Terrorism as Cancer:

The Challenges of Combating an Incurable Disease

Bryan C. Price
Director, Combating Terrorism Center
U.S. Military Academy
bryan.price@usma.edu

DO NOT CITE WITHOUT PERMISSION

Abstract
This paper provides an alternative framework to conceptualize the threat posed by
terrorism based on an epidemiological approach that views terrorism as a chronic disease like
cancer rather than as a military, ideological, or socio-economic problem. After highlighting the
similarities in the causes, behavior, treatments, and challenges of combating terrorism and
cancer, this paper presents a staging system policymakers can use to educate the public and
allocate counterterrorism resources more efficiently. This approach encourages policymakers
to see terrorism for what it is (an all but inevitable facet of modern life that can be managed but
never fully eliminated), and not what they wish terrorism to be (a national security problem
that can be solved, defeated, or vanquished). It provides policymakers with a useful model to
conceptualize the threat and treat terrorism in a comprehensive manner, from preventing
future attacks to effectively responding to them when they will inevitably occur.

Terrorism as Cancer: The Challenges of Combating an Incurable Disease

During his presidential address to the nation on December 6, 2015, President
Barack Obama spoke about the countrys reaction in the wake of the San Bernardino
shootings. He said that many Americans felt as if the threat posed by terrorism was like
being confronted by a cancer that we cannot cure.1 Although President Obama was using
cancer as a metaphor in his speech, the terrorist threat today is indeed a lot like cancer, and
counterterrorism officials in the West would benefit from adopting many of the approaches
the medical community has used to combat the emperor of all maladies.2
The United States is almost fifteen years removed from the September 11th attacks,
but it has yet to articulate a coherent and sustainable counterterrorism strategy.3
Tactically, there is no denying that the United States is much more capable at conducting
counterterrorism operations than it was before 9/11. Few states are as skilled in tracking
down and arresting or killing terrorists, and no other state can match the United States in
its ability to financially attack terrorist networks.4 Tactical success alone, however, will not
be enough to win the long war. As Sun Tzu warned, Strategy without tactics is the
slowest route to victory. Tactics without strategy is the noise before defeat.5 U.S.
counterterrorism strategy has lagged behind these tactical advances, but why?
One reason for this lag is because todays counterterrorism strategists, particularly
those in the United States and the West, have struggled to properly conceptualize the

President Barack Obama, Address to the Nation, Washington, D.C., December 6, 2015. The transcript can
be found at https://www.whitehouse.gov/the-press-office/2015/12/06/address-nation-president.
2 Siddhartha Mukherjee, The Emperor of All Maladies: A Biography of Cancer (New York: Scribner, 2010).
3 Audrey Kurth Cronin, The War on Terrorism: What Does It Mean to Win? Journal of Strategic Studies 37:2
(2014): p. 7.
4 Cronin, p. 7.
5 Sun Tzu, The Art of War, Samuel B. Griffith, trans. (London: Oxford University Press, 1963).
1

threat. A cursory review of U.S. counterterrorism strategy documents since 9/11 shows the
United States has suffered from a strategic schizophrenia in framing the problem. The 2003
national strategy for combating terrorism declared that the enemy is terrorism.6 Three
years later, the next counterterrorism strategy framed the principal enemy in a different
fashion, this time as a transnational movement of extremist organizations, networks, and
individuals and their state and non-state supporters.7 The 2011 counterterrorism
strategy yet again featured a different conceptualization of the threat. It contradicted
previous strategies, making it clear that [the United States was] not at war with the tactic
of terrorism or an amorphous transnational movement. Instead, this strategy focused U.S.
counterterrorism efforts against a specific organization al Qaeda.8 Today, the lions share
of U.S. counterterrorism attention is focused not on al Qaeda but on its rival, the Islamic
State.
As others have articulated, terrorism is a tactic, so declaring the tactic of terrorism
as the enemy does not make sense.9 Narrowing the focus to a transnational movement of
extremist organizations was an improvement but it gave too much credit to an
amorphous, non-monolithic jihadist threat. Pinning the counterterrorism rose squarely on
al Qaeda earned points for specificity, but it ignored the fact that the terrorist threat is
dynamic and evolving and could result in ignoring or missing emerging threats. The Islamic
State is just the latest case in point.

White House, National Strategy for Combating Terrorism, Washington, D.C. (February 2003), p. 1.
White House, National Strategy for Combating Terrorism, Washington, D.C. (September 2006), p. 5.
8 White House, National Strategy for Counterterrorism, Washington, D.C. (June 2011), pp. 2-3.
9 See for example, Eugene Robinson, A Team in Need of a Plan, Washington Post, December 2, 2008, p. A21.
6
7

A second reason counterterrorism strategy has lagged behind tactics is because the
terrorist threat continues to evolve in unexpected ways, oftentimes faster than strategic
policy can keep up. Despite its position as the top national security priority for more than a
decade and the billions of dollars spent on counterterrorism operations, the threat posed
by terrorism today is more geographically diffuse, decentralized, and unpredictable than it
was in the immediate years after 9/11. Moreover, the analytical frameworks that have
shaped U.S. national security strategies in the past (mainly against conventional threats)
are ill-equipped for confronting terrorism and other unconventional threats the United
States is likely to face in the future.
The following paper provides an alternative framework to conceptualize the
contemporary threat posed by terrorism and the best ways to mitigate it. The framework is
more flexible than the current model and can be adapted to manage the changing terrorist
landscape over time. It is based on an epidemiological approach that views terrorism as a
chronic disease like cancer rather than as a military, ideological, or socio-economic
problem.
This is not the first work to identify the similarities between terrorism and cancer,10
nor is it the first to apply an epidemiological approach to counterterrorism.11 The primary
contribution of this paper is that it is the first to combine these two components. There are
three primary benefits of employing such an approach.

David Katz, Terrorism as Cancer and Vice Versa: Of Waving Fists and Forgotten Gloves, Huffington Post,
December 30, 2015; Sefer Yilmaz, An Analogy Between Cancer Cells and Terrorist Organizations,
International Journal of Management Economics and Business Vol. 9, No. 19 (2013): pp. 347-364; Boaz Ganor,
If Global Jihad Isnt the Enemy, What Is? Jerusalem Post, June 16, 2010; Gregory A. Curt, M.D., Terrorism and
Cancer, The Oncologist Vol. 6 (2001): p. 401.
11 Paul B. Stares and Mona Yacoubian, Rethinking the War on Terror: New Approaches to Conflict
Prevention and Management in the Post-9/11 World, at
http://www.usip.org/sites/default/files/stares_yacoubian_terror.pdf
10

First, an epidemiological approach encourages policymakers to see terrorism for

what it is (an all but inevitable facet of modern life that can be managed but never fully
eliminated), and not what they wish terrorism to be (a national security problem that can
be solved, defeated, or vanquished).
Second, it provides policymakers with a system for classifying terrorist groups with
different operational aspirations and capabilities in a way that simultaneously avoids being
too narrow (e.g. focusing solely on individual groups like the Islamic State or al Qaeda) and
too vague (e.g. focusing on the tactic of terrorism or an amorphous, transnational
movement of violent extremism). This system mirrors the one used in oncology, and it
allows groups to move up or down based on the threat they pose at a particular time.
Finally, this epidemiological approach provides policymakers with a useful model to
conceptualize the threat and to treat the disease of terrorism in a comprehensive manner,
from preventing future attacks to properly responding to them when they will inevitably
occur.
The paper proceeds in three parts. The first section outlines the conceptual models
that have dominated counterterrorism strategies in the past. It makes the case for an
alternative model based on the epidemiological approach. The next section highlights the
conceptual similarities between terrorism and cancer, including the causes, behavior,
treatments, and challenges associated with combating both problems. The final section
applies certain concepts and lessons learned from treating cancer to the ways in which we
fight terrorism, including the application of a staging system policymakers can use to
educate the public and allocate counterterrorism resources more efficiently.

Counterterrorism Models and Previous Attempts at an Epidemiological Approach

Scholars have put forth a number of competing theoretical models to explain how
states devise their counterterrorism policies.12 The three most prevalent in the literature
are the war model, the criminal justice model, and the reconciliatory model. Proponents of
the war model view terrorism as an act of war, and therefore as a military problem
requiring a military solution. The criminal justice/legal model approaches terrorism as a
criminal act and favors the police, the judiciary, and law enforcement agencies to solve the
problem.13 Finally, the conciliation/reconciliation model views terrorism not as a military
or a criminal justice problem, but as a political problem.14 Political reforms, negotiations,
and diplomacy take the lead in this model in addressing the political grievances of terrorist
groups rather than military or police action.
On their own, these models fail to offer a proper conceptual framework to
understand the threat. Instead, they provide rather narrow solutions to how states should
deal with terrorism after it has occurred.15 In the words of Sun Tzu, these models lack
developed ideas about "strategy" and consequently suggest "tactics" that are insufficient
for the challenge. As a result, the search for a model that more accurately fits the challenges
of contemporary terrorism continues, especially for the United States.

