THE CHEMICAL WARFARE THREAT AND THE MILITARY … · An article in the March 15, 1991, issue of The...

Chapter 4

THE CHEMICAL WARFARE THREAT ANDTHE MILITARY HEALTHCARE PROVIDER

ERNEST T. TAKAFUJI, M.D., M.P.H.*; AND ALLART B. KOK, M.S.I'

INTRODUCTION

THE CHEMICAL THREAT AND ENEMY CAPABILITY

THE STATUS OF CHEMICAL PROLIFERATIONChemical Warfare Capabilities of NationsInternational Agreements and VerificationTerrorism

MILITARY CHEMICAL AGENTS

TACTICAL AND STRATEGIC USE OF CHEMICAL WEAPONSChemical Agent Delivery SystemsPhysical Properties of Chemical AgentsStrategic Concerns in the Use of ToxinsChoice of Agent and Delivery SystemDetection and Protection

RESPONDING TO THE THREAT: MANAGING CASUALTIES

FUTURE CONFLICTS IN A CHEMICAL ENVIRONMENT

SUMMARY

"Colonel, Medical Corps, U.S. Army; Commander, Waiter Reed Army Institute of Research, Walter Reed Army Medical Center, Washington,D.C. 20307-5011

^Science Applications Internationa) Corporation, Joppa, Maryland 21085

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Medical Aspects of Chemical and Biological Warfare

INTRODUCTION

Some military medical personnel view the spec-ter of chemical warfare with fear and repugnance.The images of clouds of poisonous chemicals; con-taminated terrain and equipment; and the need towork in protective masks and hot, cumbersomeovergarments are intimidating even to well-trainedsoldiers. But for medical personnel there is an addedfactor: the fear of the unknown. The milieu of thechemical battlefield is especially alien since little inthe normal professional practice of most militarymedical personnel has any resemblance to the man-agement of casualties of chemical warfare.

Although military strategists might view chemi-cal warfare agents as simply one of the means toimmobilize or destroy an enemy force, others mayview such weapons as abhorrent extensions of con-ventional warfare. Be that as it may, it is not theintent of this chapter to justify the use of chemicalweapons in battle but rather to relate the use ofchemical warfare to health issues. Although currentpolicy of the United States government prohibitsusing chemical weapons against an adversary, thispolicy is not shared by all nations; therefore, to beeffective, military medical personnel must beknowledgeable and trained.

To the military healthcare provider, chemicalwarfare crosses over the lines of strategic and tacti-cal purposes, where victory may be viewed as fulljustification of

• the means;• the difficult challenges associated with the

identification, treatment, and prevention ofspecific injuries and illnesses in a deliber-ately contaminated and highly stressful en-vironment;

• the psychologically demoralizing effect thatchemical weapons may cause; and

• the personal ethical concerns that manymedics may have about suffering resultingfrom the deliberate use of weapons specifi-cally targeted to the human element.

Although healthcare providers are usually notinvolved in the political or military decisions sur-rounding use of chemical weapons, they must be

• prepared to deal with the military and ci-vilian casualties resulting from use of suchagents;

• cognizant of what constitutes a chemicalthreat and the military tactics that could beemployed against the force, since they maybe called on to render advice to their com-manders from an individual and publichealth perspective;

• familiar with the acute and chronic medi-cal effects of chemical agents in order toplan appropriate medical support; and

• fully knowledgeable of the diagnostic toolsavailable to identify specific etiologicagents to which their patients may havebeen exposed and the most effective meth-ods of intervention and prevention.

The "chemical threat" can be defined as a state-ment of the who, what, when, where, and how ofchemical warfare. The threat may involve single ormultiple chemical agents—not only the classicchemical agents specifically developed for mili-tary applications (ie, chemicals that had beenweaponized by the 1950s), but also highly toxic in-dustrial compounds that could achieve the sameobjective. Military medical care providers need tobe well-informed of the current chemical warfarethreat in environments in which they may be calledto serve. They should also be familiar with socio-logical and psychological factors motivating the useof such weapons in a battlefield or terrorist scenario.

