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Health Framework/Research Paper: Bioterrorism in Syria

Lauren Carter

Delaware Technical Community College

NUR310- Global Health

Dr. Michele Gamble

April 25, 2021

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Abstract

Bioterrorism is becoming more predominant in the world today specifically in Syria. Biological

agents have been used to cause more harm then good in developing countries. Due to the

dominant hierarchy government in Syria with the strong power of the President biological

weapons are used daily even against Syria’s own people. The agriculture demands to keep the

economy alive has also caused accidental exposures to biological agents. The most common

biological agent seen in Syria is anthrax which can lead to severe illness and can even cause

death. It is crucial to educate Syria’s citizens what to do and expect if exposed to a biological

agent. Syria should be aware of the treatment plan and ways to prevent exposure. According to

research, the likelihood of being exposed to biological agents will keep climbing if there is no

change in decreasing the number of biological agents used within the government and if citizens

of Syria are not properly wearing personal protective equipment to stay safe in the workplace.

Overall, the best way to stay safe from biological agents is to be prepared for exposure.
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Health Framework/Research Paper: Bioterrorism in Syria

A bioterrorism attack is the deliberate release of viruses, bacteria, or other toxins to

cause illness or death (Pigott et al., 2019). Most bioterrorism attacks are used in wars,

religious cults, or terrorist attacks. These germs are often found in nature. However, they can

sometimes be made more harmful by engineering which would increase their ability to cause

disease, spread, or resist medical treatment. Biological agents spread multiple ways such as

through the air, water, or in food, therefore, the route of entry is mainly inhalation, contact,

and through the gastrointestinal tract (Pigott et al., 2019). Some can also spread from person

to person. These biological agents can be very hard to detect as some biological agents do not

cause illness for several hours or days. Some examples of biological agents are anthrax,

botulism, Ebola, and other hemorrhagic fever viruses, plague, or smallpox (Pigott et al.,

2019). Biodefense uses medical measures to protect people against bioterrorism which

includes medications and vaccinations. It also includes medical research and preparations to

defend against bioterrorist attacks. The most likely used agent in bioterrorism today is bacillus

anthracis which is the bacteria that causes anthrax. Anthrax is a Category A biological agent

of concern stating that these agents are the most deadly, harmful to human health, and can be

the most contagious (Pigott et al., 2019). This paper will be discussing how bioterrorism,

specifically anthrax, affects Syria, as well as, narrowing in on the Health Impact Pyramid

(HIP) of Syria to address the social determinants of health.

Health Impact Pyramid

The Health Impact Pyramid (HIP) is a graphical representation of tiers of influence

that may be result from public health interventions. At the base of the pyramid, indicating

interventions with the greatest potential impact, are efforts to address social determinants of
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health (Frieden, 2010). In ascending order are interventions that change the context to make

individuals’ default decisions healthy, clinical interventions that require limited contact but

confer long-term protection, ongoing direct clinical care, and health education and counseling

(Frieden, 2010). Interventions focusing on lower levels of the pyramid tend to be more

effective because they reach broader segments of society and require less individual effort

(Frieden, 2010). It is important to address the HIP tiers to ensure a full understanding on the

social determinants of a specific country which addresses how a specific country function.

Socioeconomic Factors

Syria is a country known for its social life. Family gatherings, exchanges of meals, and

frequent visits to family and friends are the norm (The Umayyads of Syria, 2021). Formally,

arranged marriages were common, however, arranged marriages are becoming less frequent

(The Umayyads of Syria, 2021). Parents ordinarily have the authority in approving or

rejecting a match. The most common religions practiced in Syria are Muslim and Christian

(The Umayyads of Syria, 2021). Relations and friendships among the different religions are

common in Syria. Sports and recreation are important to Syrians especially football (soccer),

judo, karate, and weightlifting (The Umayyads of Syria, 2021). Education is crucial to Syrians

as about four-fifths of the population is literate and have completed primary schooling and

some attending universities. The social aspect of Syrian’s lives seem adequate; however,

Syrian’s government causes havoc throughout the country.

