Convergence: a review of narco-terrorism for the osteopathic family physician

William L. Bograkos, MA, DO, FACOEP, COL, MC, FS, Army (ret.), VA Maryland Health Care System, Loch Raven Outpatients, 3901 The Alameda, Baltimore, MD 21218.

E-mail address: william.bograkos@va.gov

The world’s opium trade has a long history preceding Hippocrates and Alexander the Great. Morphine was extracted from opium in 1803 and heroin was later synthesized from morphine in 1874. In addition to influencing and managing pain on and off the battlefield, chemical advances affect the transportation of narcotics. Less bulk affects med- ical supply lines. Dried product (heroin), provides traffickers greater financial profits compared to wet and bulky opium. Ten kilograms of opium yields one kilogram of morphine, which can yield one kilogram of diacetyl morphine (heroin). In 1905, the U.S. Congress banned opium; however, advances in chemistry and medicine advanced production of opium derivatives (morphine and heroin). Methods to contain and control the opiate outbreak failed. In 1923, heroin was legally banned by the U.S. Treasury Department’s Narcotics Division in the United States and addicts went to the “black market.” A decade later an unusual alliance of cross-cultural business partners took place. Sal- vatore “Lucky” Luciano developed multi-ethnic partner- ships outside of the Cosa Nostra (“our house”).1 Greater profits were made when he abandoned barrels of whiskey for kilograms of heroin. In New York City, he profited from the mix of prostitution and heroin. He managed his prosti- tutes and his organization, and increased his revenues with the introduction of heroin. Human trafficking continues to be linked with drug trafficking.2

Business alliances influenced by globalization have evolved from ships and opium to planes and heroin. Advances in chemistry improved the ability to refine and transport heroin with greater speed and profit. Farmers grew poppies in Burma or Turkey producing exports for refineries in Shanghai or Marseilles. This resulted in greater availability of dried product on the inter- national market. An increase in product availability leads to a decrease in consumer price and an increase in drug users.

History of geopolitics teaches us that Hong Kong’s ces- sion from China to Great Britain resulted from “the Opium Wars” (1839-1842). Silver sailed from China as opium entered Chinese ports despite the protest of the Qing dy- nasty. The international stage was set for the Golden Tri- angle (Myanmar, Thailand, and Laos) and the Golden Cres- cent (Afghanistan, Pakistan, and Iran). History teaches us that addiction, corruption, and economics have always in- fluenced the nature of man. Illicit opiates have been asso- ciated with conflicts, survivors of conflict, and the purchase of arms for continuing conflicts.

Heroin is a physically addictive drug that can be smoked, snorted, or injected. Heroin and many other drugs are both psychologically and physically addictive. The National In- stitute on Drug Abuse defines addiction as “a chronic, re- lapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.”3 The World Health Organization and the United Nations Interna- tional Drug Control Program (UNDCP) estimate that “13.5 million people take opioids, including 9.2 million who use heroin and that the worldwide production of heroin has more than doubled or even tripled since 1985.”4

The United Nations Office on Drugs and Crime states, “Heroin is the most widely consumed illicit opiate in the world. Of the opium that is not converted into heroin, two thirds is consumed in just five countries: the Islamic Re- public of Iran, Afghanistan, Pakistan, India and the Russian Federation.”5 Afghanistan is the leading source of the world’s illicit opiates, followed by Myanmar, Mexico, and Colombia. Globalization has expanded the international narcotic trade linking continents, cultures, criminals, and terrorist organizations. Addiction and infectious disease know no geographic boundaries. Twenty-three percent of people who use heroin become addicted. The Afghan poppy produces a greater potency of opium than poppy from the Golden Triangle. Afghanistan’s poppies may yield 56 kg of opium per hectare compared with 10 kg/hectare from the Golden Triangle.6 Some governments and militaries have been shown to inhibit the trade profits from the Golden Triangle,7 whereas other governments and militaries pros- pered from the heroin trade.8 The United Wa State party in Myanmar built a “narco-army”9 and narco-state from their export.

The 1973 Nixon administration consolidated federal powers of drug enforcement into a single agency—the Drug Enforcement Administration (DEA)—after the Viet Nam war. The DEA mission addresses the reduction and avail- ability of illicit controlled substances on domestic and international markets.”10 Our domestic and international med- ical communities need to address the demand.