Chemical warfare agents do not need to be le-thal to be disruptive. It is not difficult to envision ascenario where medical practitioners may be thefirst to observe and recognize the effects of chemi-cal exposure—in the absence of warnings from theintelligence community. Few physical indicators ofchemical attack may be evident, other than the ini-tial observation of unusual signs and symptoms.This scenario could occur when new agents, forwhich there may be no environmental monitoring,are used. An increased incidence of symptoms con-sistent with nerve, vesicant, blood, or respiratoryagent exposure should raise immediate suspicionof poisoning, even among presumably protectedtroops. The possibility of combined use of chemi-cal and biological warfare agents should also beconsidered.

Offensive use of chemical agents continues to beattractive to some nations, for chemical agents canbe dispersed over large areas and can eventuallypenetrate even the most well-defended positions.

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The Chemical Warfare Threat and the Military Healthcare Provider

They can be employed against specific targets, in-cluding headquarters control centers and, depend-ing on the agent or combination of agents used, theeffects can be immediate or delayed incapacitation,disorientation, or death. The psychological impactis ever-present, even among well-seasoned and-trained troops equipped with full barrier protec-tion. Many of the more common classic chemicalagents—which are generally believed favored bypossessor states—can be produced inexpensivelyand quietly, and they can be stored indefinitely.Their minimal cost has earned chemical warfareagents the appellation "the poor man's atomicbomb."

Although treaties dealing with control or elimi-nation or both of classic chemical weapons may

reduce the danger that chemical warfare agentswill ever be used, difficulties in verification andin controlling the manufacturing, acquisition, andstorage of precursor chemicals make chemicalwar a continuing concern for the U.S. government.Chemical proliferation has not decreased. SaddamHussein's use of chemical warfare against the Kurdsin 1988 demonstrates how readily such weaponscan be used, even within the confines of one'sown country. The 1994 and 1995 incidents involv-ing the Aum Shinrikyo cult's use of sarin (ie, thenerve gas GB) to cause fatalities and disruption inMatsumoto and in the Tokyo subway system dem-onstrate how easily a terrorist organizationcan quietly produce and use a classic chemicalwarfare agent.

THE CHEMICAL THREAT AND ENEMY CAPABILITY

The term "chemical threat" centers on enemy ca-pability. The term capability encompasses1

• the availability and supply of specificagents;

• the delivery system or systems that wouldbe used in different battle situations;

• the facilities to produce these agents andmunitions;

• plans and procedures for the employmentof such weapons, including training for thedelivery and handling of such weapons;

• protection of a nation's own forces againstspecific agents; and

• the national will to use such weapons.

Although international disapproval may discour-age a country from using chemical agents, the ag-gressor nation may finally decide that protecting itsnational interests and survivability is more important.

An active research and development program onagents and delivery mechanisms supports the no-tion of operational use. Chemical warfare munitionsare particularly important, for weapon systemsmust deliver agent to the target and distribute thatagent with maximal effective contact. Successfulchemical warfare munition use must also be com-bined with meteorological assessment capabilities.For example, sarin, a highly volatile agent with littlepersistence on the ground, must be delivered un-der specific environmental conditions and in atimely manner that would allow greatest humancontact for optimal effectiveness. Ideal conditionsand carefully developed delivery systems are not

always necessary, however: Iraq simply pushedcontainers of chemicals out of aircraft during theIran-Iraq War.

Ordinarily, an enemy with chemical warfare ca-pability will be well equipped for chemical warfareprotection; they will have defined procedures ondecontamination, individual and equipment protec-tion, and detection and surveillance. Since chemi-cal warfare agents are nonselective in their humantargets and dangerous for the user as well as theenemy, they require that offensive and defensiveprograms be developed simultaneously. Specialmilitary teams (eg, logistical, medical, and chemi-cal corps teams trained to operate in a chemicalenvironment) and the ability to monitor meteoro-logical conditions are characteristic of nations withoffensive or defensive programs or both. In the as-sessment of enemy capability, chemical stockpiles,production capacities, and the control of use areevaluated when an offensive or a defensive postureis being determined. This is not easily accom-plished, since industrial plants that are manufac-turing products with peaceful applications may becapable of having their manufacturing processesredirected toward chemical agent production.