For a summary of this literature, see Arie Perliger, How Democracies Respond to Terrorism, Security
Studies, Vol. 21, No. 3 (2012): pp. 490-528. See also Doron Zimmerman and Andreas Wenger, How States Fight
Terrorism (Boulder, CO: Lynn Rienner, 2007).
13 For a concise summary of the war model and criminal justice model, see Ami Pedahzur and Magnus
Ranstorp, A Tertiary Model for Countering Terrorism in Liberal Democracies: The Case of Israel, Terrorism
and Political Violence, Vol. 13, No. 2 (Summer 2001): pp. 1-6.
14 Peter C. Sederberg, Conciliation as Counter-Terrorist Strategy, Journal of Peace Research, Vol. 32, No. 3
(1995): pp. 295-312.
15 For a critique of these models, see Pedahzur and Ranstorp, pp. 1-26; Perliger, pp. 493-498.
12

In the pursuit of such a model, Stares and Yacoubian proposed an epidemiological

approach to counterterrorism in 2006.16 Although other scholars have employed this kind
of approach to topics outside the field of medicine (e.g. student attrition in college,17 the
effects of natural disasters,18 and motor vehicle deaths19), they were the first to apply it to
counterterrorism. Stares and Yacoubian argued that Islamic terrorism was spread via a
social contagion process much like that of an infectious disease. Therefore, they argued, an
effective counterterrorism strategy should focus on removing one of the components of
this contagion process. In their paper, they suggested this could be done by destroying the
agent (Islamic militant ideology), shutting down the vectors (the radical mosques and
madrassas spreading the violent ideology), or somehow inoculating the host (the
populations exposed to this ideology).

Table 1: Typology and Logic of Counterterrorism Models

Counterterrorism Models
War
Legal/Criminal Justice
Conciliation/Reconciliation
Epidemiological
(infectious)
Epidemiological (chronic)

Terrorism viewed
as
Act of war
Crime
Political problem
Infectious disease

Relies most upon

Military and use of force
Police, law enforcement, and judicial system
Diplomacy/legislation to address grievances
Removing the agent or vectors, or inoculating
host
Refining treatments, promoting resiliency, and
conducting realistic expectation management

Chronic disease

Stares and Yacoubian.

Marcia I. Wells, An Epidemiologic Approach to Addressing Student Attrition in Nursing Programs, Journal
of Professional Nursing, Vol. 19, No. 4 (July-August 2003): pp. 230-236.
18 Eric K. Noji, Disaster Epidemiology: Challenges for Public Health Action, Journal of Public Health Policy,
Vol. 13, No. 3 (Autumn, 1992): pp. 332-340.
19 Keshia M. Pollack, Shannon Frattaroli, Jessica L. Young, Gail dana-Sacco, and Andrea C. Gielen, Motor
Vehicle Deaths Among American Indian and Alaska Native Populations, Epidemiologic Reviews, Vol. 34
(2012): pp. 73-88.
16
17

While there is a lot of utility in applying an epidemiological approach to

counterterrorism, it is problematic to conceptualize terrorism as an infectious disease.
Stares and Yacoubian focused on Islamic extremism, but we know that Islamic militancy
and other forms of extremist political violence do not necessarily behave like an infectious
disease. Arguably millions, if not billions, have been exposed to extremist ideology, yet a
miniscule number of those exposed ever take the leap and engage in violent extremism.
Although there is undoubtedly a social component to the transmission of extremist
ideology, the overwhelming majority of those exposed to the disease never become
terrorists.
Second, viewing terrorism as an infectious disease gives the false hope that the U.S.
government can somehow cure the threat posed by terrorism, including terrorism
perpetrated from Islamic extremists. As one notable terrorism scholar put it, it is a
fantasy to think that the war on terror can end in total victory, meaning complete military
success followed by total elimination of the terrorist threat.20 The disease of terrorism is a
complex and enduring problem. It is not an infection; it is a chronic ailment.
This paper proposes a new framework, an important modification on the
epidemiological approach proposed above. Epidemiology has two major strands - the study
of infectious diseases and the study of chronic diseases. Stares and Yacoubian chose the
infectious disease model, but this analysis suggests terrorism functions more like a chronic
disease like cancer.

Terrorism as Cancer

20

Cronin, p. 16.

Not only does terrorism behave more like a chronic disease, but many of the
challenges associated with preventing and treating cancer are remarkably similar to those
associated with combating terrorism. Terrorism scholars struggle just as much as their
oncologist counterparts to identify and understand the exact causes of terrorism and to
find the most effective ways to combat the threat. Those studying political violence and
terrorism can readily identify with cancer investigators when they say, the more they
study cancer, the more complex it seems.21 The similarities between cancer and terrorism
are striking, from the endogenous and exogenous causes of both phenomena to their
behavior.
Causes
Cancer is a disease caused by mutations of normal cells, just like terrorists are
mutated, distorted versions of what are otherwise normal people. Despite modern day
advances in medicine, doctors still lack a clear way to differentiate between benign or slowgrowing tumors and aggressive diseases, which makes early and accurate diagnoses
difficult.22 Similarly, psychologists who study terrorism have thus far been unable to
identify systemic pathologies and neuro-abnormalities in those who become terrorists.23
According to Horgan, one of the fields top scholars on this topic, There are, simply, no a
priori qualities of the terrorist that enable us to predict the likelihood of risk of
involvement and engagement in any particular person or social group that is either valid or
reliable over a meaningful period of time.24 Differentiating between cancerous cells and

Ibid.
Tara Parker-Pope, Scientists Seek to Rein In Diagnoses of Cancer, New York Times, July 29, 2013.
23 See John Horgan, The Psychology of Terrorism (New York: Routledge, 2005).
24 Ibid., p. 161.
21
22

non-cancerous cells can sometimes be just as difficult as differentiating between terrorists

and non-violent extremists. Both fields, therefore, share the daunting problem of
identifying which cells and which individuals are likely to mutate. The current debate
surrounding our ability to identify the non-extremist Syrian refugees is just the latest
incarnation of this problem in counterterrorism.
Furthermore, anyone can contract cancer, but some individuals are genetically more
predisposed to contracting cancer than others.25 Sometimes cancer mutations are triggered
by internal mechanisms, such as inherited mutations, hormones, immune conditions, and
mutations that occur from metabolism. In other cases, mutations occur because of external
factors, such as exposure to carcinogens like asbestos or tobacco, or over-exposure to
ultraviolet rays and radiation.26
The same dynamics are found in terrorism. In terrorism, however, we do not call it
mutation; we call it radicalization, and just like cancer, all types of people are susceptible.
The massive numbers of foreign fighters from all over the world that are flocking to fight in
Syria and Iraq are illustrative of this point. There are some individuals who have
predisposed social, emotional, and mental vulnerabilities that may make them more
susceptible to acting on extremist ideology and propaganda than others.27 In other cases,
individuals who do not feature these initial vulnerabilities become violent extremists when

American Cancer Society, Cancer Facts and Figures 2014, found at

http://www.cancer.org/acs/groups/content/@research/documents/webcontent/acspc-042151.pdf, p.1.
26 American Cancer Society, Cancer Facts and Figures 2014, found at
http://www.cancer.org/acs/groups/content/@research/documents/webcontent/acspc-042151.pdf.
27 L. Rowell Huesmann, How to Grow a Terrorist Without Really Trying: The Psychological Development of
Terrorists From Childhood to Adulthood, in Interdisciplinary Analyses of Terrorism and Political Aggression,
eds Daniel Antonius, Adam D. Brown, Tali K. Walters, J. Martin Ramirez, and Samuel Justin Sinclair (London:
Cambridge Press, 2010), pp. 1-21; Rukmini Callimachi, ISIS and the Lonely Young American, New York
Times, June 27, 2015.
25

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they are persuaded by overt and persistent recruitment by extremist groups. Others are
triggered by exogenous crisis events that have no direct ties to the would-be terrorist
actors. For example, Timothy McVeigh specifically cited the Ruby Ridge and Waco incidents
as spurring him to action.28 The scandal at Abu Ghraib served as a call to action for many
foreign fighters in Iraq.29 President Bashir al-Assads numerous atrocities against Syrian
citizens continues to provide motivation for far-away foreign fighters to join jihadist
groups today.30 Thus, as in cancer, there are endogenous and exogenous pathways to
terrorism.31 Martha Crenshaws distinction between preconditions and precipitants in her
seminal work on the causes of terrorism could likewise be helpful in explaining the causes
of cancer.32
Like cancer, the exact causes which radicalize terrorists are varied and
unpredictable.33 There are wealthy terrorists and poor ones, the educated elite as well as
the illiterate and the unemployed. Terrorism also occurs in failed or failing states like
Somalia and Yemen, and in mature democracies like the United Kingdom and the United
States. Neither terrorism nor cancer recognizes geographical boundaries. The
heterogeneity of the population that conducts terrorism mirrors the population that is
afflicted with cancer. Cancer affects the young and the old, the strong and the weak. The

Associated Press, McVeigh Offers Little Remorse in Letters, Topeka Capital Journal, June 10, 2001.
Tom Pyszczynski, Zachary Rothschild, Matt Motyl, and Abdolhossein Abdollahi, The Cycle of Righteous
Destruction: A Terror Management Theory Perspective on Terrorist and Counter-terrorist Violence, in Terrorism
and Torture, eds. Werner G.K. Stritzke, Stephan Lewandoski, David Denemark, Joseph Clare, and Frank
Morgan (Cambridge: Cambridge University Press, 2009), p. 161.
30 Daniel Byman and Jeremy Shapiro, Be Afraid, Be a Little Afraid: The Threat of Western Foreign Fighters in
Syria and Iraq, Brookings Policy Paper No. 34, November 2014, p. 12.
31 Clark McCauley and Sophia Moskalenko, Mechanisms of Political Radicalization: Pathways Toward
Terrorism, Terrorism and Political Violence Vol. 20 (2008): pp. 415-433.
32 Martha Crenshaw, The Causes of Terrorism, Comparative Politics vol. 13, no. 4 (July 1981): pp. 381-385.
33 Matt Apuzzo, Who Will Become a Terrorist? Research Yields Few Clues, New York Times, March 27, 2016.
28
29

11

disease can strike an old, overweight, chain-smoking, and alcoholic coal miner, but it can
also strike a young Olympic athlete in world-class shape.

