Biological Attack

Polio is back from the brink of extinction -- ravaging the battlefields of Syria and spreading across the Middle East.

As the annual hajj came to its end in early October, and hundreds of thousands of pilgrims departed Saudi Arabia having honored the highest traditions of Islam, the kingdom cautiously breathed a sigh of relief: No epidemic erupted among the roughly 1.4 million visitors. But though it may have seemed that attentions were focused on concern over the possible spread of the Middle East respiratory syndrome MERS -- a disease that has affected more than 135 people in eight countries, killing 45 percent of those infected -- for months Saudi health authorities have been keeping a nervous eye on another disease, polio, which is spreading rapidly across the Middle East, most recently inside war-torn Syria.

Though Saudi Arabia has been polio-free for decades, its Ministry of the Hajj has always borne special responsibility for the health and safety of all religious pilgrims to the holy city of Mecca. In Muslim tradition Crown Prince Abdullah, himself, is the custodian of the Two Holy Mosques, accountable for any tragedies that befall sacred visitors.

Given the intense religious significance of Saudi Arabia's responsibilities, all possible disease outbreaks among pilgrims are a concern for the government. But it has been a long time since the Ministry of the Hajj had to take a position that stands diametrically opposite to the stance held by some followers of the faith: when it came to polio, the Kingdom stood firmly against Muslim extremism. This year, the ministry insisted that all pilgrims be fully immunized against polio, and bring proof of vaccination as part of their visa application process. Given that Muslim extremists -- the Taliban and some al-Qaeda adherents -- oppose polio vaccination, and have executed immunizers, the Saudi position was gutsy.

Whether it was successful, however, we'll have to wait and see. The hajj has ended, and hundreds of thousands of pilgrims are now returning to their homelands all over the world. Because the incubation time for polio can be as long as 35 days Saudi authorities will not be sure that their measures worked until mid-November.

Nonetheless, it's clear that polio -- which just two years ago was on the verge of eradication, with active cases confined to just three countries -- is resurgent, and the news is grim.

For the first time in 16 years, wild polio viruses are spreading in war-torn Syria, causing paralysis in afflicted children. On Oct. 19, the regime's Ministry of Public Health declared a polio emergency and the World Health Organization (WHO) confirmed a "hot outbreak" that is actively expanding around Damascus. In the last week, polio cases have been identified in Ethiopia, Somalia, and among about a dozen Somali refugees in Kenya. As of Oct. 16, the number of 2013 active polio cases found in the three "endemic nations" (Afghanistan, Pakistan, and Nigeria) are far outnumbered by the toll in new outbreaks outside those countries: 99 children have contracted the disease in endemic nations, versus 197 in outbreak areas like the Horn of Africa, which had been free of polio. And in mid-October the United Nations Security Council called upon Khartoum and Juba to carry out mass vaccination campaigns after three cases of polio were found in the new nation of South Sudan.

Polio is not a mysterious disease -- how it is spread among people and the role vaccination can play in its prevention are well understood. The world has struggled for decades to eradicate polio -- a global effort that has cost billions of dollars and millions of man hours. Billionaire philanthropist Bill Gates added his weight and wealth to the polio campaign a few years ago, noting this summer that, "We're raising the money to get it done by 2018. When these problems leave the rich world, they're out of sight, out of mind.... Polio is where we have a very concrete plan. It's raising $5.5 billion -- of which the [Bill & Melinda Gates] Foundation is going to give $1.8 billion. If we get credibility from the polio success, we can be more articulate about a malaria or measles elimination plan."

But politics and religion can foil even the best technology and financing.

Victory seemed near in 2011 when vaccination coverage reached levels sufficient in most of the world to stop spread of the virus (which typically occurs through fecal transmission from infected individuals into water supplies or via close contact with others). By early 2011, polio was confined to Pakistan, northern Nigeria, and Afghanistan -- all areas in which distrust of government and Western health services in Muslim communities was high. Backed by the Rotary Club International, Gates, and the Global Alliance of Vaccine Initiatives (GAVI), health officials worked closely with leading imams worldwide to assuage fears about immunization and counter false claims that the vaccines would either sterilize children or give them AIDS. The WHO was finally full of optimism about the polio fight.

But that summer, the U.S. Central Intelligence Agency narrowed its 10-year search for Osama bin Laden to a compound in Abbottabad, Pakistan. In hopes of confirming bin Laden's presence behind the compound's fortifications, American recruited Pakistani physician Dr. Shakil Afridi to carry out a fake hepatitis B immunization effort in the area. The scheme called for Afridi to gain entry to the compound, needle-immunize the children inside, and bring the used syringes to CIA operatives for DNA identification of the youngsters. Afridi never managed to get permission from the compound's sentries, and the effort failed.