In 2001, approximately 13 metric tons of heroin entered the United States and were used by American citizens.11 Since September 2001 there have been various definitions of “terrorism.” Most definitions reference “criminal” behav- ior and “political” intent or objective. The 1984 U.S. Army Counter-terrorism Manual defines terrorism as “the calcu- lated use of violence or threat of violence to attain goals, often political or ideological in nature, by intimidation, or coercion. Terrorism is a criminal act, sometimes symbolic

in nature, intended to influence an audience beyond the immediate victims.”12 The “terrorist” is a criminal. The intent and ideology of “terrorism” and criminal organiza- tions differentiate but do not necessarily separate the two groups of criminals—they both consist of organized crimi- nals. They plan, operate, recruit, and finance for the benefit of their cause. Their primary targets are civilians. Criminal organizations involved in narco-trafficking are linked to narco-terrorists through the business of narcotic and other trade practices (i.e., weapons, human trafficking/smuggling, money laundering). Their “lines of operation”13 from base through land and sea to objective are invested. Organized crime and terrorist structures may differ, but both seek to prevent compromise to their own security.

In an organizational pyramid (Fig. 1), leadership sits at the peak, supported by the “active cadre” of the organiza- tion. This “command staff” (Fig. 2) is supported by a layer of “active support” (operators, logisticians, planners) upon a foundation of “passive support.” Active cadre may also include lawyers, accountants, and other special staff. Passive financial support for the “cause” is sought from char- ities. With narco-terrorism, passive support is also derived from populations who use and abuse the narcotics. Counter- measures used to defeat criminal organizations include de- veloping wedges to divide and disrupt layers, and divide and disrupt their financial and membership base. This applies to the modern day social network of the “Global Salafi Jihad.” Follow the money. Identify supply lines and remove them. All plagues and associated outbreaks need to be contained and controlled.

All organizations depend on financial support. Our own National Incident Management System14 gives equal importance to each section; however, when viewed with opera- tional experience, the variables of time and depth of re- sources (financial and human) are appreciated. Longevity requires a strong financial base.

‌Figure 1 Organization of a Terrorist Group.42

‌Figure 2 Incident Command system: Command Staff and General Staff.43

to further, or fund, premeditated, politically motivated vio- lence against noncombatant targets with the intention to influence (that is, influence a government or group of peo- ple).”15 When Steven Casteel made this statement, the Fu- erzas Armadas Revolucionarias de Colombia (Revolution- ary Armed Forces of Colombia; FARC) and its narcotics trafficking and associated violence were destabilizing Latin America. Today Latin American drug traffickers, terrorists, and narcotics are transnational. In 2003, our DEA “identi- fied seventeen Foreign Terrorist Organizations, as desig- nated by the Department of State, with potential ties to the drug trade.”16 The first U.S. indictment and arrest of a “member of a terrorist organization involved in drug traf- ficking”15 was six months after September 11, 2001. He was a commander within FARC. Latin America is home to the National Liberation Army, FARC, Sendero Luminoso (Shining Path), and the United Self-Defense Groups of Colombia (AUC). All are designated by the U.S. State Department as Foreign Terrorist Organizations. All are con- sidered narco-terrorists.

Today, Latin American narco-terrorist organizations pro- vide Hamas and Hezbollah with multiethnic international partnerships between two continents. The U.S. Southern Command counter narcotic strategies are “integrated into its theater military mission because illegal drug production and trafficking problems cannot be separated from the eco- nomic, social, and political ills of the region.”7 Partner nations train through an aggressive Counter Drug/Counter Narco-terrorism program, yet “47 % of the heroin that reaches the U.S. emanates or passes through Colombia.”17 Although both cocaine and heroin are drug-profiting businesses, heroin may have special appeal for the long- range business planner. Cocaine use, abuse, and addiction may kill the consumer within five years, whereas the heroin user may be able to maintain their addiction for more than a decade. Availability and purity of the product affects both the financial cost and the potential for overdose. “Heroin is more lucrative for dealers. While a kilogram of cocaine might fetch between $10,000 and $35,000, a kilo of heroin could be worth as much as $180,000.”11 The direct cost of the Madrid train bombings was estimated to have been

$10,000. The Istanbul truck bomb attacks, the Jakarta JW Marriot Hotel bombing, the Bali bombing, the USS Cole attack, and the East Africa embassy bombing combined cost an estimated $180,000.18