Figure 1: US death rates for various diseases

Despite the fact that doctors have been studying cancer for thousands of years,
epidemiologists know only the basics about the causes of cancer. Billions of dollars have
been spent on cancer research in recent decades, but advances in early diagnoses and
aggressive treatments have not resulted in a commensurate reduction in invasive
cancers.34 As shown in Figure 1, when one adjusts for the size and age of the population,
the death rate for cancer dropped only 5% from 1950 to 2005.35 To put this reduction in
perspective, the death rate for the flu, a prominent infectious disease, dropped 58% over
the same time period.

34
35

Parker-Pope.
Kolata.

12

U.S. counterterrorism efforts have not fared much better. Extrapolating from other
estimates on the cost of post-9/11 conflicts and counterterrorism programs designed to
protect the country from terrorist threats, the United States has spent close to $4 trillion on
counterterrorism in the past fourteen years.36 Although U.S. counterterrorism efforts have
succeeded in preventing another successful strategic attack on the homeland since 9/11, a
feat that should not be glossed over, many policymakers and practitioners would say that
the threat from terrorism is more complicated today and threatens U.S. interests in more
places than it has since 9/11. Although much counterterrorism rhetoric since 9/11 has
focused on the need to deny safe havens to terrorist groups, the Islamic State now governs
territory in two countries (including Iraq which the United States occupied from 20032011) that is equivalent to the size of Pennsylvania.
Table 2: Comparing the causes of cancer and terrorism
Overarching
cause
Endogenous
Causes
Exogenous
Causes

Causes of Cancer
Mutation of normal cells

Causes of Terrorism
Mutation of normal people (radicalization)

Genetic predisposal, hormones, immune

system

An individuals predisposed social,

emotional, and mental vulnerabilities to
extremist propaganda
Recruitment, reaction to crisis events (e.g.
Ruby Ridge, Abu Ghraib, etc) or
environment (oppressive political
situation)

Exposure to radiation, UV rays, diet, exercise

Behavior
One of the reasons why cancer is such a debilitating disease is its ability to
metastasize in unpredictable ways.37 The metaphor that the threat of terrorism is like a

See for example Neta C. Crawford, U.S. Costs of Wars Through 2013: $3.1 Trillion and Counting, available
at http://www.usf-iraq.com/wp-content/uploads/2013/03/Us_Costs_of_Wars.pdf. Crawford builds on the
work of Amy Belasco, The Cost of Iraq, Afghanistan, and Other Global War on Terror Operations Since 9/11,
Congressional Research Service, March 29, 2011.
37 Mukherjee, pp. 196-7.
36

13

metastasizing cancer is not lost on top U.S. counterterrorism policymakers.38 President

Obama has used the metaphor numerous times, the most recent of which occurred in his
December 2015 address to the nation.39 The last two Secretaries of Defense have argued
the threat from terrorism has metastasized since 9/11 on multiple occasions.40 After the
November 2015 attacks in Paris, numerous pundits and policymakers have used the word
metastasize to describe the threat posed by the Islamic State.41
Cancer metastasis occurs when cancerous cells from the primary tumor spread to
other parts of the body. The metastasized cancer can spread via a number of different ways,
the most common of which occurs when it is carried through lymph nodes or the
bloodstream. How cancer metastasizes depends on several factors: the properties of the
original cancerous cells; the properties of the non-cancerous cells around the cancer and
the overall immune system; and the properties of the cells located within the delivery
system (lymph nodes or bloodstream) and those within the cells where it tries to take
root.42 It is important to note that the properties of all these components are dynamic and

Nor is it lost on scholars. See Sefer Yilmaz, An Analogy Between Cancer Cells and Terrorist Organizations,
International Journal of Management Economics and Business 9:19 (2013), pp. 347-364; Boaz Ganor, If Global
Jihad Isnt the Enemy, What Is? Jerusalem Post, June 16, 2010.
39 President Barack Obama, Address to the Nation, Washington, D.C., December 6, 2015; Amaani Lyle,
Obama Discusses National Security During Worldwide Troop Talk, Department of Defense News, September
11, 2015.
40 Secretary of Defense Chuck Hagel, speech delivered at the CSIS Global Security Forum, November 5, 2013,
Washington, DC. Transcript can be found at
http://www.defense.gov/Speeches/Speech.aspx?SpeechID=1814; Jacqueline Kilmas, Ashton Carter: Islamic
State metastasizing, U.S. Intervention Desperately Needed, Washington Times, March 11, 2015; Secretary of
Defense Ash Carter, Statement on the U.S. Military Strategy in the Middle East and the Counter-ISIL
Campaign, House Armed Services Committee, Washington, D.C., December 1, 2015.
41 Greg Miller and Craig Whitlock, Caught Between Internal and External Terror Threats, France Struggles to
Cope, Washington Post, November 14, 2015.
42 http://www.cancer.gov/cancertopics/factsheet/Sites-Types/metastatic
38

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change over time. In other words, what once may have been an inhospitable spot for cancer
to grow and thrive in the body may soon become a hospitable one, and vice versa.43
Applying these concepts to the current fight against violent extremism requires little
mental effort and is a useful exercise for counterterrorism policymakers. Carrying the
analogy forward in a counterterrorism context, the cancerous cells are the terrorists in this
conceptualization, and the hosting community (or specific types of organs that are more
hospitable than others) of non-violent citizens represent the non-cancerous cells in which
the tumor grows.
The properties and make-up of the non-cancerous cells can often dictate how easy
or difficult it is for the tumor to grow and spread. The Islamic State, a Sunni group, has
enjoyed great success setting up shop in the predominantly Sunni provinces of Ninewa,
Salah ad Din, and Anbar, but it would not be able to survive in Shia-dominated Basra or
Badr City. The lymph nodes are comparable to the terrorist influencers and recruiters that
spread and amplify the message of the terrorist cell to others. Terrorist cells are
dangerous by themselves, but like cancer, they become much thornier problems once the
terrorist lymph nodes are involved. Removing these terrorist lymph nodes early in a
terrorist groups lifecycle may prevent more terrorist violence from spreading throughout
an area, or at a minimum slow the pace that it can spread.44

Applying this concept to counterterrorism, consider the inhospitable environment for AQI during the Anbar
Awakening where mainstream Sunni Iraqis threw out extremist factions like AQI. Today, the environment
created by the Shia majority and Maliki-led government in Iraq is fertile ground for AQIs resurgence in
Anbar.
44 It should be noted that the pace at which the cancer of terrorism spreads is unlike that of an infectious
disease. The terrorist lymph nodes merely amplify the spread of political violence; they do not guarantee its
spread.
43

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Although charismatic leaders can serve as terrorist lymph nodes - individuals like
the Shining Paths Abimael Guzman or LTTEs Vellupillai Prabhakaran- the lymph nodes
need not be the organizations patriarch. Al Qaeda propagandists such as the Americanborn Anwar al-Awlaqi and the Islamic States Abu Muhammad al-Adnani are also
illustrative examples of terrorist lymph nodes.
If al-Awlaqi and al-Adnani are the terrorist versions of lymph nodes, then the
internet, social media, and what practitioners refer to as the dark web can be understood
as the bloodstream which spreads the terrorist cancer to other parts of the world. The
properties of the bloodstream (technology, bandwidth, access, hardware, software,
encryption, security, etc.) affect the delivery of the metastasized terrorism to new places. In
the late 19th century, the spread of terrorist propaganda was done first via pamphlets and
newspapers, later on television and web forums, and today through social media and hitech encrypted software.45 For groups like al Qaeda, their message resonated with
followers, but the group found it increasingly more difficult for its primary messengers (bin
Laden and Zawahiri) to relate to younger generations. The Islamic State has solved this
problem, not necessarily with a drastically different message than that of al Qaeda, but by
promoting new and more relatable messengers and doing so through a sophisticated, sleek,
and attractive delivery system that resonates with more people, especially the younger
generation.46

J.M. Berger, Social Media: An Evolving Front in Radicalization, Testimony before the House Homeland
Security Committee, Washington, D.C., May 7, 2015; Aaron Brantly and Muhammad al-Ubaydi, Extremist
Forums Provide Digital OPSEC Training, CTC Sentinel Vol. 8, No. 5 (May 2015), pp. 10-14.
46 Daniel Milton, The Islamic State: An Adaptive Organization Facing Increasing Challenges, Chapter 3, The
Group That Calls Itself a State (West Point: Combating Terrorism Center, 2014), pp. 46-56.
45

