Author:
Rene Kanayam
Italian Team for Security, Terroristic Issues and Managing Emergencies

DOI: 
Research Paper
Received: May 2
Accepted: June 27

Abstract: The definition of Medical Intelligence is by all accounts a broad and complex scientific task that needs to encompass wider ramifications of using medical and biological data to advance national security interests. The paper focuses on examples of using the medical discipline in the form of an exhaustive collection of medical data in order to arrive at very specific results significant in the pursuit of national security or political stability, albeit only from the point of view of a particular actor – the state.  The three representative cases are illustrated to arrive at a fundamental understanding of how the medical data – intelligence – can be used if the medical environment is burdened by the imperative to further strategic state-devised objectives. In the organization of a fictitious inoculation campaign in rural Pakistan by the Central Intelligence Agency in 2011 to track down the whereabouts of Osama bin Ladin through mapping the DNA pattern of purported bin Ladin’s relatives, the state actor focused specifically on collection of human biological samples while deploying covert tactics – both disregarding the purported motive of the “health campaign” as well as executing the operation on the foreign soil. In another example, perceiving the potential uncontrolled population growth as a direct threat to both vital national interests, as well as the country’s public image, Uzbekistan, on the state level, has engaged in mass forced sterilization programs to curb the national birth rate.  In a similar perception, the treatment of the rare disease of leprosy in Uzbekistan historically encompassed methods incompatible with medical ethics and basic human rights.

The precedents will be examined as part of the wider discourse on what constitutes Medical Intelligence, and what is permissible within the framework of national security concerns.

Keywords: Medical, Intelligence, National Security, Vaccination, Sterilization, Leprosy 

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Introduction

Medical Intelligence as a particular vector of activities is defined by the US Department of Defense as having a direct relationship to military medical planning and as such is placed as part of activities of the Defense Intelligence Agency, in a specific, thematic and real-life events-oriented discourse the definition encompasses wider ramifications of using medical and biological data to advance national security interests.

The paper wishes to examine the historical examples of using the medical discipline in relation to the domain of national security.  The analysis of what specifically constitutes Medical Intelligence is being made with both the focal point of medical intelligence - biologically derived empirical information - as well as the potential repercussions when such intelligence is used in the sphere of national security planning and implementation.

Three particular instances will be illustrated as part of the article – the first being the fictitious inoculation campaign in rural Pakistan by the Central Intelligence Agency in 2011 to track down the whereabouts of Osama bin Laden through mapping the DNA pattern of purported bin Ladin’s relatives.  This “medical” operation aimed specifically to collect human biological samples among the group of unsuspecting individuals deployed covert tactics involving the locally hired medical personnel and cast multiple questions with regard to the justification of such an operation on foreign soil.

The other examples will focus on medical practices in Uzbekistan where the state engaged in mass forced sterilization programs to curb the national birth rate, ostensibly to ensure sufficient food and water resources for the existing population and thus warranting the overall political and economic stability.  A similar approach has been applied in Uzbekistan to the treatment of leprosy patients whereby the ill are first tested without the required individual consent and then forcibly removed from their regular household domain and transported to lifetime hospice-type facilities.  The national security concerns about a disease difficult to treat as well as the country’s image are apparently of paramount priority, overriding any notions of human rights.

In the cases of both Pakistan and Uzbekistan, the issues of Medical Ethics and the Hippocratic Oath need to be examined how and when they collide with national security concerns – also from the point of view that the medical data collected for seemingly justified purposes, in fact, becomes an “actionable intelligence”, whereby the interests of the state actor take precedence over the interests of the nation’s population.