In a changing world, where the traditional East-West conflict has subsided in the face of steadilyincreased chemical agent proliferation among manyThird World nations, the chemical threat appearsto be increasing from smaller nations or politicalsplinter groups with little or no sophisticatedchemical warfare industrial capability. Hence wemust be prepared for chemical agent attack fromterrorist elements, and for crude delivery systems

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as well as highly developed offensive chemicalwarfare operations. Political instabilities andchanges toward radicalism only heighten the dan-gers and concerns that defensive programs can beconverted to offensive efforts, and, although clas-

sic chemical warfare agents are harder to produceand stockpile in large quantities without being no-ticed, small amounts of some older agents can bemanufactured in relatively crude laboratories andused to create disruption.

THE STATUS OF CHEMICAL PROLIFERATION

Until 1987, when the Soviet Union admitted forthe first time that it possessed an offensive chemi-cal warfare capability, the United States was theonly publicly declared state capable of conductingchemical warfare. In July 1988, long after a UnitedNations commission had confirmed Iraqi use ofchemical agents (mustard and nerve agent) againstIran (a flagrant violation of the 1925 Geneva Proto-col, which Iraq had signed in 1931), Iraq also de-clared an offensive capability. Apart from the threenations mentioned, estimates of countries that pos-sess chemical agents, and the nature of the agentsthey possess, must rely on sources other than offi-cial statements. Given this, it is not surprising thatpublished lists of states with chemical warfare ca-pability have varied widely. However, a key trendin chemical warfare capability over the past 20 yearsis evident: an increasing number of states are likelyto possess such weapons.

Chemical Warfare Capabilities of Nations

The magnitude of world interest in offensivechemical warfare capability was made evident dur-ing an open hearing of the U.S. Senate Committeeon Governmental Affairs on 9 February 1989, whenWilliam H. Webster, former Director of Central In-telligence, presented a list of weapon states. Theconfirmed chemical weapon possessor states werethe United States, the Soviet Union, Iraq, and Iran.France has subsequently declared a chemical war-fare capability, bringing the number of possessornations to five. Countries currently suspected ofpossessing chemical weapons or in the process ofacquiring them are identified in Exhibit 4-1. Sev-eral other nations are being closely monitored forsigns of an acquisition program.1

An article in the March 15, 1991, issue of TheWashington Post2 described the latest annual reportof the Office of Naval Intelligence, listing 14 nationswith "an offensive chemical-warfare capability"; thelist included Egypt, Israel, Pakistan, and South Ko-rea, 4 nations that receive large quantities of mili-tary aid from the United States. Four additionalnations (Saudi Arabia, Indonesia, South Africa, andThailand) were purported to possibly possess such

a capability, and then more nations were believedto be in the process of developing or seeking to de-velop chemical weapons. Interestingly, this list con-flicts with a U.S. Department of Commerce list thatdoes not list the strong trade partners of South Ko-rea, Indonesia, and Thailand as having definite of-fensive capability. In a 1993 U.S. House of Repre-sentatives Committee on Armed Services report, 31nations were mentioned as possessing or having theability to develop offensive chemical weapons.3

Offensive chemical warfare capabilities dependon such factors as chemical agent quantities, typesof agents weaponized, modes of delivery, doctrinefor use, means of self-protection, and other consid-erations that together characterize the total threatposed by a chemical warfare-capable state. Suchdetailed analysis of the threat posed by each pos-sessor state is beyond the scope of this chapter, andinterested readers should review classified andunclassified sources for each nation.

A general idea of the classic agents was providedby the Soviets when chemical armaments were dis-played for the first time to Western visitors in 1987,and later by Iraq when its arsenal was inspected.The Soviets showed a wide variety of chemicalweapons delivery systems that could carry blister-ing agents (mustard and Lewisite), nerve agents(soman, sarin, and VX) or the riot control agent CS(2-chlorobenzalmalononitrile). Some of these agentswere thickened to increase battlefield deposition andpersistence (see Military Chemical Agents, below).

United Nations weapons inspectors, on gainingaccess to Iraq's arsenal in 1991, found primarilysulfur mustard, sarin (and a sarin analog, GF), andanother nerve agent, tabun.4 The Iraqi chemicalwarfare development program was well developed,and included experimentation with VX. Far beyondpushing barrels out of helicopters, the sophisticatedIraqi chemical weapons delivery systems now in-cluded aerial bombs, artillery rockets, artilleryshells, cluster bombs, and mortars. Seventy-fivechemical warfare ballistic missile warheads werealso discovered, filled with sarin/GF mixtures orbinary nerve agent (in binary systems, two indi-vidually less-toxic reagents are mixed in the weaponat the time of use to form the agent).