‌Profitable plague

President Obama uses the term “plague”19 in his National Drug Control Policy. Drug use, abuse, and addiction present a chronic plague, not only of the American people but of all people. Globalization; international commerce; interna- tional crime; and national, international, and transnational terrorism are linked through convergence of narco-terror- ism. It should be obvious that heroin use “endangers health and safety.”19 Illicit intravenous drug use is also associated with HIV, the viral hepatitides, and other blood-borne dis- eases. Illicit intravenous drug use is associated with the airborne threat of tuberculosis. Drug trafficking is also as- sociated with sex workers and sexually transmitted diseases. These are slow chronic diseases that differ from the threat of deliberate epidemics (bioterrorism).20 Illicit drugs also serve as vectors for outbreaks of violence. Monies flow toward suppliers as drug users become passive support for

the drug supplying organizations. Finances, not political ideology, link terrorist organizations with criminal organi- zations. Money distribution and money laundering follow. As state support of terrorism decreases, organizations seek financial revenue through charities and criminal behav- ior. Drug trafficking may have another strategic purpose, according to the World Health Organization: “Not only does it provide funds; it also furthers the strategic objectives of the terrorists. Organizations believe that they can weaken their political and ideological enemies by flooding their societies with addictive drugs.”21

Rachel Ehrenfeld, PhD, defined narco-terrorism as “the use of drug trafficking to advance the objectives of certain governments and terrorist organizations.”22 In 1990, she addressed Latin American left wing terrorism associated with Marxist/Leninist ideology. She also addresses what we refer to as “stove pipe” cultures influenced by the various missions, roles, and responsibilities of national agencies (DEA, CIA, DoD). Her writings discuss the use of narco- trafficking/narco-terrorism within “low intensity conflict”23 (LIC) and reference Soviet “special reconnaissance” tactics and strategy that target the moral influence of nation states. Drug use affects the public health infrastructure of the state, depletes finances, and attacks the “moral influences” of its people (communist, socialist, or capitalist) in developed, developing, failing, and failed states. Illicit narcotics affect all people, all religions, and all regions.

In 1996, 3286 Turkish citizens were killed by terrorism- related events (of which 2516 were associated with the Partiya Karkaren Kurdistan [PKK]).”24 Turkey remains a major transit route for heroin, most of it entering through Iran. The PKK (and others) have been directly involved in heroin traffic and have profited from taxation on the heroin trade.”25 The PKK’s financing has shifted from state sup- port to include “Syria and other states interested in weak- ening Turkey”26 to Kurdish diasporas in Europe and the drug trade. The war in Iraq has opened routes for PKK drug traffickers. Heroin is now routed through Iraq as well as Iran26 and has increased drug revenues. Taxation during transit brings in revenues, and huge profits continue to be made once the product reaches consumers within the Euro- pean Union (EU). Heroin enters through the porous borders of the “Balkan Route,” providing profits and weapons for organized crime, the Albanian mafia, and the Kosovo Lib- eration Army.27 Drug monies buy light arms and contrib- uted to the 2004 Madrid train bombing.28 Regional popu- lation displacement, secondary to outbreaks of violence and social economic instability, affects the international com- munity.

“The special religious edict to distribute hard drugs as an ideological weapon in the war against Israel and the West probably originated in Iran.”29 The “Party of God”—Hez- bollah— has been linked to drug production, distribution, money laundering, and the training of “al-Qaeda, Al-Jihad, Hamas, the Japanese Red Army, Abu Nidal’s organization, Force 17, New People’s Army, the IRA, Chechen rebels, Fatah, the Red Brigade, Palestinian Islamic Jihad and the

Medellin Drug Cartel.”30 Hezbollah provided protection for Shiite producers, distillers, and transporters in the Beka region of Lebanon and has profited “up to $200 million a year”29 from the heroin business. Their political base is maintained ironically from its involvement in health, edu- cation, and religious and social service to the Shiite popu- lation. It has been suggested that the Fatwa from “Iranian Ayatollahs rather than Lebanese religious scholars”29 per- mitted the distribution of drugs as an ideological weapon. “We are making these drugs for Satan—America and the Jews. If we cannot kill them with guns, so we kill them with drugs.”21 Links to diasporas and narco-terrorists in Latin America has shed light on Hezbollah finance. International terrorism and the use of explosives against Jewish and Israeli institutions in Buenos Aires link Iranian Hezbollah to local narco- criminals.