When the CIA scheme was reported in July 2011 by the Guardian, it spurred outcry from public health leaders (myself included) regarding the peril posed by linking the agency's efforts to already politically sensitive vaccination campaigns. Horribly, the backlash unfolded as we had predicted. Today, polio is spreading in Somalia and Pakistan in areas where Taliban and other Islamist extremist groups have managed to contort the entire CIA/hepatitis saga: Collusion in immunization efforts is, they claim, tantamount to supporting the CIA, U.S. drone attacks, and a laundry list of other perceived American sins against Islam. Never mind that the polio vaccine is oral, no needles are used, and the Afridi/CIA scheme was all about those needles -- the "Big Lie" has spread. To date, extremists in Pakistan have waged countless attacks on polio immunization workers -- most of them, unpaid female volunteers -- and their security details, killing at least 20 of them since December 2012, and injuring many more in bomb, knifing, and gun assaults.

The Kingdom of Saudi Arabia this summer issued unique health requirements for umrah and hajj pilgrims hoping to avoid spread of disease, after the WHO in May called upon all travelers worldwide to get vaccinated. Among them was insistence on polio vaccination, including a requirement of valid certification from local health authorities. Which meant that those waging attacks on polio vaccinators (allegedly in the name of Islam), could not engage in the religion's most holy ritual unless they could prove that they were fully immunized.

But the Islamic world now faces a genuine crisis with polio, as radical factions continue to attack vaccinators and decry immunization as a dangerous Western scheme. The full extent of the Somali outbreak is not known, as foreign health professionals now find the country too dangerous. Even the die-hard war zone physicians of Médecins Sans Frontières (MSF) gave up on Somalia in August citing the deteriorating security atmosphere. MSF workers have suffered stolen medical supplies, kidnappings, violence of all kinds, and other atrocities. The organization's departure left Somalia's health system in a shambles, undermining an already fragile network of public health clinics that had served as the primary centers of child vaccination. The United Nation's child health program, UNICEF, distributes vaccine supplies to Somalia, but has pulled its personnel back to Kenya. (Somali refugees have carried the virus into Kenya and Ethiopia.) And since June, when al-Shabab attacked a U.N. complex in Mogadishu, there has been a steady outflow from the country of both humanitarian organizations and Somali refugees. Last month's al-Shabab attack on a Nairobi shopping mall has further cemented belief that the nation's security situation is unraveling, putting all forms of public health -- including polio control -- in a tailspin.

Across the Arab Spring regions of the Middle East, the public health situations have spiraled out of control, with outbreaks and failed vaccination efforts noted this year from Morocco to the Iranian borders, Alexandria to Lake Victoria.

And now, some seven million Syrians are now displaced, scattered across Syrian territory and neighboring nations of Turkey, Kurd-controlled Iraq, Lebanon, and Jordan. At least 1 million of them are children under 12 years of age, according to UNICEF. Inside Syria, the public health situation has deteriorated so markedly that the population is now beset by the return of most vaccine-preventable diseases, including measles, hepatitis B, whooping cough, and polio. More than a third of the nation's hospitals have been bombed to smithereens, another 20 percent have sustained sufficient damage to render them useless, and some 15,000 health professionals have fled the nation. On Sept. 15, a group of doctors and Nobel laureates issued a plea to the world, saying Syria's healthcare was "at the breaking point."

This month, Jordan will launch a costly national child immunization program to stop the spread of measles and polio from the encampments of Syrian refugees to the rest of the nation. Lebanon and Turkey are anxiously watching as the Syrian refugee populations within their borders swell to the point of bursting and illnesses spread. For Lebanon, the situation is especially dire: not only does the added Syrian population increase the country's human population by 25 percent, but it brings with it many of the same factions and disputes that were behind Lebanon's bloody civil war in the 1980s. And Israel, which has been conducting a mass immunization campaign, vaccinating approximately 850,000 children since August 2013 -- when polio viruses were discovered in sewer systems located in several parts of the country -- is far from completing its efforts on this front.

Indeed, the core of the polio crisis remains in radical Islamist areas of Pakistan and these attacks on immunizers have been brutal, security details have been unable to protect themselves, much less the healthcare workers, and there is discussion of issuing a global travel advisory regarding the dangers of contracting polio in the country.