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EXHIBIT 4-1

CHEMICAL WARFARE CAPABILITIES OF NATIONS

Exhibit 4-1 is not shown because the copyrightnot allow the Borden Institute to grant permission tjamedia. The current user must apply to the publishillustration in any type of publication media.

Dermission granted to the Borden Institute, TMM, doesother users and/or does not include usage in electronic

r named in the figure legend for permission to use this

Adapted with permission from Burck G, Flowertree CC. International Handbook on Chemical Weapons Proliferation. New YorkNY: Greenwood Press; 1991: 164-165.

Prior to its destruction, Iraq's primary chemicalwarfare agent production facility at Al Muthanna,Iraq, produced thousands of tons of agent. Thecomplex included well-built, underground, bunker-type complexes, billed as sites for pilot plantsfor pesticide production but apparently capableof VX production. Another facility served as aninhalation chamber for making lethality estima-tions. Two other sites were built at Fallujah, Iraq,to make chemical precursors for use at the AlMuthanna plant, although one of the Fallujahplants, while containing stored agent precurs-ors (for VX, GB, and HD [mustard]), was adaptedfor malathion pesticide formulation. Theseexamples illustrate why it can be difficult, withlimited inspections or information from opendeclarations, to distinguish facilities designed forthe chemical industry from those for munitionsgeneration.

These chemical manufacturing facilities are onlypart of Iraq's chemical warfare capability. Iraq, likeLibya, also invested heavily in the development of

facilities for the production of indigenously gener-ated delivery components.

The current development of offensive chemicalwarfare capabilities varies among the possessorstates and is now particularly dynamic. First, theUnited States and Russia, which has inherited thechemical weapons arsenals of the Soviet Union,have embarked on a program to radically reducethe chemical agent stocks held by both sides by thelate 1990s. Second, in January 1992, some 125 na-tions signed a treaty, formulated over 24 years, atthe Chemical Weapons Convention in France, call-ing for the prohibition of the production, storage,use, and transfer of chemical weapons; and for theelimination of chemical warfare arms and produc-tion facilities.5 By January 1993, 130 nations hadsigned the treaty, and more are expected to follow.

During the 1980s, some nations vastly increasedtheir development of offensive chemical capabili-ties, particularly in the Middle East, where chemi-cal warfare capability substitutes in some respectsfor a nuclear weapons capability. A rapid transition

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from nascent development programs to fullweaponization occurred in Iraq, Syria, and Libya,and Iraq unleashed chemical weapons against Iranin 1984. Iraqi use of mustard and nerve agents con-stituted the first full-scale use of chemical weap-ons in battle since World War I.

The effective elimination of the Warsaw Pact andthe dissolution of the Soviet Union have greatlydiminished and reconfigured the overall chemicalthreat from that part of the world. The exportationof Soviet technology has been a continuing process,and it is likely that the chemical weaponry and tech-nological know-how was well disseminated to de-veloping nations. The Russians have declared achemical agent stockpile of about 40,000 tons(higher than the 30,000 of the United States).67 Asof 1996, it appears that all of the former SovietUnion's chemical weapons containers and munitioncomponents are maintained at seven sites in Rus-sia. As is done in the United States, most of the agentis primarily stored in nonweaponized containers;the weaponizable portion appears to consist entirelyof soman- and VX-like nerve agents, sulfur mus-tard, and Lewisite. Mixed preparations are commonin the arsenal. With all chemical warfare agentsunder a single central control, the possibility ofunauthorized weapons proliferation by former So-viet border nations, several of which are politicallyunstable, should be greatly diminished, althoughthe possibility of chemical weapons proliferationthrough theft under a climate of economic turmoilremains real. Uncertainties regarding dispersal, andmanagement procedures concerning that stockpile,suggest that some chemical weapons could be lostwhile awaiting destruction.8

The Soviet military appeared to have investedconsiderable effort toward the development offorces capable of operating in a chemical warfareenvironment.9 According to the U.S. Defense Intel-ligence Agency, Soviet facilities associated with theproduction, testing, and storage of chemical or bio-logical agents or both continued to expand through1987.10 Today, a variety of chemical warfare deliv-ery systems are available to Russian military forces,including artillery, bombs, free rockets, ballisticmissiles, and cruise missiles.