The United Nations Office on Drugs and Crime (UN- ODC) has reported that 60% of Afghan opium moves through Iran on its way to Europe.31 The HIV rate in Iran is 25% among heroin users.30 When opium prices soared in 2000, many Iranians switched to the cheaper opiate, heroin. After the Bam earthquake in 2003, emergency medical supplies included methadone to treat opium withdrawal despite the fact that the largest seizures of Afghan heroin occur in the Islamic Republic of Iran. Iran leads interna- tional efforts with “23% of all heroin interceptions,” fol- lowed by Turkey (16%), the U.S. (9%), and China (8%).5 Iran’s 12,000 anti-narcotic police and border guards deter traffickers so that the Balkan route shifts south through Pakistan. A kilo of heroin may be worth US $2000-$2500 in Afghanistan, rising to US $3000 on the Afghanistan/Paki- stan border and to US $5000 at the Iran/Afghanistan bor- der.5 Price increases reflect the risk and numbers of person- nel on the payroll. Prices increase to US $8000/kg on the Iran/Turkey border. Iranian heroin profits are estimated to be US $450- 600 million per year.5

Pakistan and Afghanistan are both opium-producing countries. Afghanistan harvests 50 times more opium than Pakistan. Most of the processing of opium takes place in mobile laboratories along the Afghanistan/Pakistan border. Although opiates are consumed by their citizens, most of the heroin is exported to Europe. The new Central Asian Re- publics are displacing heroin traffic toward Russia. “In Cen- tral Asia, the Islamic Movement of Uzbekistan (IMU) is the most widespread and best-financed terrorist group. It seeks to use its excellent connections with the Taliban and al Qaeda to topple the Karimov regime in Uzbekistan and establish a wider Islamic state in Central Asia. The IMU is known to rely heavily on narcotics trafficking over a num- ber of Central Asian routes to support its military, political, and propaganda activities. That trafficking is based on mov- ing heroin from Afghanistan through Tajikistan, Uzbeki- stan, and Kyrgyzstan, into Russia, and then into Western Europe.”21

Heroin users in Pakistan are estimated to consume 20 tons of pure heroin annually.32 Pakistan’s Internal Political Division of the Inter-Services Intelligence (ISI) is alleged to

“In 2004, approximately 523 tons of morphine was pro- duced worldwide from opium for medical purposes.”8 Aus- tralia and France produce half, with India, Turkey, Spain, and Hungary producing the rest. None of Afghanistan’s opium from their poppy fields is used for licit opiates. Afghan narco-cartels are now beyond taxing. They are in- volved in producing, processing, stockpiling, and exporting drugs. “Ninety percent of the world’s opium comes from Afghanistan; less than 2% is seized there (more than 20% of global cocaine supply is seized by its main producer, Co- lombia).”6 Opium is a profitable “cash” crop. “In 2006, the opium harvested from the 4% of arable Afghan land brought in more than 35% of the country’s total gross national product.”8 The huge profits from narcotics rarely build pub- lic health or critical infrastructure for the farmers. Profits benefit the narco-traffickers, narco-terrorists and those who are corrupted by the drug money. Heroin state armies do not report to governments. They become governments.

Crop eradication is counterproductive to counter-terror- ism and counter-insurgency operations. Foreigners destroy- ing crops only allow insurgents to win the hearts and minds of the farmers. Crop eradication also leads to the stockpiling of opium, morphine and heroin by businessmen who await the change of market prices. Narco-states become failing states and the focus of regional instability.

Mr. Antonio Maria Costa, past Executive Director of the UNODC, recommended that counter-insurgency and coun- ter-narcotic efforts “reinforce each other so as to stop the vicious circle of drugs funding terrorists and terrorists pro- tecting drug traffickers.”8 Yury Fedotov, the new Russian UNODC Executive Director, now leads the challenge to contain and control the epicenter and profitable plague from the Golden Crescent. Russia is threatened by both Central Asian terrorist organizations and the chronic threat of Rus- sian organized crime. Russian organized crime, like the Byzantine eagle, looks east and west strengthening business alliances with the Italian mafia, Mexican and Colombian narco-traffickers, Japanese Yakuza, Chinese Triads, and Ni- gerian smuggling groups.

The January 2004 Afghan Constitution identified opium as a threat to the state. “An August 2004 National Council of Ulema fatwa declared poppy cultivation contrary to Is- lamic sharia.”34 The 2006 Afghan National Drug Control Strategy identifies eight pillars of government activities required to combat narco-terrorism: public awareness, in- ternational and regional cooperation, alternate livelihoods, demand reduction, law enforcement, criminal justice, erad- ication, and institution-building. US strategy in Afghanistan includes five pillars: alternative livelihoods, elimination and

eradication, interdiction, law enforcement and justice re- form, and public information. U.S. National Drug Control Strategy35 at home lists three national priorities: “stopping use before it starts” (prevention), “healing American drug users” (response), and “disrupting the market” (deterrence). Public health strategies that address heroin demand and addiction as a brain disease will affect drug distribution, treatment, economics, and stability.