Fictitious Vaccination Campaign as means of attaining National Security objectives

The most notorious abuses of medical science can probably always be found in the annals of intelligence agencies’ activities.  While the notion that “the medical knowledge makes best assassins” may sound grotesque, the Israeli MOSSAD’s technological unit and the associated Israel Institute for Biological Research have developed the most potent and lethal substances used in targeted killings by precisely understanding not only what biological medium works best but also working out the optimal medical way of administering the substance, to both cause a guaranteed death as well as leaving little or no traces.  Bergman (2018, p. 454) notes that deadly substances are manufactured as part of perfecting “regular” pharmaceutical research further.  In every case, a thorough understanding of human biological mechanisms as well as records of minute medical data derived from secreted research is indispensable to carry out an operation devised as a result of a national security imperative.  Be it an attempted killing of Khaled Mashal, the former head of Hamas in 1997, or the elimination of Mahmoud al-Mabhouh, Hamas’s weapons procurement specialist in 2010, the description of the MOSSAD operations leaves no doubt that only medically trained operatives could ideally execute the government orders.

Understandably, the details of the modus operandi related to the operation of tracing down Osama bin Laden’s whereabouts in Pakistan are shrouded in secrecy.  Already in 2011, however, a few months after the confirmed death of Osama bin Laden, major international news outlets reported the particulars of the “fake vaccination campaign by the CIA to obtain bin Laden’s relatives’ DNA”. 

The actual operation to eliminate bin Laden codenamed “Operation Neptune Spear” on Pakistan’s territory on May 2, 2011, contributed to further damaging already strained US-Pakistan relations, but it also triggered a so-called “Abbottabad Commission Inquiry” by the Government of Pakistan.  The inquiry (initially classified by the country’s Prime Minister but subsequently leaked to the public by Al Jazeera), in its major part focusing on the events of May 2, inevitably had to shed light on the previously conducted “vaccination” campaign involving a local medical professional (Dr. Shakeel Khan Afridi), ostensibly a locally CIA asset:“… he was recruited by the CIA under the cover of USAID in 2008.  In January 2011, he was assigned by the CIA to conduct a Hepatitis-B vaccination campaign for females in Abbotabad’s rural areas.  He was instructed to give a special emphasis to Pathan Gali where the Osama bin Laden’s Compound was located.  … He was able to provide actionable intelligence including “voice prints” to the CIA.  … Dr. Afridi received approximately Rs 10 million from the CIA and had been cultivated and ultimately used in CIA’s project to assassinate Osama bin Laden.” (Iqbal J. et al., 2013, p. 115)

The sizeable report compiled as the result of the Abbotabad Commission Inquiry, listing in detail the results of interviews with individuals having access to or some relation to the Osama bin Laden compound, further outlines the particular circumstances during which blood samples were obtained while administering not only the Hepatitis-B vaccines but also polio vaccines.  The Guardian report from July 2011 suggested that the establishment of bin Laden’s relatives’ DNA in the vicinity of the compound was not successful (any obtained DNA was supposedly compared to that of bin Laden’s sister who died in Boston in 2010).  The CIA also never directly commented on the vaccination campaign.

The creativity of the CIA in tracking down the most wanted individual in the history of the United States notwithstanding, the modus itself deployed to obtain DNA samples from the local residents believed to be related to bin Laden leaves some questions from both medical and ethical perspectives:

a. While the Hepatitis-B vaccine is administered in three doses, apparently the second and third doses were never administered, leaving those who did receive the first dose in a medical limbo.

b. Needless to say, informed consent to conduct the underlying purpose of the vaccination was never received.

c. A medical professional applied his skills with the knowledge that the physical liquidation of an individual constitutes the ultimate objective of the “medical” operation.

d. Although the White House (not the CIA) announced in 2014 that the CIA does not use the vaccination programs as a cover for their operations, Pakistani society, in general, grew strongly distrustful of any inoculation campaigns that may have been conducted afterward:

The news [about CIA covert activities utilizing vaccination being discontinued] comes in the wake of a series of militant attacks on polio vaccination workers in Pakistan, with legitimate healthcare workers targeted as being US spies. The attacks have forced organizations such as the UN to suspend polio vaccination efforts in Pakistan, and have severely hampered anti-polio efforts, with parents refusing to have their children vaccinated. (The Lancet, 2014)