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Like a metastasizing cancer, the threat of Sunni extremist violence has evolved in
unpredictable ways. Sometimes metastasized cancers are able to grow and prosper in new
places, and sometimes they fail to take hold for reasons that are difficult to explain. While
these metastasized cancers still retain some of the properties of the original tumor, the
cancer often changes in significant ways. For example, ten years ago it would have been
unimaginable that a terrorist organization that is publicly hostile to al Qaeda would
establish a caliphate spanning two states in the Middle East and attract more foreign
fighters to its cause in three years than al Qaeda did in the past 25 years. Thus, few if any
could have predicted in the years following 9/11 that the threat from Sunni extremism
would evolve the way it did, not even al Qaeda and certainly not Western counterterrorism
policymakers. The major takeaway from oncology that counterterrorism policymakers
should heed in regards to treating metastasized cancers, however, is that treatments which
were effective against the original tumor may not work the same against metastasized
cancers found elsewhere in the body.
Table 3: Comparing the spread of cancer and terrorism
Behavior
Indep.
Variables

Spread of cancer
Unpredictable, capable of metastasizing
Properties of original cancer cells
Properties of the micro-environment that
includes non-cancerous cells
Properties of the delivery system (blood
stream, lymph nodes)

Spread of terrorism
Unpredictable, capable of metastasizing
Properties of the individual terrorists
and individual terrorist groups
Properties of host communities
Properties of the delivery system (social
media, amplifiers like Anwar al-Awlaqi)

If epidemiologists face similar challenges regarding cancer behavior and have been
unable to determine the exact causes of cancer, how have they approached combating the
disease? More importantly, what can terrorism scholars learn from their counterparts in

17

oncology? To combat cancer, doctors focus on prevention, diagnosis, treatment, and

palliative care.
Prevention
Cancer and terrorism share many similarities when it comes to prevention. Doctors
cannot prevent anyone from getting cancer, just like states cannot prevent all terrorist
attacks from occurring. Both are chronic problems in society. Doctors, however, have
identified ways to reduce the chances of contracting cancer, such as avoiding risky
behaviors like smoking tobacco, excessive drinking, and overexposure to the suns harmful
rays. According to the American Cancer Society, the combination of obesity, high-caloric
intake and lack of physical activity is the second-leading cause of cancer in the U.S.47 Thus,
the population can reduce their chances by living healthier lives.
Similarly, states can reduce their chances of spawning terrorist groups by enacting
similar macro-level behaviors and policies, like providing minority groups meaningful
access and voice to the political system and taking active measures to bring
disenfranchised groups back into the mainstream fold. The oppressive and sectarian
environment created by Prime Minister Nouri al-Malikis government in Iraq after U.S.
forces largely left in 2011 is a recent example of what not to do. Malikis policies cemented
the Shia stranglehold on power, disenfranchised Iraqi Sunnis, and created a fertile ground
from which the desperate and badly weakened pre-cursor to the Islamic State could recruit
from and exploit.48

Jacque Wilson, Report: Pancreatic Cancer Second Most Deadly By 2030, CNN, May 19, 2014.
Michael Knights, The ISILs Stand in the Ramadi-Fallujah Corridor, CTC Sentinel Vol 7, Issue 5 (May 2014),
pp. 8-12.
47
48

18

Doctors recommend eating a balanced diet and getting 60 minutes of exercise every
day to minimize ones chances of contracting cancer, but the majority of society fails to
meet this standard on a regular basis. Similarly, many states often find enacting the longterm, macro-level policies to prevent terrorism hard to do, especially when the benefits
derived from such activities are often delayed and rarely directly observed. Even if these
types of policies are enacted and enforced, they are insufficient by themselves to eradicate
terrorism completely. They may, however, reduce the likelihood of terrorist attacks in the
long-term.

Table 4: Comparing the prevention of cancer and terrorism

Overall conclusion
Long-term
methods

Preventing cancer
Never entirely possible
Avoiding risky behaviors (smoking
tobacco, drinking, and overexposure to UV
radiation), diet and exercise

Preventing terrorism
Never entirely possible
Avoiding risky behaviors (oppressing
minority segments of the population,
disenfranchising marginalized groups)

Diagnosis
Oncologists adjust their treatment strategy depending on the type of cancer they are
confronting and how advanced the disease is in the body. Doctors can identify some
cancers very early, which can often increases the patients chances of surviving. Other types
are more difficult to identify early on, including some which if not identified in time can
make treatment more difficult and possibly futile. While doctors cannot prevent patients
from getting cancer nor accurately predict who will develop it before it strikes, the early
identification and treatment of certain types of cancer like colon cancer for example
have dramatically increased patient survival. If colon cancer is not identified at these early
stages, however, there may be little a doctor can do to treat the disease.

19

The same concepts apply to counterterrorism, where policymakers are at a similar

disadvantage in preventing and predicting terrorist attacks, especially when they take
place abroad. Early diagnosis is equally important in counterterrorism. Like certain cancer
treatments, some counterterrorism tools are more effective the earlier they are employed
in a terrorist groups lifecycle. Leadership decapitation is one example. According to one
empirical study, terrorist groups that lose their leader to kill or capture in the first year of
existence are more than eight times more likely to end than groups who have not been
decapitated. If leadership decapitation occurs ten years into the groups lifecycle, however,
the effect is cut in half. If decapitation occurs 20 years after the group has formed, then
killing or capturing the leader may have no effect on the groups mortality whatsoever.49 In
both cancer and terrorism, the timing of treatment matters.
Table 5: Comparing the treatment of cancer and terrorism
Diagnosis tenet
Rules of thumb

Cancer
Early screening increases survivability
Diagnosis should drive treatment (not
one size fits all)

Terrorism
Early screening can prevent escalation
Diagnosis should drive treatment (not one
size fits all)

Treatment - Tactical Approaches

Avoiding risky behaviors can reduce ones chances of developing certain types of
cancers in the long-term, but at the tactical level, the secret to battling cancer lies in two
critical tasks: preventing mutations from occurring in normal cells, and finding ways to
eliminate cells when they do mutate without damaging too many of the healthy ones.

Bryan C. Price, Targeting Top Terrorists: How Leadership Decapitation Contributes to Counterterrorism,
International Security 36:4 (Spring 2012): pp. 9-46.
49

20

The same critical tasks are found in combating terrorism. The tactical keys to
success in combating terrorism are also twofold: (1) preventing radicalization from
occurring and (2) eliminating terrorists without causing collateral damage in civilian
populations or creating new terrorists. The latter has been a guiding principle for the U.S.
militarys counterterrorism and counterinsurgency operations for years. Then a
commander in Iraq, David Petraeus used to ask the following question to his soldiers
before they went out on missions. Will this operation take more bad guys off the street
than it creates by the way its conducted?50 It is the counterterrorism equivalent to the
Hippocratic oath.
The current debate on the use of drones is also illustrative here. Although drones
have undoubtedly removed scores of high-ranking terrorists from the battlefield, concerns
about collateral damage and unnecessary civilian casualties question whether drones are
counterproductive as a counterterrorism tool. Instead of reducing the number of terrorists,
critics argue, the negative externalities of drone usage end up producing more.51
In the early days of treating cancer, the only tool in the toolbox for oncologists was
the knife. Without a proper understanding of the disease, doctors combating cancer
operated with a more-is-better mentality when it came to surgically removing cancerous
tumors. This more-is-better approach carried over when chemotherapy and radiation
were added to the oncologists repertoire. Commenting on the early mistakes of
chemotherapy, one doctor said, If we didnt kill the tumor, we killed the patient.52 As a

Sara Israelsen-Hartley, Gen. David Petraeus, the Top Commander in the Middle East, Comes to BYU, Desert
News, March 25, 2010.
51 For an expanded argument on this, see Audrey Kurth Cronins Why Drones Fail, Foreign Affairs
(July/August 2013).
52 Mukherjee, p. 143.
50

21

result, numerous cancer patients unnecessarily suffered and died during these early years
when surgeons and oncologists went too far, cutting out too much or prescribing doses of
radiation or chemotherapy that were too high. Even if the patients survived these brutal
treatments, the surgery left them so disfigured and sick that many wished they were dead.
American playwright Anna Deavere Smith once aptly said, Cancer therapy is like beating
the dog with a stick to get rid of his flees.53
The early days of modern counterterrorism mirror this evolution in cancer
treatment. Instead of using a knife to do more harm than good like those early surgeons,
the French used its preferred tool in its counterterrorism repertoire the hammer in its
attempt to defeat the National Liberation Front in Algeria in the 1950s. As depicted in the
movie Battle of Algiers, the French won the battle, but lost the war, in large part due to their
heavy-handed and indiscriminate counterterrorism tactics.54 The French succeeded in
removing the cancer, but it irrevocably damaged significant amounts of healthy tissue,
and as a result lost the patient to the independence movement. Over time, however, both
oncologists and counterterrorism officials have expanded their respective arsenals to go
beyond the knife and the hammer.
Oncologists in the 1950s recognized that cancer was a unique foe. It was a total
disease an illness that gripped patients not just physically, but psychically, socially, and
emotionally.55 Doctors during this era developed the concept of total care because they felt
only a multipronged, multidisciplinary attack would stand any chance of battling this

Ibid., p. 305.
See also Alistair Hornes A Savage War of Peace: Algeria 1954-1962 (New York: NYRB Classics, 1977).
55 Mukherjee, p. 125.
53
54