The Kingdom of Saudi Arabia practices Sharia law, under Sunni Wahabbi interpretations. As the home of the Islamic world's most sacred sites, and birthplace of the Prophet Mohammed, Saudi Arabia can set standards for Muslims worldwide. Having issued a decree over the summer calling upon all pilgrims to the hajj to demonstrate they had received valid polio immunization, authorities took an important step: Riyadh signaled that regardless of what shenanigans Afridi and the CIA were involved in two years ago, protecting children from permanent paralysis merits support for vaccination. We can only hope that the Saudi health decree will be heard and heeded across the Muslim world -- before it is too late and polio spreads to under-vaccinated regions of Africa, Asia, perhaps even Europe. Given the shocking decline in child immunization compliance across much of Europe and the United Kingdom, driven by false claims that vaccines cause autism, many children may be especially vulnerable were polio to be reintroduced to the region.

Daniel Berehulak/Getty Images

National Security

The Price of War

A new report details the civilian costs of U.S. drone strikes -- and failures to compensate the families of victims. 

On a sultry evening in August 2012, five men gathered under a cluster of date palms near the local mosque in Khashamir, a village of stone and mud houses in southeastern Yemen. Two of the men were locals and well known in their community. The other three were strangers.

Moments later, U.S. drones tore across the sky and launched four Hellfire missiles at the men. The first three missiles killed four of the men instantly, blasting their body parts across the grounds of the mosque. The final strike took out the fifth man as he tried to crawl to safety.

Yemen's Defense Ministry described the three strangers as members of al Qaeda in the Arabian Peninsula (AQAP), a group that the United States calls al Qaeda's most active branch. The men were killed, ministry officials said, while "meeting their fellows."

But these two "fellows" had no known links to AQAP. Rather, they were precisely the kind of Yemenis that the United States has sought as allies in its fight against al Qaeda. One, Salim Jaber, was a 42-year-old cleric and father of seven who preached against violence committed in the name of Islam. The other was the cleric's 26-year-old cousin Walid Jaber, one of the village's few police officers.

Just three days before his death, Salim Jaber had delivered a particularly adamant sermon against AQAP at the Khashamir mosque. The three strangers then showed up in the village in search of the cleric, relatives of the Jabers said. Fearful that the men might be seeking revenge for his sermon, Salim met with them only after his cousin offered to accompany him for protection.

Salim Jaber is yet another innocent casualty in America's covert war on terror. His case is one of six that I document in a new report for Human Rights Watch about the toll of America's largely unacknowledged air strikes in Yemen. All six strikes were so-called targeted killings, the deliberate slaying of a specific person by a government under color of law. All six raise questions about the legality of the Obama administration's targeted killing program. All six help explain why many Yemenis fear the United States more than they fear AQAP.

On President Obama's watch, the United States is estimated to have carried out hundreds of targeted strikes that have killed thousands of people, primarily in Pakistan but also in Yemen and Somalia. The Obama administration acknowledges the program's existence but, with rare exceptions, refuses to publicly confirm individual strikes, including the six that I investigated during two trips to Yemen.  Among the details that the United States will not reveal are how many people it has killed, including civilians. It also refuses to detail the full legal framework under which it carries out the killings, or what actions it takes, if any, when attacks go awry.

In Yemen, it's an open secret that the CIA and the Joint Special Operations Command have carried out an estimated 80 targeted killings in the country since 2009, killing more than 470 people, most with drone-launched missiles. Yet the United States has only formally acknowledged the two strikes that killed three American citizens: the cleric Anwar al-Awlaki, whom U.S. officials described as chief of foreign operations for AQAP; Samir Khan, the editor of AQAP's English-language magazine, Inspire; and Awlaki's teenage son Abd al-Rahman Anwar al-Awlaki, who was killed in an attack that targeted someone else.

It's as if the hundreds of Yemenis also killed in U.S. strikes -- including dozens of civilians -- never existed. "We Yemenis are the ones who pay the price of the ‘war on terror,'" said Faisal Jaber, a relative of the two Jaber cousins killed in Khashamir. "We are caught between a drone on one side and al Qaeda on the other." 

Salim Jaber, who had been preaching against Islamist violence for more than a year prior to his death, lived in the coastal city of Mukallah but had come home to Khashamir for a relative's wedding. In the sermon he delivered at the Khashamir mosque the Friday before he was killed, "He used harsh words and challenged them [AQAP] to provide proof of the justness of their attacks on America, and invited them to a debate," said Faisal Jaber during an interview in Sanaa, the Yemeni capital. The day before the attack, Faisal added, he asked Salim to tone down his sermons.