Forced sterilization as the means of curbing the population

Uzbekistan, already the most populous Central Asian republic (also in the domain of the post-Soviet Union, after the Russian Federation) in 2016 at the end of Islam Karimov’s reign (by official accounts 32 million on the territory of the country, with to 8 million overseas), has encountered another population boom in recent years whereby in 2024 the official census declared almost 38 million inhabitants within the country’s borders – this way also suggesting that the forced sterilization programs in the country are the things of the past.  It is therefore understandable that the concerns over both food and potable water security were always on the top of the government agenda – during Karimov’s years some of the Uzbek expatriates abroad suggested that the regime could be brought down if several million Uzbek migrants working in Russia would suddenly return home – the possible risks associated with lack of food supply for the masses could lead to general revolt and the change of regime.

The first cases of forced sterilization in Uzbekistan were reported as early as 1999 and according to the data collected from hundreds of hospitals across the country, from 1999 to 2003 surgical sterilization was applied widely across Uzbekistan as a tool to control the birthrate.  The second wave of sterilization (in the form of forced hysterectomies), traced in interviews and media reports, began in late 2004 and early 2005 (Antelava, 2013, pp. 13-14).  Another wave of sterilization programs is believed to have begun in April 2009 when President Karimov issued a decree related to the claimed protection of the health of mothers and children (Antelava, 2013, pp. 25-26).  The decree does not even mention any sterilization processes and it is only ironic that it was meant to be interpreted to enforce the birthrate control.

Because of the existence of a documented multitude of additional “Orders” issued by the Ministry of Health, stipulating “voluntary surgical sterilization” accompanied by the so-called “secret addendums” prescribing forced sterilizations (or “voluntary” consent obtained under false pretexts), it is understood that all of the clinics and hospitals in the country catering to reproductive health had quotas imposed on them concerning sterilization procedures (Antaleva, 2013, pp. 28-30).  With the significant amount of empirical data acquired by BBC correspondent Natalia Antaleva in 2013 from medical professionals, dissidents and local journalists through numerous interviews and records examination, it is clear that the reproductive health centers across Uzbekistan had systematically used already existing medical information (age of women, number of children in the family, general health conditions concerning possible future births, level of education, residence location, etc.) to single out those individuals where the sterilization “warranted merit” because of the government policies.   In many cases, the “forced” procedure was executed in its literal sense of the word – even with the clear objections from the concerned individual.

As in the case of leprosy control in the following part of the paper, the main reasons behind the forced sterilization are observed to be population control and Uzbekistan’s public image – both supposedly increasing the aspects of national security (the factors are inter-related as the controlled population numbers equal adequate access to food, water and land resources; and Karimov’s government highly sensitive to any outside criticism did not have to deal with the portrait of the country as “poor because overpopulated”.  Antaleva (2013, p. 19) however surmises that the population control explanation is less convincing because nobody knows the actual population of Uzbekistan, with a population census before 2013 being conducted only in 1989.

From the point of view of ensuring political stability sterilization, if only not in its coerced form, may seem to be a rational program – but without the informed consent of the sterilized women it becomes just another form of mass oppression.  It also points to the fact that medical data of patients and data regarding the incumbent birth rates can be misused in order to arrive at a narrow aspect of national security concern regarding the available resources.

Government control of leprosy cases in Uzbekistan

In 2016, during one of the author’s visits to Uzbekistan, a discussion ensued with a local medical professional with regard to acute clean water shortages in the country, especially in the hot summer season.  While highly infectious diseases such as cholera are also present during these seasons, leprosy, in particular, seems to be the most stigmatized and thus government-controlled disease still present in the country.  Understandably, the other transmittable illnesses such as HIV/AIDS or other STDs are omnipresent as well – it is perhaps the notion of leprosy as “the disease of the past” or “a tropical disease of the Third World” that makes the government officials nervous when the cases are exposed.