22

disease.56 As a result, doctors today use multiple arrows in the oncology quiver surgery,
radiation therapy, chemotherapy, and palliative care. Not only is it common for doctors to
use several of these treatments in combination, but they attack each type of cancer
differently. No two cancers are treated the same. For example, if caught early enough, colon
cancer can be completely removed by simple surgery. For testicular cancer, chemotherapy
is the most effective treatment. Lung cancer is regularly treated with all three methods
surgery, chemotherapy, and radiation.
Since there is no magic bullet when it comes to counterterrorism either,
policymakers would benefit from adopting a similar nuanced approach that oncologists
employ. For example, there is a lot of talk about a whole of government approach to
American counterterrorism, but critics contend that the United States has overemphasized
and over-resourced the military response to al Qaeda at the expense of non-military
means.57 The same has been said for the conflict against the Islamic State, where the
debates over military options often drown out those on lesser appreciated non-military
tools such as diplomatic measures, counter threat finance, and other lower profile, longerterm, more prosaic efforts like those found in many countering violent extremism (CVE)
programs.58 Even though there is a lot of nave rhetoric about the ease in which a willing
coalition could defeat the Islamic State through military means, several leading scholars
suggest it is more practical and pragmatic to focus on aggressively containing the

Ibid.
Cronin, p. 20.
58 Ibid., pp. 20-21.
56
57

23

contemporary disease of the Islamic State rather than think we are capable of eradicating
it using the same old and ineffective methods of the past. 59
There is widespread agreement that the United States cannot kill its way to victory
in the fight against Islamic extremism. In fact, this refrain is said most often and most
powerfully by those tasked with executing the military response to terrorism.60 Although
many agree that our counterterrorism approach should be more balanced in the future,
with more emphasis on the non-military means, there is little research that tells
policymakers what that optimal balance looks like.
Oncologists have been working for decades to find the right balance of treatments to
combat certain cancers, laboriously identifying which types respond to surgery,
chemotherapy, radiation, other drugs, and combinations thereof. In the early days of
modern oncology, doctors found that by adding drugs in combination they could get
synergistic effects on killing cancer cells.61 Using drugs in concert dramatically lowered
the chance of resistance and increased cell killing,62 but dialing in the optimal dosage,
frequency, and sequence those drugs should be administered took a long time and
hundreds of thousands of clinical trials. The same is likely true for the employment of
various counterterrorism tools, although terrorism scholars have a ways to go before they
reach the level oncologists are at today in determining optimal treatments.

Ibid; Stephen Biddle and Jacob Shapiro, Heres Why We Can Only Contain the Islamic State, Not Bomb It
Back to the Stone Age, Washington Post, December 1, 2015.
60 For example, in 2008 former Secretary of Defense Robert Gates said we cannot kill or capture our way to
victory" in the long-term campaign against terrorism. See Ann Scott Tyson, Gates Warns of Militarized
Policy, Washington Post, July 16, 2008.
61 Mukherjee, p. 141.
62 Ibid.
59

24

Additionally, like oncologists fighting cancer, counterterrorism practitioners and

policymakers would be wise to publicly acknowledge that some treatments may have longterm positive effects that outweigh their short-term negative effects. For example, having
to endure the nasty side-effects of chemotherapy and radiation treatment may seem both
counterintuitive and counterproductive to a cancer patient. Even the most optimistic
patients likely question how these debilitating treatments help them get better when all of
their initial side effects (e.g. extreme nausea, hair loss, weight loss) make them feel
demonstrably worse in the short-term.63
The same could be said for the consequences of using counterterrorism tools like
targeted killings. Although some terrorism scholars contend that targeted killings,
especially when they are executed via drone strikes, invite retaliatory terrorist attacks and
are tactics that violate Petraeuss COIN/CT Hippocratic oath of creating more terrorists
than they remove from the battlefield,64 others scholars disagree. Although terrorist groups
rarely catastrophically disintegrate following the loss of their leader, decapitated groups
are more likely to end sooner than non-decapitated groups.65 Like certain cancer
treatments, some counterterrorism tactics will likely have long-term benefits that outweigh
their short-term costs. Both long-term and short-term effects need to be considered when
crafting sound policy, and thus far most of the scholarly work evaluating the effectiveness
of counterterrorism policies has disproportionately focused on short-term effects. If

Loren Grush, Chemotherapy: How Cancer Drugs Impact the Body Long-Term, FoxNews, June 2, 2014.
See for example Jenna Jordan, When Heads Roll: Assessing the Effectiveness of Leadership Decapitation,
Security Studies 18:4 (2009).
65 Price, Targeting Top Terrorists.
63
64

25

oncologists operated under the same mentality, chemotherapy and radiation treatments
would have never become mainstays of combating cancer.

Table 6: Comparing the treatment of cancer and terrorism

Tactical
Problem #1

Treating cancer
Preventing mutations from occurring in
normal cells

Tactical
Problem #2
Rule of thumb
Inherent
danger

Destroying cancer cells without damaging

good ones
Earlier the better
Sometimes treatment can have
unpredictable consequences such as
further metastasis, creating new cancers

Early
Treatments
Historical
mistakes

Surgery, Chemotherapy

Early
mentality

Using unilateral treatments in isolation

(either surgery, chemotherapy, or
radiation)
More is better remove the tumor and
the tissue around it so as to ensure it does
not spread (e.g. early mastectomies)

Early Results

Dismemberment and/or death: if we

didnt kill the tumor, we killed the patient.

Evolution in
treatment

Cancer seen as a total disease in 1950s,

requiring a multidisciplinary, multipronged approach to properly treat

Treating terrorism
Preventing non-radicalized individuals
from radicalizing and foiling plots before
they occur.
Destroying terrorists without collateral
damage and without creating new ones
Earlier the better
Sometimes CT efforts can have
unpredictable consequences such as the
spread and creation of new groups (e.g. AQ
franchises, rise of IS)
Occupation, mass arrests, indiscriminate
and violent oppression/crackdowns
Emphasizing unilateral measures
overreliance on over-reactionary
military/police violence
More is better destroy the terrorist
group quickly and violently, even if it
produced collateral damage (e.g. French vs.
FLN in Algeria) which created more
terrorists
Increased threat - indiscriminate and
heavy-handed state response legitimized
terrorist concerns, swayed fence-sitters to
support terrorists cause, and rallied others
to the cause
CT seen as a transnational problem that
requires a whole-of-government approach
and multilateral cooperation to properly
mitigate; more emphasis on non-kinetic
treatments

Treatment Staging System

Oncologists employ a staging system for classifying the severity of cancer based on
the size of the tumor and the degree to which the cancer has spread throughout the body.
This staging system helps doctors estimate the prognoses of their patients and it helps
26

them select optimal treatments. It also provides a common terminology for both patients
and doctors to evaluate the results from the selected treatments. These staging
classifications change over time as doctors learn more about specific cancers and the best
ways to treat them.66
The same approach may be useful in counterterrorism. Critics contend that todays
U.S. counterterrorism strategy is too open-ended, overly reliant on preemptive warfare,
and devoid of clear boundaries.67 The decision to characterize the war with jihadist groups
like al Qaeda and the Islamic State as a fight against a global insurgency implies that the
United States should engage in a war on violent extremism anywhere, and thus fight an
open-ended global campaign everywhere a classic recipe for imperial overstretch.68
Creating a staging system similar to the one found in oncology can help mitigate
some of the problems inherent in todays counterterrorism challenge. A staging system
would provide a template to policymakers from which to understand and bound the threat,
identify the proper treatments appropriate for each stage, and allocate resources
accordingly. It would also educate the American public on which threats pose severe
problems for the United States and that will not be defeated anytime soon. When
conditions on the ground change i.e. the group has somehow enhanced its capabilities, it
starts to threaten vital U.S. interests, and/or the host nations counterterrorism capabilities
have either improved or have proven incapable changes to the groups classification can
easily be made. This type of classification system would also help solve the goldilocks

National Cancer Institute Fact Sheet, National Cancer Institute, Washington D.C. Found at
http://www.cancer.gov/cancertopics/factsheet/detection/staging.
67 Cronin.
68 Ibid., pp. 5-6, italics original.
66

27

problem that currently plagues the current Authorization for the Use of Military Force,
which critics claim is either too narrow or too all-encompassing.69
Like cancer stages, a counterterrorism staging system would be progressive. It
would allow groups to move up and down the scale depending upon the capability of the
group and the risk it poses to U.S. national security. Groups in Stage 0 would be comparable
to cancer in situ where abnormal cells are present but pose minimal risk. Examples from
this grouping would include all domestic terrorist groups in the United States, from both
extremes on the political spectrum. It would also include lone wolf terrorists like Ted
Kaczynski (the Unabomber) and homegrown terrorists like Major Nidal Hasan. For
groups in this stage, the most effective counterterrorism tools come from the criminal
justice/law enforcement model discussed earlier. This left of the boom stage is also
where CVE programs will be the most effective, where they can educate and potentially
dissuade those with extremist viewpoints from perpetrating political violence.
It is important to note, however, that the probability of fatal terrorist attacks
occurring in this stage is never zero, a talking point that must be made clear to the
American people and reiterated frequently.70 There will undoubtedly be terrorist attacks
from individuals and even some groups in this stage, but like Stage 0 cancer, attacks from
those in this group are tragic, but relatively anomalous and do not pose significant risks to
national security. This stage will also feature groups who have fallen from relevance but
who require pressure to prevent their resurgence. Oncologists say that cancer must be
Ilya Somin, Reactions to the Obama Administrations Proposed ISIS AUMF, Washington Post, February 15,
2015.
70 To provide an example of this in the cancer community, one American Cancer Society report listed the 5year survival rate of those diagnosed with Stage 0 cervical cancer to be between 80-93%. The reports
findings can be found at http://www.cancer.org/cancer/cervicalcancer/detailedguide/cervical-cancersurvival.
69