Syrian’s government is a unitary multiparty republic with one legislative house (The

Umayyads of Syria, 2021.). Syrian’s president takes mass control over his people and they do

exactly as he states. Syria’s government allows for pathogens to be used as weapons for

destruction not only in warfare but also in situations when their own people do not abide by
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the president. The use of biological agents in Syria such as anthrax has increased and has

“killed more than a thousand innocent Syrians, including hundreds of children” (Vos et al.,

2020). Due to the hierarchy of the government, the individuals that live in Syria suffer and at

times are killed due to the unknown use of anthrax within the areas of where Syrian’s live

which can be inhaled or contracted through the skin (Anthrax, 2019). Most biological agents

are used in terrorist attacks which Syrian’s president orders. The Syrian President and his

people use biological weapons to cause death or illness to targeted groups which are even

citizens of Syria (The Umayyads of Syria, 2021). Ongoing chaos and the devastation caused

by more than a decade of conflict due to the long civil war which caused a horrific death toll

has caused the economy to nearly collapse and wiped-out Syria’s economic freedom. Wars

and terrorism have destroyed Syria’s economy and government. Not only is bioterrorism seen

within the government and terrorist attacks, but it is seen accidentally in Syrian’s place of

work. Agriculture constitutes an important source of income (The Umayyads of Syria, 2021).

Syrian’s raise livestock including sheep, cattle, camels, and poultry. Anthrax is commonly

found in herbivores such as sheep, goats, and cattle that ingest spores from contaminated soil

(“Anthrax”, 2019). As Syrian’s consume the meat or inhale aerosolized anthrax spores while

collecting their wool at a factory, they become very ill and can even die (“Anthrax”, 2019).

Overall, bioterrorism is seen throughout Syria due to the significant use of biological agents

within the government and unfortunately Syria’s own innocent people are killed due to these

agents like anthrax.

Changing the Context to Make Individuals’ Decisions Healthy

Due to Syria’s government and the use of biological agents in terrorism actions it has

caused great devastation across the country. Syria’s own people have lost their lives due to the
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hierarchy control of the government and the constant use of biological agents. The best way to

help Syria and to make a difference in this country is to decrease the involvement with the use

of biological agents. It is crucial to decrease terrorism and the easy access in using biological

agents as weapons like anthrax. To make a change, it must start with Syria’s government. It is

critical to work on Syria’s government to not allow one ruler to have so much power.

President Bashar al-Assad is the ruler currently that drives off the use of biological agents as

he uses it as weapons in war and against his own people (The Umayyads of Syria, 2021).

Maybe it is time to find a new President or spread the power and hierarchy to multiple others

instead of just one person holding all the power. It would be even better if they could conform

their government into a democracy so all people had a voice, but I am sure that would nearly

be impossible to do. If Syria divides the power or gets a new President that is not so strongly

sold on the use of biological agents, then Syria would be in a better state. Biological agents

are not only seen in terrorism in Syria but also in the workplace of many individuals. As

agriculture is dominant in Syria with raising livestock including sheep, cattle, camels, and

poultry, biological agents can be commonly found in these herbivores by ingesting

contaminated soil. Therefore, when Syrian’s are farming, they must be cautious with how they

are doing their job. It is crucial for Syrians to wear appropriate clothing and gloves when

caring for these animals which could possibly be infected (Pigott et al., 2019). Anthrax is the

most commonly seen biological agent on herbivores, therefore, Syrians must be educated on

the different signs and symptoms of what to expect if exposed (“Anthrax”, 2019). Anthrax can

be in the wool of these animals which can spread quickly when working in a wool factory or it

can be in the meat of the animal butchered which is why it is crucial to appropriately cleanse

all meat before preparing it for a meal. Overall, Syria must first focus on changing the
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hierarchy of their government and decrease the use of biological agents. Lastly, the people of

Syria must be cautious when working with herbivores or in meat and wool factories.

