A Microscopic Insurgent

By Mark D. Drapeau, a fellow at the Center for Technology and National Security Policy at the National Defense University (THE NEW YORK TIMES, 04/12/07):

Last week the United Nations warned of a potential epidemic of deadly cholera in Baghdad, noting that there had been more than 101 cases. This was hardly a surprise: cholera, caused by a bacterium that produces severe diarrhea, broke out in Kirkuk, in northern Iraq, in August and has now spread to at least half of Iraq’s 18 provinces. At least 30,000 Iraqis have displayed cholera-like symptoms and more than 2,500 cases have been confirmed in Kirkuk alone.

In the West, diarrhea is a mild illness relieved by an over-the-counter pill. In the developing world, cholera is a rapid killer, with death due to dehydration coming as quickly as two to three hours. More typically, without treatment of water and electrolytes, shock occurs in less than 12 hours, with death within a day.

The threat is bad enough in the overcrowded communities of poor countries, but epidemics thrive in war zones. In dense areas like Baghdad or refugee camps, the Vibrio cholerae bacterium spreads quickly via untreated water or raw sewage. Latrines in these places often adjoin living quarters, making the spread of germs almost inevitable, and mothers commonly scavenge for leftover food to feed children — food that may be mixed with contaminated water or feces.

It’s no coincidence that Iraqi areas with the filthiest water and most raw sewage are breeding grounds for both V. cholerae and insurgents. In a perverse feedback loop, insurgents in these places are more likely to become ill, but conditions for the surrounding populace simultaneously deteriorate, increasing support for the insurgency. Another perverse circumstance is that chlorine is often used to treat cholera-infected water, but because insurgents have started using chlorine trucks in bombing attacks, restrictions on chlorine distribution have led to reduced water treatment and possibly increased the prevalence of cholera.

War and sickness are inextricably intertwined. Large groups of men living at close quarters on scant sleep are perfect carriers. Indeed, microbes have had a larger effect on the outcome of wars than many care to admit, from smallpox outbreaks in the French and Indian War to the pandemic influenza in World War I. As Clausewitz (who died from cholera in 1831) might have said, war is the continuation of disease by other means.

In Iraq, of course, it’s not only insurgents and civilians who are at risk of disease. Given the asymmetric nature of conflict, which group do we expect to be more affected by an epidemic: large, centralized conventional military forces or small, agile insurgent units? The answer is that a 10 percent loss within a 5,000-member brigade is far more devastating than losing two members of a 20-man terrorist cell. And suicide bombers don’t call in sick.

Disease doesn’t respect borders any more than it does sides in a conflict. Officials in Tehran reported last month that the cholera epidemic had crossed from Iraq into Iran. Syria, Jordan and Kuwait have stepped up border surveillance and disease-detection programs. Saudi Arabia has cited the disease in suspending trade with both Iraq and Iran, and in some cases has banned Muslim pilgrims from entering with food or water.

What can be done within Iraq to reduce the spread of cholera? Despite the general ineffectiveness of the Baghdad government, the Ministry of Health has begun a large cholera-awareness campaign outlining basic procedures for water decontamination. Still, while this is helpful, plastering cities with informative posters and having doses of vaccine on standby is an incomplete strategy. To stop the flow of cholera, the best solution is a clean-water program and better management of waste. The government and the American authorities need to improve sanitation, especially in Baghdad’s slums and in downtrodden rural areas.

Epidemics flowing through fragile new democracies are more than a medical problem. Iraq’s leaders need to decide now how they will preserve the continuity of government services in case of an overwhelming outbreak: Is the military prepared to step in if the civil and medical authorities are indisposed? How will security be maintained if army barracks or police stations succumb?

Cholera is a grave threat for the American project in Iraq, but also an opportunity to capture the hearts and minds of the population. The average Iraqi will feel truly secure only when the vicious disease-poverty-insurgent feedback loop is snapped. As we plan the post-surge phase of American operations, our leaders must bear in mind that healthy people make healthy decisions that serve as the bedrock for healthy societies.