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systematically treated long after every visible sign of it has vanished,71 and terrorist
groups are no different. After all, there are good reasons why doctors often use the term
remission rather than cure when referring to successful responses to treatment. The
precursor to the Islamic State, al Qaeda in Iraq / Islamic State of Iraq, was thought to be in
its death throes in 2011,72 and when pressure from the United States and its Iraqi partners
was removed, it rebounded and returned to prominence in a scary way.
Stage 1 terrorist groups have openly perpetrated violence in the past and pose a
security threat to their host countries, but their violence is largely localized. These groups
do not possess the ability to conduct transnational attacks, and thus they pose only a
limited threat to U.S. regional security interests. To economize on U.S. counterterrorism
efforts and to ensure these groups do not evolve and progress into the next stage, the
United States should focus its efforts on building partner capacity and security force
assistance operations. Rather than committing counterterrorism resources which are
already in short supply to combat groups that, while deadly, do not pose imminent risks to
U.S. national security, the United States should propmote coalition efforts and provide
support to augment the counterterrorism campaigns of the host nation or host nations.
Groups advance to Stage 2 when they threaten U.S. interests abroad and when they
destabilize regional security. Additionally, groups in this category may exist in countries
that possess weak or ineffective counterterrorism capability or countries that offer safe
haven, even if this safe haven is not necessarily explicit but only implied. In other words, it
is not enough for the United States to rely on building partner capacity alone in order to

Mukherjee, p. 138.
Greg Miller and Craig Whitlock, U.S. Weakens al-Qaeda Groups Around the World but Hasnt Wiped Any
Out, Washington Post, September 11, 2014.
71
72

29

mitigate the threat these groups pose. To combat groups in this category, more reliance on
regional security forces (e.g. ECOWAS, EU, NATO) is needed, and the United States should
provide increased military assistance and enablers to these regional security forces. The
assistance provided by the United States in support of OPERATION SERVAL since 2012 is a
useful template for treating groups in this category. Rather than committing a major
deployment of U.S. soldiers on the ground, the United States complemented French military
forces with strategic lift, aerial refueling, and intelligence, surveillance, and reconnaissance
platforms which our allies lacked.73
Stage 3 groups are transnational terrorist organizations that threaten U.S. interests
abroad. They may also threaten to attack against the U.S. homeland but lack the current
capability to do so or the timing simply is not conducive to meeting their political objective.
Groups like Lebanese Hezbollah, the Pakistani Taliban (TTP), and Lashkar-e-Taiba (LeT) fit
into this latter category. Lebanese Hezbollah has been targeting Americans and citizens
from the West since the 1980s,74 and the TTP was responsible for training Faisal Shahzad
who came close to perpetrating a spectacular attack in Times Square in 2009. 75 These
organizations have demonstrated both the motivation and the capability to conduct
transnational attacks against the U.S. homeland and U.S. interests abroad. Once groups
reach this stage, they pose a direct national security threat to the United States, and the
sponsor nations or host nations in which they reside are often unwilling (because they use
these groups as proxies, like Iran does with Hezbollah) or unable to combat them
Michael A. Sheehan and Geoff Porter, The Future Role of U.S. Counterterrorism Operations in Africa, CTC
Sentinel (February 24, 2014), pp. 1-4.
74 National Counterterrorism Centers Hizballah group profile at http://www.nctc.gov/site/groups/
hizballah.html.
75 Anne E. Komblut and Karin Brulliard, US Blames Pakistani Taliban for Times Square Bomb Plot,
Washington Post, May 10, 2010.
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effectively (as in the case of Iraq and Syria today against the Islamic State). As a result, all
kinetic and non-kinetic means are at the disposal of the United States for groups in Stage 3,
including unilateral military force if necessary.
The other archetypical candidate for a Stage 3 group would be LeT, a Pakistani
element that has conducted transnational attacks in the past, continue to exist at the
pleasure of their donor state. In other words, if the Pakistani government wanted to
destroy LeT for whatever reason, it could likely do so, or at a minimum make them a Stage
1 or 2 threat.
Finally, Stage 4 groups pose a serious and unmistakable threat to the U.S. homeland.
Groups like AQAP have already conducted attacks against U.S. targets in the homeland and
abroad, and possess both the motivation and the demonstrated capability to do so in the
future. As in cancer, the primary difference between Stage 4 and Stage 3 groups is that the
former are unlikely to be cured any time soon, regardless of the resources dedicated to
fighting the disease.
AQAP was the group responsible for the failed 2009 attack by the underwear
bomber Umar Farouk Abdulmutallab over Detroit and the foiled plot to destroy several
transcontinental cargo planes in flight with bombs hidden in printer cartridges in 2010.76
These foiled attacks were thought to be the handiwork of Ibrahim Hassan al-Asiri, arguably
the worlds most deadliest and skilled bombmaker.77 The current political chaos in Yemen
has led the country into another sectarian civil war, a vacuous security environment that
will likely benefit al-Asiri and AQAP. The fear among counterterrorism experts is that this

Nick Bunkley, Would-Be Plane Bomber Is Sentenced to Life in Prison, New York Times, February 16, 2012.
Anissa Haddadi, Al-Qaidas Body Bombs Increase Fears of Global Attacks by Master Bomb-Maker Ibrahim
Hassan Tali al-Asiri, International Business Times, May 14, 2012.
76
77

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environment will provide AQAP with safe haven and the ability to plot attacks against the
United States, like al Qaeda did in the vacuous security environment in Afghanistan in the
late 1990s and early 2000s.
There are several benefits of employing this type of staging classification system.
First, such a system would facilitate the prioritization of counterterrorism efforts across
the U.S. government. Currently the State Departments FTO list contains 58 terrorist
groups, yet the list does not differentiate which groups present more of a threat to the
United States than others. Second, this type of classification would send a clear signal to the
international community about how the United States views the threat landscape.
Classifying terrorist groups in a staging system may not be popular with the states in which
these groups reside, but it would be no more controversial than putting them on the FTO
list. Moreover, with the knowledge that higher staging classifications trigger new
authorities, to include unilateral and kinetic operations, donor and host states receive the
classification as a signal to either do something about the threat or face escalatory
measures from the United States and hopefully the international community.
Finally, this staging system would serve an important function in educating the
American public about the threats facing the United States. A classification like the one
proposed would help bridge this gap between public perception and reality. It would also
be a constant reminder that low-level in situ terrorist attacks like the Boston bombing,
the shooting in Garland, Texas, and more recently in San Bernardino, California, are
persistent threats, but not catastrophic ones.

32

Table 7: Example of what a counterterrorism staging classification system might look like
Definition

Stage

Archetypical
Examples
US violent LW and
RW, Homegrown
terrorism

Terrorism "in situ" - presence of political extremists but

no extant threat of violent radicalism; states that have
political environments ripe for political violence;
baseline level of terrorism (which is never 0)

Terrorist groups that have perpetrated violence in a

localized setting but are not transnational; pose limited
threat to regional U.S. interests

FARC, Abu Sayyaf

Group, JI, Taliban,
IMU

Terrorist groups that possess the capability to threaten

U.S. interests abroad, destabilize regional security; exist
in states with weak CT capability
Transnational terrorist groups that threaten US
interests abroad, destabilize regional security, pose
threat to attack US homeland but either lack the
current capability to do so, or the timing is poor.
Transnational groups that pose a threat to the US
homeland; possess both the capability and the
motivation to do so; host country hostile to US

Boko Haram, AQIM,

al- Shabaab, Jabhat alNusra, Hamas, HQN
Hezbollah, TTP, LeT

II

III

IV

Islamic State, AQAP,

AQ Core in the FATA

Primary Treatments
Surveillance, law enforcement, CVE, addressing grievances
before they become crises (political enfranchisement,
minimizing gross wealth disparity, non-violent conflict
negotiation).
Build partner capacity (BPC) and security force assistance
(SFA), minimal US military assistance, all non-kinetic means
available (designation, counter threat finance, lawfare)
Same as above, but increased reliance on regional security
forces and increased US military assistance and enablers (ISR,
FID, UW, drones), potential light footprint; joint exercises
UW, ISR, air power, enablers, drones, unilateral direct action if
necessary. BPC/SFA still important, but once groups reach this
stage, it is generally a sign that the host country is either
unable or unwilling to combat the threat effectively.
All kinetic and non-kinetic means available, including unilateral
direct action. Unlikely to be "cured" but pressure must be
consistently applied. Group enjoys sanctuary and/or access to
weapons of mass destruction.