The origin and nature of the overall chemicalagent exposure threat to U.S. troops changed con-siderably during the 1980s. Although the threat ofchemical warfare confrontation with former War-saw Pact nations appears eliminated, the prolifera-tion and use of chemical warfare agents within un-stable sectors of the Third World has raised greatconcern regarding the potential for future use of

chemical warfare agents both with respect to openconflicts and to terrorist activities. For Third Worldnations, chemical weapons are less expensive andeasier to acquire, and are a more credible threat thannuclear weapons. The adaptation and incorporationof chemical agent-containing munitions to conven-tional or missile delivery systems can give a weakernation a military threat with which to counterbal-ance that of neighbors that possess a greater con-ventional capability.

Nations may initially acquire a limited chemicalwarfare capability through the transfer or purchaseof bombs or artillery-compatible chemical warfareshells. In some cases, unweaponized agent mayhave been transferred.11 Alternatively, nations mayinvest in the development of chemical industriesthat involve the manufacture or acquisition ofchemical precursors or intermediates. In this way,wealthier nations (eg, Iraq, Libya) or those under astrong, perceived threat (eg, Syria) may increasetheir chemical warfare potential by acquiring thetechnology and facilities to synthesize agents andincorporate them into munitions that are compat-ible with existing or newly acquired delivery sys-tems. Industrial compounds such as organophos-phates (pesticides), phosgene, chlorine, and cyanideare not difficult to obtain.

Economic factors such as wealth, profit incen-tives, international debt, and isolation can contrib-ute to the proliferation of chemical warfare capabili-ties. For example, oil-rich nations ruled by dictators(eg, Libya, Iraq) have been able to use their profits toacquire expensive delivery systems such as ballisticmissiles and long-range bombers, along with asso-ciated support aircraft.1213 When shunned by ma-jor arms-systems producers such as the UnitedStates, Britain, France, and Russia, the oil-rich na-tions have approached other Western sources orthose in less-developed nations, some of themdeeply in need of foreign capital, such as Brazil,Chile, Argentina, Yugoslavia, Israel, Egypt, NorthKorea, or the People's Republic of China.121G

Inevitably, there is a trickle-down effect in thearms world, as aging munitions and weapons sys-tems are replaced and move from the major weap-ons producers to their Third World client states, andfrom the latter to other nations. For example, theSoviet Union probably supplied a chemical warfarecapability to Egypt,11 which, in turn, first suppliedSyria,15 which, in turn, supplied Iran.16 It should benoted that some weapons systems, especially fromthe former Eastern Bloc countries, were designedto operate in a chemical warfare theater.9 As notedearlier, a defensive capability is generally held to

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be prerequisite to an effective offensive chemicalwarfare capability.

The profit motive has driven many private in-dustries to supply Iraq and Libya with technology,infrastructure, and chemical precursors for the syn-thesis of nerve and blister agents in large volume,and the manufacture of artillery shells and bombsrequired for their delivery. Until recently, West Ger-man government export control was minimal, re-sulting in the involvement of some 86 German firmsin Iraq's development of chemical and nuclearweapon capabilities and ballistic missile design. Aconsiderable number of companies in Austria, Brit-ain, France, Italy, Switzerland, and the United Stateswere also involved in these efforts. Products in-cluded chemical agent production plants and pre-cursor compounds, computer systems, machinetools, casting and milling technology and facilities,weapon and ammunition production facilities, mis-sile technology and "super gun" components.16 Com-mercial dissemination of chemical warfare capabili-ties will be a continuing problem in the years ahead.

International Agreements and Verification

Despite such uncertainties, a chemical weaponsreduction agreement17 was reached in 1990 betweenthe United States and the Soviet Union that will (1)effectively stop chemical weapon production and(2) reduce each nation's chemical agent stocks to avalue of 5,000 metric tons by the year 1999 (by theend of the year 2002, this number will fall to 500tons). Destruction of the remainder is contingent ona commitment for similar, total chemical warfarestock elimination by other chemical warfare-ca-pable nations.1819

On May 13, 1991, U.S. President George Bushfurther advanced his 1989 plan before the UnitedNations to destroy 98% of the U.S. stockpile in thefirst 8 years under a new, proposed treaty. Underits conditions, he pledged (1) to destroy all U.S.chemical weapons within 10 years and (2) never touse chemical weapons again.20 (However, antici-pated difficulties in chemical weapon demilitariza-tion and destruction may prolong the presence ofchemical weapon depots.) This message sent a clearchallenge to other powers to eliminate chemicalweapons. The United States ratified the treaty on24 April 1997, which was a few days before thetreaty went into effect. Although signed by nearly160 nations, it must still be ratified by most of thosenations. The treaty still leaves in doubt the devel-opment and use of chemical warfare agents by de-veloping nations or nonsigners of such agreements

(most notably Libya, Iraq, and North Korea).Chemical warfare treaty ratification by nations suchas Iran, given the behavior of its neighbor, Iraq, mayprove to be understandably difficult in the short term.