"I said, ‘You should be careful, your family is worried that something will happen to you.' Salim said, ‘If we all keep silent then who will speak out? If we keep silent, these people will destroy the country.'"

Twice on Aug. 29, the day of the strike, a black Suzuki Vitara sports utility vehicle with unmarked plates stopped outside Salim Jaber's family home. The second time, the three strangers inside the car sent neighborhood children to ask for the cleric to come out. Salim's father went to the car and told the men that his son would return after Isha, the evening prayer. When the prayer ended, several villagers saw the three strangers drive to the back entrance of the mosque. Salim was standing in the front of the mosque with a group of friends.

The three men summoned the cleric, again through a village boy. Wary, Salim told his friends he thought it best to meet the men over dinner at his house. But when his cousin, Walid Jaber, who was carrying his police handgun, offered to accompany him, Salim agreed to walk to the back of the mosque and meet the men. "Walid said, ‘We are both men, what are you scared of? It is not good manners,'" Faisal Jaber said.

Salim and Walid approached the three strangers and sat with two of them beneath the date palms. Several men from the village gathered at a corner to watch, fearing the strangers might try to harm the Jabers. But, even if that was the strangers' intent, the drones struck first.

"The first of the missiles hit the circle of men directly," Faisal said. "When the men [villagers] heard it, they all ran toward the spot where it landed. Then the second missile struck and shrapnel flew over their heads. The third missile came from an angle and took off the roof of the car and hit them again. The fourth missile took a bit of time. Maybe they were checking to see if they were still alive. They [the villagers] saw a man crawling and the fourth missile hit that man and his body was thrown 20 meters or more onto the wall of a sheep's manger near the mosque. His body was intact. Only the back of his head was gone."

The villagers waited several minutes and then approached slowly, said Abdullah Jaber, a cousin of Salim and Walid who was among those at the scene. "It was dark except for the burning car," Abdullah Jaber said. "We could make out many body parts scattered several meters apart -- fingers, hands, internal organs. Most bodies had no legs and one was without a face. Another had no head. Until now they still have not found that head.... Imagine this horror."

Ahmad Jaber, Salim's 79-year-old father, said he heard the explosions and arrived at the mosque as villagers were collecting body parts in red and blue water pails.  "No one dared tell me," he said. "Finally, one of them came to me and took my hand and said, ‘Where is Salim?' I said I did not know, that we were waiting for him to have dinner with us. He said, ‘Alhamdulillah, Alhamdulillah, Alhamdulillah [Praise God, Praise God, Praise God], Salim is dead.'''

Later that night, two men brought Ahmad Jaber into the mosque and supported him by each arm as he viewed the corpses, wrapped in plastic under blocks of ice, as the village had no refrigerated morgue. "The people opened the first bag and asked, ‘Is this Salim?' I said, ‘No.' They opened the second bag, and the third, and the fourth. Then they opened the last one. It was Salim. At that point, I could not move."

Relatives said they identified Salim only by a few remaining bits of his face and beard, and Walid by the remains of his handgun and his ornate belt, which was somehow intact.

Faisal Jaber showed Human Rights Watch a series of photos and videos he had taken the day before and the day after the strike. The set from before the strike showed Walid dancing and Salim smiling at the wedding party that the cleric had come home to attend. Walid's ornate belt is clasped around his white robe. The set from after the strike showed the three strangers' vehicle melted into a twisted mass behind the mosque and remnants of what Human Rights Watch later identified as Hellfire missiles. The photos also showed dismembered body parts and faces burned beyond recognition. They showed holes from missile fragments in the walls of nearby homes and the date palms' broken branches. The trees had been the pride of the village; today, they no longer bear fruit.

Every man, woman, and child in Khashamir has seen the photos and videos, Faisal Jaber said. "Now when villagers see these images," he added, "they think of America."

One theory in Khashamir about why Salim and Walid were killed is that the U.S. government  assumed the cousins were militants because they were meeting with the three alleged AQAP members. If so, the Jabers' deaths would underscore the peril of so-called signature strikes, in which the Obama administration reportedly targets individuals based on patterns of behavior rather than specific knowledge that they were engaged in hostilities against the United States.