Note: This is not an exhaustive list. The groups listed are simply archetypical examples. The important aspect is the
staging framework, not the individual groups that populate the various stages.78

Palliative Care
Finally, oncologists use palliative care at every stage of the cancer treatment
process, from diagnosis to death. Palliative care in cancer treatment encompasses pain
management, building emotional resilience, refining coping skills, and establishing proper
expectations.79 At first blush, it may be difficult to see how this could apply to
counterterrorism, but this may be an area where counterterrorism policymakers can
perhaps learn the most from their oncology counterparts.
Consider the 2013 Boston bombing and the massive response that followed.
Although those involved with bringing the Boston bombers to justice did a heroic job,
A counterargument to this kind of staging system may suggest that Stage 0 threats are more likely to kill
more Americans on the homeland than Stage 4 threats. While this is likely the case, these threats do not pose
as catastrophic a threat as Stage 4 groups. In other words, although tragic, the United States can likely endure
other San Bernardino-like attacks but it would find it difficult to cope with numerous attacks on the scale of
9/11. Again, the important point raised by this paper is the utility of a staging system and not which groups
populate the various stages that will be left up to policymakers to decide.
79 National Institute of Health, National Cancer Institute at http://www.cancer.gov/about-cancer/advancedcancer/care-choices/palliative-care-fact-sheet.
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shutting down a major U.S. city for three days after the detonation of two relatively
rudimentary homemade bombs is not, and cannot be, a sustainable model moving forward.
After taking into consideration the financial impact associated with locking down an entire
metropolis for several days, one estimate pegged the cost of the response at $333 million.80
The financial district, the citys mass transit system, several Boston airports, and countless
businesses and shops were all closed. One reporter for the New Yorker put it this way:
The decision to shut down Boston, though doubtless made in good faith
and from honest anxiety, seemed like an undue surrender to the power of
the terrorist actas did, indeed, the readiness to turn over the entire
attention of the nation to a violent, scary, tragic, lurid but, in the larger
scheme of things, ultimately small threat to the public peace. What
terrorists want is to terrify people; Americans always oblige.81
Like New York and Paris, Boston is a resilient city, and life in both cities soon returned to
normal after enduring high-profile terrorist attacks. U.S. counterterrorism officials should
be nervous, however, given that the pressure cooker bombs were relatively easy and
inexpensive to build (allegedly costing the Tsarnaev brothers approximately $400).82
Additionally, the attack and the subsequent manhunt received an overwhelming media
response. Copycat terrorists looking for both a great return on their investment, copious
amounts of media attention, and a costly and disruptive counterterrorism response, will
likely view the Boston bombings and the attacks in Paris, San Bernardino, and Brussels as
attractive templates in the future.
Many of the policy recommendations that came out of the Boston bombings autopsy
of the response, however, focused on ways to improve intelligence collection and law

Jessica Rinaldi, Adding Up the Financial Costs of the Boston Bombings, NBC News, April 30, 2013.
Adam Gopnik, Dzhokhar Tsarnaev, Lost and Found, New Yorker, April 19, 2013.
82 Doug Stanglin, Al Qaedas Magazine Warns of More Lone Wolf Attacks, Washington Post, June 3, 2013.
80
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enforcement methods to prevent and manage future attacks. The same has been true thus
far in the aftermath of the Paris attacks. Very little attention was given to ways in which the
government can properly prepare the public emotionally for what will undoubtedly be
more terrorist attacks in the future.83 This is a mistake in the authors opinion, and an
indication that we should consider the palliative care model to remedy this gap in our
overall counterterrorism strategy.
An important part of palliative care is proper expectation management. Thus, it is
interesting that oncology and counterterrorism share similar evolutionary histories,
including how each field framed their respective problems and the initial institutional fixes
to subsequently solve those problems. For example, in 1945 the United States declared its
War on Cancer, even referring to it as a crusade at one point.84 It stood up a national-level
organization from scratch, the National Cancer Institute, which was supposed to be
stripped of its bureaucratic excesses and serve as the antidote to the ad hoc, diffuse, and
stove-piped campaign that was complicating previous efforts at finding a cure.85 President
Richard Nixon boasted in 1971 that we would have a cure for cancer by 1976.86 In 2000,
then presidential candidate George W. Bush called for a medical moonshot, vowing to
double the budget of the National Cancer Institute in the hopes of finding cure to cancer in
5 to 10 years.87 No cures were found during that time period, but that did not stop
President Barack Obama from promising a cure for cancer in our time at the start of his

Cronin, p. 21; see also Dan Bymans panel comments at Al-Qaida, the Islamic State, and the Future of the
Global Jihadi Movement: A Conversation with Ambassador Tina Kaidanow, The Brookings Institution,
Washington, D.C., September 16, 2015.
84 Mukherjee, pp. 113-115.
85 Ibid., p. 117.
86 Gina Kolata, Advances Elusive in the Drive to Cure Cancer, New York Times, April 23, 2009.
87 George W. Bushs remarks made at the Sun City Center in Florida on April 22, 2000. A transcript of the
remarks can be found at http://transcripts.cnn.com/TRANSCRIPTS/0009/22/se.02.html.
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first term.88 He doubled down and called for a new moon shot in his last State of the
Union address.89
In an eerily similar fashion, following the 9/11 attacks, the U.S. government
announced its War on Terrorism. Like the war on cancer six decades prior, President
George W. Bush even called the war on terror a crusade at one point.90 The government
again stood up a national-level organization from scratch, the National Counterterrorism
Center, that was supposed to be stripped of its bureaucratic excesses and serve as the
antidote to the ad hoc, diffuse, and stove-piped campaign that was complicating previous
efforts at fighting terrorism. Similar to how ambitious presidents called for the defeat of
cancer, the 2003 National Strategy for Combating Terrorism ambitiously vowed to defeat
terrorism.91
To date, neither the War on Cancer nor the War on Terrorism has succeeded in
ending their respective conflicts. The United States and other countries have spent billions
of dollars to better understand and combat both problems, but neither malady has been
eradicated. In fact, neither can be completely eradicated, a conclusion that oncologists have
been quicker to acknowledge than their counterterrorism counterparts.
As a result of this pragmatism, medical practitioners are starting to frame the
conflict with cancer in a different manner today, something that the counterterrorism
community may want to adopt. In fact, there is a recent push in the medical community to

Kolata.
Barack Obama, 2016 State of the Union address, Washington, D.C., January 12, 2016. Transcript can be
found at http://www.nytimes.com/2016/01/13/us/politics/obama-2016-sotu-transcript.html?_r=0.
90 Remarks by President George W. Bush, White House, Washington, D.C., September 16, 2001. President Bush
said, This crusade, this war on terrorism is going to take a while. The transcript can be found at
http://georgewbush-whitehouse.archives.gov/news/releases/2001/09/20010916-2.html. The White House
would later issue an apology for using the word crusade. See Bob Woodwards Bush At War, p. 94.
91 White House, 2003 National Strategy for Combating Terrorism, p. 15.
88
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stop using war-like metaphors and to discourage the notion of winning when it comes to
dealing with terminal diseases like cancer.92 Those looking to move away from war-like
metaphors recognize that cancer and other deadly diseases are inherent parts of the
human condition, so there is little utility in framing them as opponents in war. For example,
when a patient loses his battle with cancer and succumbs to the disease, society does not
paint that patient as a loser. While battle metaphors may empower certain patients to
fight diseases, some medical practitioners believe that battle metaphors can be very
harmful to patients.93
Counterterrorism policymakers may want to follow their medical counterparts in
reframing the problem posed by terrorism in the current environment. Today there is
significant disagreement within the counterterrorism community about how the United
States should conceptualize victory.94 If, as one noted terrorism scholar put it, no one
seems to know what winning means,95 then what is the appropriate distinction between
war and peace? The war on terror is commonly described as perpetual, persistent, and with
no end in sight. The same is true for the long-term conflict with cancer. If this is indeed
reality, then maybe the U.S. government should take a page from the medical community
and rethink its decision to frame the conflict as a war. Doing so could reduce the media

Paula Span, Fighting Words are Rarer Among British Doctors, New York Times, April 22, 2014.
Ibid.
94 Cronin; Philip H. Gordon, Can the War on Terror Be Won? Foreign Affairs (November/December 2007);
James Kitfield, Inside Americas Shadow War on Terror and Why It Will Never End, DefenseOne, May 18,
2014.
95 Cronin, p. 2.
92
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attention and overinflated sense of legitimacy that groups like the Islamic State and al
Qaeda use to appear more powerful and capable than they really are.96
The argument put forth in this paper is that the United States should frame this
long-term conflict with terrorism as a chronic disease. Like cancer, terrorism is and will
continue to be an inherent and dangerous part of the human condition. Framing terrorism
like a chronic disease does not stop counterterrorism policymakers from doing everything
in their power to combat groups like al Qaeda and the Islamic State, to include using
military force, but policymakers should be honest with their constituencies about the risks
of terrorism and the extent to which the states counterterrorism efforts can mitigate them.
As Cronin writes, if Americans believe that anybody that calls himself or herself al-Qaeda
has to be unable to hurt anybody for this war to end, then this war will never end.97

Policy Recommendations
An epidemiological approach that treats terrorism as a chronic disease like cancer
produces several meaningful policy recommendations:
1. Stop using the term defeat as a counterterrorism objective.
Because defeating terrorism is an unattainable goal, making it the ultimate
counterterrorism objective is counterproductive and arguably nave. The United States has
neither the political will necessary to eradicate these groups nor does it have the unilateral
capability to do so. When the United States makes defeat its policy objective and it fails to
achieve this standard, it provides the enemies of the United States with ammunition they