Reluctance by possessor states to employ chemi-cal weapons, which could be termed "the chemicalwarfare threshold," has seemed to be relatively highsince World War I. However, the Iraqi precedent,the ineffective world response to Iraq's use ofchemical warfare, and the perceived effectivenessof this use all suggest that the chemical warfarethreshold has been substantially lowered. Thegrowing list of states motivated, for reasons of of-fense or deterrence, to develop relatively low-tech-nology, low-cost weapons of mass destructiongreatly increases the likelihood that military per-sonnel will have to contend with casualties ofchemical warfare.

Finally, the problem of verification of treaty com-pliance continues to be difficult even with on-siteinspections. The former Director of Central Intelli-gence, William H. Webster, stated on 15 October 1988:

After all, any country with a petrochemical, pesti-cide, fertilizer, or pharmaceutical industry has thepotential in terms of equipment, raw materialswarfare, and technical expertise to produce somechemical agents. Without direct access to such fa-cilities, it is nearly impossible to know whetheractivities being undertaken are of a commercial ora military nature.21(p9)

This concern was reiterated in congressional testi-mony following the Persian Gulf War.18

Terrorism

Finally, no threat assessment would be completewithout addressing the terrorist dimension. Terror-ism may derive from clandestine, state-directed ini-tiatives22 or, more commonly, from small splintergroups with special interests or agendas. Groupswith training and financial backing need only to setup small laboratories to make chemical or biologi-cal warfare agents. For example, while investigat-ing Red Army faction activities in 1980, Frenchpolice uncovered in an apartment a clandestinelaboratory capable of producing botulinum toxin.23

This suggests that state-sponsored terrorism couldserve as a conduit for the testing of the products ofrapidly emerging biotechnology techniques. It alsoplaces healthcare providers in a position in whichthey may be the first to encounter and evaluate thedangers of new and emerging threats. Also notableis the successful manufacture of a military nerve

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agent by able university students recruited by AumShinrikyo. Psychological manipulation and reli-gious zeal were combined to support the terroristactions of this organization, which was well fundedby its members.

Chemical and pharmaceutical industries con-tinue to spread around the world, providingunsponsored terrorist groups access to precursorsand chemicals. Compounds such as chlorine, phos-gene, and cyanide are commonplace, and theft ofsuch materials has been reported.24

In addition to terrorist actions, accidents willoccur as manufacturing with potent industrialchemicals becomes widespread. Although indus-trial compounds are not traditionally classified aschemical agents, they are lethal and potent (eg, thedisaster in Bhopal, India, which is discussed laterin this chapter). Poor economic conditions mayalso promote theft of agents and their chemicalprecursors and illegal transfer of weapons—notonly by international brokers but also by industrialworkers.

MILITARY CHEMICAL AGENTS

Military chemical agents are characterized ac-cording to several features. Among them arethe nature of their use, their persistency in thefield, and their physiological action. Toxic chemi-cal warfare agents are capable of producing inca-pacitation, serious injury, and death. These agentsare further characterized by their physiological ac-tion and are discussed in detail in their individualchapters. Table 4-1 lists the major chemical warfareagents.

Nerve agents such as tabun (GA), sarin (GB),soman (GD), and VX inhibit acetylcholinesteraseenzyme throughout the body, notably in the ner-vous system. This causes hyperactivation of cho-linergic pathways, causing convulsive seizures andrespiratory failure. VX differs from its "G" agentcounterparts in its low volatility.

Vesicants, such as sulfur mustard (HD) and thearsenical Lewisite (L), cause irritation and vesica-tion of the skin and mucous membranes, notablyof the lungs. Mustard exposure to the skin is insidi-ous, causing no immediate discernible effects to theskin for several hours; blistering occurs 12 to 24hours after exposure.25 Although mustard causesfew deaths, its vesicating properties are incapaci-tating, and casualties require 1 to 4 months of hos-pitalization. Lewisite blisters heal within severalweeks.

