times more British soldiers died from pneumonia, typhoid, and dysentery than in battle. In the American Civil War, two-thirds of all deaths were due to pneumonia, diarrheal disease, and malaria.

World War I was the first war in which combat caused more deaths than disease. (The Spanish influenza epidemic struck toward the end of the war and is not included in these figures.) Florence Nightingale had already revolutionized hospital hygiene practices during the Crimean war of the 1850s, reducing death rates from hospital-acquired infection from 40 percent to 2 percent. But during World War I, the penetrating wounds caused by machine guns were quickly contaminated, and the only way to control the resulting gas gangrene was amputation. That drove the development of powerful wound disinfectants.

After 1941, penicillin reduced post-operative pneumonia death rates from more than 30 percent to less than 10 percent, and surgical infections dropped to about 5 percent. During the Iraq War, more U.S. soldiers died from suicide than infectious disease. These days, mass displacement and the resulting crowded refugee camps mean that it is now mainly civilians who suffer the infectious consequences of conflict.

Biological warfare goes back two millennia. Assyrians poisoned enemy water sources in the 6th century B.C. In 1346, Tartars catapulted bodies of plague victims over the city walls of Caffa in Crimea to break the siege—and potentially kick-started a second plague pandemic. In 1650, Polish forces shot their enemies with saliva from rabid dogs. In Italy, Napoleon flooded Mantua’s plains in an effort to spread malaria. In the United States, Confederate sympathizers allegedly sold clothing from patients with yellow fever and smallpox to Union troops. Often inadvertently but sometimes deliberately, European settlers spread smallpox with devastating effect among the indigenous American population.

During World War I, Germany unsuccessfully tried out anthrax. During World War II, Japan used prisoners of war as guinea pigs for experiments with gas gangrene, anthrax, cholera, dysentery, and plague, killing at least 3,000 people. In the field, Japanese troops sprayed plague-infested fleas over Chinese villages, killing 10,000 people—but also 1,700 of their own troops. In the 1970s, the Soviets experimented with anthrax, smallpox, and Marburg (an Ebola-like virus causing vascular meltdown) and engineered a multi-drug resistant plague. Iraqi leader Saddam Hussein’s biological weapons program included Scud missile warheads of botulinum, anthrax, and aflatoxin.

But these biological weapons have significant drawbacks. Beyond being unpredictable and difficult to control, anthrax or sarin attacks are too visible and risk a global reaction. And in war, they kill in far smaller numbers and much less reliably than common diseases and wound infections. In contrast, the behavior of Assad’s preferred pathogens is predictable. Here lies the key to a far more insidious strategy: By deliberately degrading an already precarious public health situation, the new biological warfare is able to fly under the radar.

Assad’s most visible mass atrocities include indiscriminate attacks on and the resulting forced displacement of civilians, devastating sieges, and assaults on hospitals. But an unappreciated dimension of his total-war strategy has been his attacks on public health infrastructure and programs in order to fast-track the epidemic diseases that thrive in the crowded living conditions created by mass displacement, while simultaneously withholding essential public health tools and medicines.

The aim is to weaken the entire population in these areas and overburden the rudimentary medical facilities that were able to survive in an effort to punish populations opposed to Assad. While there is a brutal battlefield logic to these attacks on health care infrastructure, they are prohibited by the Geneva Conventions, which are designed to spare civilians—and the institutions on which they depend—from the hazards of war. Assad is deliberately engaging in war crimes.

His strategy is complex, but its impact is devastatingly simple. For example, the maintenance of water treatment and sanitation stations ceased after the Assad regime arrested engineers and maintenance staff and stopped paying their salaries. The Syrian military deliberately bombed water and power plants. Waste disposal stopped, encouraging vectors of infectious diseases such as rats and sandflies to breed. As untreated sewage built, the government withheld chlorine, a prerequisite for clean water.

Beyond bombing hospitals, primary health clinics, laboratories, and blood banks, Assad’s forces went after doctors, criminalizing those who treated civilians and arresting, torturing, and executing any health care worker who defied government policy. After eight years, these efforts have killed more than 800 medics and driven an estimated 15,000 doctors out of the country.