Long-Lasting Protective Interventions

The number one long-lasting protective intervention against biological agents

specifically anthrax which is commonly seen in Syria is the anthrax vaccination (“Anthrax”,

2019). Unfortunately, because of the limited supply of the anthrax vaccination it is usually

only given to military personnel or individuals at high risk for exposure such as laboratory or

factory workers. The anthrax vaccination recommends five injections over 18 months and

then and annual booter shot given between the ages of 18-65 (“Anthrax”, 2019). For the

people of Syria this would benefit to get this vaccine so that when exposed to anthrax from

bioterrorism or dealing with herbivores they are less likely to get sick or die. However, due to

limited supply the best way to protect the people of Syria is wearing proper personal

protective equipment (PPE) specifically when working with animals such as cattle and sheep.

When handling animals’ wool or when butchering meat, Syrians should wear gloves, goggles,

mask (specifically N95 if available), gown, and protective booties over shoes (Pigott et al.,

2019). This may seem a little extreme, but it is best practice especially since there is no way

to detect if anthrax has contaminated the animals. It is crucial to be prepared by wearing PPE

and working in a well-ventilated workplace to prevent from contracting anthrax which leads

to severe illness and potential death (Pigott et al., 2019). Unfortunately, as bioterrorism exists

in Syria and is commonly seen due to the use of biological agents with the government, it is

hard for Syrians to be prepared as getting exposed to anthrax is unknown. For the citizens of

Syria, they must be cautious when riots or wars occur as biological agents could be in use.
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Overall, the best preventable measures are the anthrax vaccination and wearing proper PPE

when being exposed to biological agents.

Clinical Interventions

When an individual is exposed to biological agents specifically anthrax it is critical to

reach medical assistance immediately. Time is crucial when exposed to biological agents

(Adalja, 2020). If a Syrians become exposed, they must go to the hospital or call for medical

assistance. If medical assistance comes to assist, they must isolate the patient as much as

possible while the response personnel should be wearing all appropriate PPE. The on-scene

treatment for an anthrax exposure is primarily supportive care and recognition of being

exposed to a biological agent (Adalja, 2020). Once arrived at a medical facility, lab work must

be drawn, and IV fluids must be started (Pigott et al., 2019). The removal of all clothing and

cleanse the patient is a mandatory. The next crucial treatment is beginning antibiotics which

will initially be intravenous (IV) antibiotics (Pigott et al., 2019). The antibiotics recommended

are ciprofloxacin, doxycycline, levofloxacin, or moxifloxacin (“Anthrax”, 2019). Antibiotic

treatment must go on for 60 days initially starting out as IV then transferring to orally

(“Anthrax”, 2019). Other treatment measures include oxygen as needed and VTE prophylaxis

(Adalja, 2020). An antitoxin treatment may be administered which is raxibacumab and

anthrax immune globulin which is given to help reduce the effect of anthrax systemically

(“Anthrax”, 2020). The nurses at the medical facility must perform frequent assessments to

assure adequate airway, breathing, and circulation (Adalja, 2020). It is important to educate

upon discharge the importance to take full course of antibiotics for 60 days, eat well-balanced

diet, follow-up with primary care outpatient, and be aware of signs and symptoms of exposure

to biological agents. It is also recommended that the Centers for Disease Control (CDC) is
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notified of exposure to biological agents, so it is the nurse’s job to call the CDC (“Anthrax”,

2019). However, the best protection against biological weapons is prevention by

immunizations and knowing how to react prophylactically when exposed by biological agents.

Counseling and Education

As a nurse the most important thing that can be done about exposure to biological

agents is education. Specifically, when focusing on anthrax it is important for the public of

Syria to know what signs and symptoms to look for so they can receive care efficiently. The

signs and symptoms vary due to the route of contamination. If a person is experiencing

inhalation anthrax the signs and symptoms, they may experience is fever, non-productive

cough, shortness of breath, chest pain, weakness, headache, chills, nausea, and vomiting

(“Anthrax”, 2019). If the person was contaminated with anthrax through the gastrointestinal

route meaning consumed it through meat typically, they will experience dysphagia (difficulty

swallowing), nausea and vomiting, bloody diarrhea, and massive ascites (“Anthrax”, 2019).