The individual engaged in discussion and then provided a shocking description of how general practitioners routinely carry out examinations for leprosy without a patient’s knowledge or consent (checks being as benign as just poking a patient’s hands with sharp objects) and more shockingly what follows next – the patient is immediately sent off to the only leprosarium in the country (deep within the Autonomous Republic of Karakalpakstan), with all of his immediate family also being examined.  The village of Shurkul about 20 km from the capital of the autonomous region Nukus, where the leper colony is located, is so isolated that it is difficult for an outsider to find it on the map, let alone reach it (Hook Report, 2023). 

Although the Karakalpakstan leper colony today houses only 5 people on permanent cases (with a reported 229 people with the chronic but non-contagious form of the disease), and after 2016 when Uzbekistan simplified the procedures for the import of drugs for the treatment of rare diseases (Hook Report, 2023) the outpatient treatment seems to be an option as well.  Some 30-40 years ago the number of patients was higher, and as recently as in 2016 the admission to the colony usually meant a lifetime confinement to the colony.  While there is no mention of drastic security measures within or around the colony today, some time ago the location was apparently guarded by the army and the supplies for the leprosarium was transported there by helicopters to minimize the contact with the patients.

There are two significant points in relation to the above within the medical intelligence discourse:

1. Medical data can still be collected without the proper consent of those being examined (at the same time, in the case of Uzbekistan the government does not supply the official statistics to the World Health Organization and the number of newly infected is only a matter of unofficial accounts).

2. The rather outdated notion about the curability of the disease contributes to the state-level conviction that in order to minimize the perceived public health risks as well as to “protect” the image of the country to the external parties (both according to the state with a supposed higher level of national security), the transgressions in medical practices are acceptable and required.

Conclusions

The medical sector at large, and the vast existing databases of modern medicine are by definition omnipresent and relatively easily accessible troves of intelligence.  The question is, are the state mechanisms and systems capable of protecting the data against national security interests and imperatives that very often override any other societal concerns? Although the issues of Medical Ethics and the Hippocratic Oath can be examined in how they collide with the issues of national security and intelligence gathering in each separate precedent, the short answer to the above question is that in practice it is not feasible to rely on commonly accepted assumption that human rights, inextricably linked to the medical field, will be observed and protected.  In outlined examples, the medical data that is readily available has always the potential to become an “actionable intelligence” - if the data possessor deems it fit to further the interests of the state actor. The example of the fictitious inoculation campaign to acquire biological data without the concerned individual’s consent highlights the painful reality whereby there are no red lines in the realm of government intelligence operations.  It cannot be expected that anything will change in the foreseeable future. The cases of forced sterilization and the method of treatment of rare diseases present a piece of clear evidence that the Constitution and the adopted laws supposedly protecting the citizens with regard to their medical well-being have little impact on the societal processes when they can easily be nullified by presidential decrees or ministerial orders.  A persistent subordination of the general medical science and the data derived from conducting medical practice to the “higher good” of often intangible notions of national security as a result undermines the very fundaments of the nation’s security that were put forth as priorities. Within a wider context of Medical Intelligence, the discourse should probably be applied also to veterinary science as the interrelation between human and animal health is becoming ever so consequential.  The countries where economic sustainability depends on animal husbandry cannot afford to neglect the veterinary sector as animal well-being will have a direct correlation to securing national interests.   In an era when zoonotic diseases occur without adherence to a particular geographical region, the adequate and all-encompassing collection and management of veterinary data earns the same spot accorded to human medical intelligence.  Given an ancient adage that “a medical doctor treats humans while a veterinary professional treats humankind” the medical intelligence field deserves to be applied across categories dealing with living organisms – and only in such a contextual relationship can the sound national security policies be formulated.

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