Another theory is that the United States decided the Jaber cousins were acceptable collateral damage -- the wartime calculus allowing civilians to be killed during an attack on an enemy target, provided that the anticipated military gain outweighs the loss of civilian lives. But it's hard to imagine how the military advantage of killing the three alleged militants -- none of them known AQAP leaders -- outweighed the loss of an anti-AQAP cleric.

The Obama administration justifies targeted killings by asserting that it is in a global war against al Qaeda and "associated forces," such as AQAP, which can indeed pose a serious threat. Yet more than 12 years after the September 11 attacks, it's far from clear that the struggle between the United States and these groups amounts to an armed conflict as recognized by international humanitarian law or the laws of war.  Even if one were to accept the Obama administration's concept of a global war against al Qaeda, the laws of war require parties to a conflict to take all feasible precautions to protect civilians from harm. The veil of secrecy that shrouds U.S. targeted strikes -- even when they kill civilians -- makes it impossible to know whether the United States has made that effort. The silence also adds to the difficulties families face in seeking redress for unlawful deaths.

Two of the attacks I investigated in Yemen indiscriminately killed civilians in a clear violation of the laws of war. One was a strike in 2012 near the central Yemeni city of Radaa that destroyed a sports utility vehicle and killed 12 villagers, including a pregnant woman and three children. The presumed target, an alleged local leader of AQAP, had been traveling along the same road but was nowhere in sight when the missile struck the car. Relatives found the charred bodies of their loved ones coated in the sugar and flour that they were bringing home from the local market.  

The other indiscriminate attack, a pre-dawn strike in 2009 on the hamlet of al-Majalah in southeast Yemen, killed 14 alleged militants in a suspected training camp -- but also 41 Bedouins sleeping in two other encampments nearby. Cruise missiles launched by the U.S. Navy showered hundreds of cluster munitions on the sleeping nomads, two-thirds of them women and children. Indiscriminate weapons that pose unacceptable dangers to civilians, cluster munitions carry a large number of so-called "bomblets" and disperse these explosives over a wide area, causing mass carnage. Nearly four years after the al-Majalah attack, the site remains littered with unexploded bomblets that make it too dangerous to enter.

In the other four strikes that I investigated, including the one that killed the Jabers, the evidence suggests that the United States took out alleged AQAP members who may not have been valid targets under the laws of war or that the strikes caused disproportionate civilian harm.

During his confirmation hearings in February to become the next director of the CIA, John Brennan, then Obama's chief counterterrorism advisor, said the United States worked with local governments to compensate families in the "rare instances" of wrongful deaths and carried out reviews of such strikes. My investigations found no evidence of that in Yemen.

After Human Rights Watch and other organizations began pressing the U.S. and Yemeni authorities about redress, the Yemeni government compensated some relatives of civilians killed in U.S. attacks. But payments have been haphazard, slow to come, and, in many cases, inadequate. In the case of the 2009 attack that killed 41 Bedouins, the families of those killed have received compensation only for their meager possessions -- mostly goats and beehives -- lost in the attack, not for their dead relatives.

After the airstrike in Khashamir that killed Salim and Walid Jaber, enraged villagers created a roadblock that stopped government cars along the main road through the province. It ended when local leaders persuaded them villagers to rally peacefully instead. Most of the village joined a march four days after the strike, chanting "No to killing innocents" and "Obama, this is wrong."

Local authorities arranged for a stipend for Salim's eldest son, who is deaf and mute, and promised they would find the young man a job upon completion of his studies. The family also received an apologetic phone call from an officer with Yemen's U.S.-funded and trained Counter-Terrorism Unit, Faisal Jaber said. In June, the office of President Abdu Rabu Mansour Hadi told the Jabers that the government would provide condolence payments of 2.5 million Yemeni rials ($11,600) each to Salim and Walid's families. But, when Human Rights Watch last contacted Faisal Jaber two weeks ago, the payments had yet to arrive.

In a speech last May, President Obama for the first time outlined his administration's policies on targeted killings. Among other measures, Obama said, the United States does not strike unless there is "near-certainty" that civilians will not be harmed. The White House has refused to say when that policy was or will be implemented, and it did not respond to queries about the attack that killed Salim and Walid Jaber and the other strikes that I investigated.

The new evidence of civilian deaths that Human Rights Watch found in the field underscores that it is long past time for the Obama administration to go public on how many people it is killing in targeted strikes, how many of those killed are civilians, how many attacks were unlawful, and what the United States is doing to ensure that future attacks comply with international law. As the voices of the victims slowly emerge, the United States needs to stop covering its ears and start taking action.

-/AFP/Getty Images