Lastly, a person can experience exposure cutaneous through exposure of handling animal

hides which individuals experience small pruritic papules with serosanguinous fluid with

ulcer base then transfers to a vesicle and then to a painless black eschar (“Anthrax”, 2019).

These cutaneous vesicles are typically seen on the head, neck, forearms, and hands. As a

nurse it is critical to educate about the signs and symptoms of exposure to anthrax and to

educate that individuals receive early and efficient medical treatment to recover. To make sure

the individuals of Syria understand it is always helpful to use the teach-back method so the

nurse knows that the individuals of Syria can speak to the signs and symptoms they are

supposed to look for. Nurses can also hand out educational pamphlets with images that are

appealing to the readers eyes to make sure they have information to readily available and to
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refreshen their memory on what to look for. There are several models or theories to explain

why people engage in certain health behaviors and what can be done to encourage changes in

those behaviors. I believe the Ecological Perspective is what relates best to the action of

bioterrorism. The Ecological Perspective is a concept that suggest that factors influencing

specific health behaviors occur at different levels which are closely linked to social

environments (Skolink, 2021, p. 173). The public policy which states that the “local, state,

and federal policies and laws that regulate and support healthy actions and practices for

disease prevention, early detection, control, and management” is very eye opening as Syria’s

government sees the use of biological agents as a good and dominating power to have

(Skolink, 2021, p. 173). Therefore, the government has so much power to regulate and support

the use of biological agents and believes it is critical for Syria to have and to use for the better

of their country. However, it is harming their country and the citizens that live there.

Recommendations

There are many recommendations that I would make to help the country of Syria. First,

it is important to encourage Syria’s government to be set up differently or for more than one

person to have so much power. I would also stray away from the use of biological agents as

weapons especially to the citizens of Syria in which do no wrong. Secondly, I would be more

prepared since biological agents are becoming more of a reoccurrence in use. Therefore, I

would provide funds and guidance due to the use of biological agents. I would provide

appropriate training with emergency response to exposure to biological agents such as

anthrax. I would have laboratories ready for testing to find out more about how or what the

biological agent exposure was. I would develop a plan to follow that all citizens of Syria are

aware of when individuals are contaminated with biological agents. I would highly
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recommend and encourage that individuals receive the anthrax vaccine, and each citizen have

their own PPE to use daily. I would educate and provide additional reading handouts about

biological agents and what to do if contaminated. I would educate the importance of receiving

medical treatment as soon as possible after contamination as well as complete the antibiotic

course to get better. It is extremely important to make sure Syria is aware that biological

agents are being used everyday and to make sure the citizens are prepared if exposed.

Professional Opportunities

The professional opportunities available in the global health field for biological agents

and bioterrorism are limitless. One opportunity is being a bioterrorism researcher which is a

highly trained professional in chemistry, biology, and other scientific fields that conduct

research on bioterrorism. Another opportunity is scientist and laboratory specialist in which

conduct studies on biological agents and learn the ins and outs on how it effects humans.

Another professional opportunity are nurses specifically in the emergency room and

physicians as they see individuals affected with biological agents firsthand. It is critical for

these personnel in the hospital setting to be appropriately trained and prepared for biological

agent attacks. Lastly, an example could be a data collector or an individual that works for the

Center for Disease Control (CDC) to keep track of where biological agents are used and how

it affects humans. It is important to keep our data up to date to provide adequate care and so

that we are educated on where bioterrorism is occurring the most.

Conclusion

Overall, bioterrorism is commonly seen in Syria. Due to the hierarchy of government

and the importance of agriculture to keep the economy alive has allowed for biological agents

to take over. Nurses are to make sure that the country of Syria is well educated and prepared
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for biological attacks. As Anthrax is the most commonly seen biological agent it is crucial to

have Anthrax vaccinations available and to have antibiotic treatment on hand to treat

exposure. It is important to make sure that Syria’s emergency response team is prepared for a

biological agent outbreak. It is critical that all individuals of Syria working with animals or in

wool factories to have the appropriate PPE available to them as well to those individuals that

live closely to where bioterrorism takes place. The best solution to Syria’s bioterrorism is to

ban the use of biological agents from this country as it has done more harm then good.

References

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