See for example David Coates, Weighing the Arguments on U.S. Military Action Against ISIS, Huffington
Post, March 9, 2015. Accessed at http://www.huffingtonpost.com/david-coates/weighing-the-argumentson_b_6830606.html.
97 Ibid., p. 18.
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use to recruit and fund their operations. Declaring defeat as the ultimate goal may appeal to
the countrys overall sense of righteousness, but if the United States has neither the ability
nor the willingness to do so, every day the Islamic State or al Qaeda exists hurts Americas
credibility and strengthens that of its enemies.
Instead, the United States should acknowledge that al Qaeda and the Islamic State
(not to mention other jihadist organizations that will inevitably follow in their footsteps)
will remain enduring threats for the foreseeable future. The argument for this is based on
two primary reasons. First, as long as the United States remains a world power with global
interests, it will remain a convenient foil for jihadist organizations to blame America for a
host of grievances. Non-state actors will continue to wage asymmetric warfare as long as
the United States remains conventionally superior, which is all but a certainty in the
decades ahead. Second, Iraq, Afghanistan, and Syria have exposed the limitations of the
United States in its ability to affect both the conditions that ostensibly give rise to violent
extremists in other countries and the way in it can effectively respond to these threats
when they do arise.
Backing away from using defeat as the objective does not mean the United States is
surrendering in this fight or that it is soft on terrorism. It does mean the United States
should cease any of its efforts to apply relentless pressure to continuously degrade these
groups. Instead, it is a sign that the United States is being pragmatic, and like it declared in
the beginning of the Cold War, ready to fight in this conflict for as long as it takes in the
long-term. The Islamic State and other enemies of the United States are viewing this
conflict in decades, centuries, and generations. It is time the United States and its allies do
the same. Therefore, an epidemiological approach would recommend replacing defeat
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with prevent and treat. This would stop the impractical and meaningless debates about
what defeat means and what winning means and get policymakers, practitioners, and
scholars focused on improving how we prevent and treat this disease more effectively.
2. Move away from the AUMF construct and employ a staging system similar to the one used
in oncology.
The current authorities used by the United States against the Islamic State, alShabaab, and the Haqqani network were all derived from a policy document written less
than one week after the 9/11 attacks. The authority allows the United States to use force
against against those nations, organizations, or persons he determines planned,
authorized, committed, or aided the terrorist attacks that occurred on September 11, 2001,
or harbored such organizations or persons, in order to prevent any future attacks of
international terrorism against the United States by such nations, organizations, or
persons.98 The calls to update the AUMF are numerous and yet there has been no
meaningful action to do so.99 This poses both legal and practical problems for the United
States in the future.
For example, the Islamic State can be lethally targeted because it has historical ties
with al Qaeda in Iraq, a group that had obvious ties with al Qaeda core, the perpetrators of
9/11. Today, however, the Islamic State and al Qaeda are mortal enemies, and there is no
evidence that the author is aware of that suggests current members of the Islamic State
members had anything to do with 9/11 attacks. This is not an argument to suggest the
Authorization for the Use of Military Force, 107th Congress, Public Law 107-40, September 18, 2001.
Accessed at http://www.gpo.gov/fdsys/pkg/PLAW-107publ40/html/PLAW-107publ40.htm.
99 Bob Corker, Bob Corker: Congress Should Update the 9/11 Law on the Use of Military Force, Washington
Post, May 22, 2014; President Barack Obama, Letter from the President Authorization for the Use of United
States Armed Forces in Connection with the Islamic State of Iraq and the Levant, February 11, 2015; James
Arkin, After One Year of War on ISIS, No AUMF in Sight, RealClearPolitics, August 5, 2015; Somin.
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United States should not target the Islamic State, or more importantly the growing number
of groups pledging baya to the caliphate, only that the authority for doing so needs to be
updated.
Employing the staging system detailed above is a useful alternative. This would
make the basis for U.S. lethal targeting capabilities-based rather than ideologically- or
affiliation-based like it currently stands. Such a staging system would be more transparent,
flexible, and proactive than the current way the United States does business. It would also
serve as a useful tool to educate the American public.
3. Lower the bar on triggers to activate non-kinetic tools in the CT toolbox.
The argument for lowering the bar to activate U.S. non-kinetic tools such as terror
designations is one of timing. The U.S. State Department and Treasury Department follow
an extremely detailed and meticulous process for designating individuals and
organizations as terrorists, and they take painstaking efforts to ensure these designations
can stand up in court. In the current system, emerging terrorists and terrorist
organizations can operate for months and years before they trigger non-kinetic
counterterrorism tools like asset freezes, prohibitions on international travel, and the
naming and shaming associated with diplomatic designations. By the time these nonkinetic tools are activated by the United States, some groups have well-established
resource streams and diversified portfolios, and they can therefore subsist for several
years before these designations and their accompanying constraints can take effect.
For example, the Haqqani network had been operating with virtual impunity for
over a decade following the U.S. invasion of Afghanistan before it was placed on the FTO list
in late 2012. The designation has undoubtedly hurt the organization and hampered its
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capability, but the Haqqani network had more than ten years to buffer and mitigate the
effects of designation. A study analyzing the effectiveness of the State Departments FTO list
showed that, on average, groups were more lethal in the year after they were designated
than in the year prior to designation.100 If the United States is looking to reduce the amount
of times it has to use the hammer in its counterterrorism efforts, then there must be a
subsequent relaxation in the standards established for activating non-kinetic tools in
counterterrorism.101
Lowering the standards for designating groups on terror lists would be analogous
to oncologists who make adjustments to the treatment protocols for different types of
cancer. For example, if clinical trials show patients contracting a certain type of cancer
earlier in age than in previous generations, they will lower the recommended screening
age. If data shows that certain cancers are advancing more quickly than previously
believed, they may authorize more aggressive treatments earlier in the treatment protocol.
There are tradeoffs in making these changes, and all entail different risks, but it is futile to
employ certain treatments if the cancer has already advanced beyond a certain stage.
Policymakers will face similar tradeoffs if they lower the standards for triggering
non-kinetic tools. Doing so will likely lead to more false positives on the designation list.
Lowering the bar will potentially open the United States to more scrutiny in the courts.
These may be acceptable evils, however, if policymakers believe employing these non-

Bryan C. Price, Designated Haters: Evaluating the Effectiveness of FTO Designations. Paper presented at
the Annual Meeting of the International Studies Association, Toronto, March 2014.
101 President Barack Obama, Remarks by the President at the United States Military Academy
Commencement Ceremony, West Point, NY, May 28, 2014.
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kinetic tools earlier in the groups lifecycle will likely enhance their short- and long-term
effectiveness.
4. Do more to prevent the spread of terrorism by influencing the lymph nodes and the
bloodstream.
A lot has been written about U.S. struggles in the war of ideas and the challenges of
executing an effective counter-narrative campaign against jihadist organizations like the
Islamic State.102 More can be done to make it harder for jihadists to spread their vitriolic
propaganda online.103 One area where the United States and other Western states can
influence this dynamic is in diplomatic tools like terrorism designations. The Specially
Designated Global Terrorism (SDGT) list that is maintained by the Treasury Department
and which designates individuals and entities as terrorists focuses primarily on terrorist
operators, financiers, and logistical personnel who provide materiel support to terrorist
organizations. Of the 651 individuals designated on this list, only 32 had propaganda roles
in their organizations.
5. Make palliative care an important part of CT strategy, promote proper expectation
management of the threat posed by terrorism, and educate the American people about the
risks and consequences of such attacks.
If the United States is serious about creating a truly resilient nation, one that
maintains appropriate expectations about the threat and the countrys ability (and in some
cases its inability) to mitigate that threat, it should utilize a palliative care approach similar
Manal Omar, The U.S. Will Never Win the Propaganda War Against the Islamic State, Foreign Policy,
January 9, 2015; Pete Favat and Bryan Price, The Truth Campaign and the War of Ideas, CTC Sentinel Vol. 8,
No. 7 (July 2015): pp. 9-12.
103 Scott Higham and Ellen Nakashima, Why the Islamic State Leaves Tech Companies Torn Between Free
Speech and Security, Washington Post, July 16, 2015; Ronan Farrow, Why Arent YouTube, Facebook, and
Twitter Doing More to Stop Terrorists from Inciting Violence? Washington Post, July 10, 2014.
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to the one employed by oncologists fighting cancer. Future terrorist attacks against the
United States are inevitable,104 especially if we choose to live in a free society that values
and protects civil liberties. Failure to arm citizens with proper expectations about terrorist
threats and the skills needed to enhance the countrys collective resilience following future
attacks will result in predictable consequences. Americans will continue to over-react to
low-level and unsophisticated attacks which are largely impossible to prevent, the
politicization of these attacks will increase, and numerous knee-jerk policy prescriptions
will create ideal conditions for extremist propagandists to exploit, thus continuing the cycle
of violence that fuels extremist political violence.

Conclusion
Terrorism and cancer are both insidious maladies featuring endogenous and
exogenous causes that are complex and poorly understood. Like terrorism, cancer has been
part of the human condition for thousands of years, and doctors trying to treat the disease
have made many of the same mistakes that policymakers have made in countering
terrorism. Policymakers should see terrorism as oncologists see cancer, as an inherent part
of the human condition. If we have learned anything from the thousands of years grappling
with cancer, we cannot cure an incurable disease. What we can do and what we ought to
do, however, is learn how to combat it and cope with the problem more effectively.

See Peter Baker and Eric Schmitt, California Attack Has U.S. Rethinking Strategy on Homegrown Terror,
New York Times, December 6, 2015.
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