‌World at Risk

In the “World at Risk”36 the current threat of weapons of mass destruction (WMD) is reviewed. Justification of use based on religious duty is discussed. Narcotics are omitted. Heroin smuggling routes may serve as the same routes for WMD smugglers. Cash crops buy small arms for interna- tional terrorists, insurgents, and inner city gangs at home and abroad. Profits purchase police, lawyers, judges, and the assassins willing to kill those who are not corrupt (“silver or lead”). Drug money has the potential to buy scientists or weapons of mass destruction for those with apocalyptic vision.

Heroin itself has been used as a commodity. Accept and acknowledge the reality of convergence, then attack global terrorism and global narco-trafficking with a united effort of hard and soft power. Use international diplomacy, strategic communications, military partnerships, and economic and public health resources. The public health threats of narcot- ics and biological agents require a unity of effort between international security organizations and public health sys- tems. It is time to strengthen medical prevention and re- sponse within counter-terrorism. Our military and police physicians already support deterrence efforts.

Interrupt financial flow required for arms, explosives, and logistical bases. Divide the base and layers of the organizational pyramid. Where coalitions converge, divide them. When heroin unites criminal and terrorist coalitions, attack the illicit heroin. Divide the layers of the narco- terrorist pyramid. Prevent the organizational links from forming. Profits catalyze and strengthen organizations. Re- move the catalyst (drug money) and destabilize the product (narco-terrorism). Historical lessons from the long war on organized crime combined with lessons from “low-intensity conflict” benefit counter-drug strategic planners. Narco-ter- rorism alters the dynamics of low-intensity conflict by in- fluencing change, discontent, poverty, violence, and insta- bility. The profit is financial, social, and moral. When we acknowledge that year after year, tons of heroin enter our country, we acknowledge that sophisticated “lines of com- munication” exist, are invested, and serve our adversary. When tons of heroin can penetrate our “homeland defense” and “homeland security,” so too can grams of dried, refined, biological weapons. Deliberate epidemics need to be con- tained and controlled with public health strategies.

Public support to narco-traffickers lasts as long as the money and benefits last. When the purity and quantity of the drug begins to affect their own house (population), narco- terrorists lose their public support. When the narco-traffickers and terrorists lose support of the people, fear is ex- changed for past promises of hope. To cut off financial support to narco-terrorism, multi-agency cooperation is mandatory, not just to attack their refineries and distribution operations, but to attack their money laundering, banking practices, and charity networks. This includes attacking and disrupting financial alliances within the Black Market Peso Exchange,37 the hawala, the hundi, and the Chinese Under- ground Banking System.38

The transnational terrorist network of al Qaeda has been linked with “almost all of the terrorist/extremist groups identified as being involved in narcotics trafficking.”21 Al- though al Qaeda has not transitioned to become the global narco-cartel, their transnational involvement in narco-traf- ficking presents a global threat. Opiates bring a pandemic upon all people, and political ideology is sacrificed for profit. The “UNODC-WHO Joint Programme on drug de- pendence treatment and care”39 addresses drug use and dependence as a public health issue. It lists drug use within the top 10 risk factors to health in developed countries. It estimates that 205 million people in the world use illicit drugs, 25 million are drug-dependent, and drug use is among the top 20 risk factors to health worldwide. In the United States “approximately 3.8 million Americans age 12 or older reported trying heroin at least once during their lifetime.”40

The international community’s response to the conver- gence of international crime and terror united the U.N. Drug Control Programme with the Centre for International Crime Prevention, forming the UNODC. The UNODC’s mission is “to reach out to services providers to improve the quality, accessibility and affordability of drug dependence treatment and rehabilitation services.”39 Its mandate is “to assist mem- ber states in their struggle against illicit drugs, crime and terrorism.”39

‌Conclusion

Our “National Security Strategy” lists “Public health chal- lenges like pandemics (HIV/AIDS, avian influenza) that recognize no borders” and “illicit trade, whether in drugs, human beings, or sex, that exploits the modern era’s greater ease of transport and exchange”41 as major examples of challenges provided by globalization. The globalization of the heroin trade and the resulting pandemic of addiction require a transnational response from our global medical community. Illicit narcotics contribute to a world at risk. Counter the demand and availability of illicit opiates with access and availability of treatment, with drug courts, with dedicated educated physicians, and with access to buprenor- phine-credentialed physicians. Training in buprenorphine in

the treatment of opioid dependence is offered by the Amer- ican Osteopathic Academy of Addiction Medicine. Be cog- nizant of the price and availability of heroin on the Amer- ican street. Prevention and treatment efforts at home can influence cash crop profits in Afghanistan, Myanmar, Co- lombia, and Mexico.

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