Pulmonary toxicants, such as phosgene (CG)and diphosgene (DP), injure the respiratory tract,causing suffocation. Phosgene intoxication rapid-ly leads to pulmonary edema. The initial effectsof eye exposure resemble those of tear gas; se-vere pulmonary edema follows in about 4 hours,eventually leading to death. It is notable that bothphosgene and elemental chlorine (an immediatephosgene precursor), which can cause pulmonaryedema and hemorrhaging, are industrial com-pounds.

Finally, cyanides such as hydrogen cyanide (AC)and cyanogen chloride (CK) both release cyanideions in the body. Lower doses cause headaches,weakness, disorientation, and nausea; higher dosescause circulatory effects, seizures, and respiratoryand cardiac failure. While often attributed to itsblockade of energy metabolism, the mechanisms ofcyanide intoxication remain unclear and may in-clude cellular targets more sensitive to inhibitionthan cytochrome oxidase.

The most common agents in modern arsenals arevesicants and nerve agents. Cyanides and pulmo-nary toxicants are thought to be represented in somestockpiles, but are typically less toxic and more dif-ficult to employ because of their physical charac-teristics. Some cyanides and pulmonary toxicantshave specific characteristics that make them appro-priate for military use, such as rapid rate of action,very low persistency, and the ability to penetrateor damage protective equipment.

Other chemicals present in military arsenals in-clude incapacitating agents, which produce physi-ological or mental effects, or both, rendering indi-viduals incapable of performing their assignedduties. Recovery may take several hours to severaldays, although intensive medical treatment may notbe required. Riot control agents produce intenseeffects, such as irritation of the skin, eyes, and respi-ratory tract, but recovery is normally rapid when ex-posure is terminated. Unfortunately, little is knownabout the long-term effects of many of these agents,and this is an area of increasing medical concern.

Chemical smoke agents are used to obscure ob-jects or areas from observation or from engagementby weapons with electro-optical control systems.They are usually not toxic in field concentrations,but may cause eye or respiratory irritation in higherconcentrations. Some smokes have adverse chronicexposure effects. Other compounds with military

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TABLE 4-1

CHEMICAL WARFARE AGENTS


U.S. Army Code Agent

Cyanides

AC

CK

Nerve Agents

GA (Tabun)

GB (Sarin)

GD (Soman)

GFVX

Lung Toxicants

CG (Phosgene)

DP (Diphosgene)

Vesicants

HD (Mustard)

L (Lewisite)

HL

Incapacitating Agent

BZ

Tear Gases

CN

cs

Vomiting Gas

DM (Adamsite)

Hydrogen cyanide

Cyanogen chloride

Ethyl N,N-dimethyI-phosphoramidocyanidate

Isopropyl-methylphosphonofluoridate

1,2,2-Trimethylpropyl methylphosphonofluoridate

Cyclohexyl-rnethylphosphonofluoridate

o-Ethyl S-[2-(diisopropylamino)ethyl] methylphosphonothiolate

Carbonyl chlorideTrichloromethyl chloroformate

bis-2-Chloroethyl sulfide

2-Chlorovinyl dichloroarsine

Mustard-Lewisite mixture

3-Quinuclidinyl benzilate (QNB)

2-Chloro-l-phenylethanone

2-Chlorobenzalmalononitrile

10-Chloro-5,10-dihydrophenarsazine

applications include agents used in flame warfare,such as thickeners for napalm and incendiary ma-terials, and herbicides (defoliants).

Thus far, discussion has centered on chemicalcompounds with a military application. Otherhighly toxic industrial chemicals also pose a poten-tial risk to the military. The disaster in Bhopal, In-dia, in December 1984, when an estimated 8,000 per-sons died and another 30,000 were injured frombreathing methylisocyanate and chlorine releasedin an industrial accident, is just one of many ex-amples of the devastating effect of poisonousgases.26

Chlorine and phosgene are industrial com-pounds that have been and could again be used asmilitary weapons by an enemy with access to suchmaterials, and medical personnel should also beprepared for such emergencies should military mis-sions be in close proximity to industrial plants. Thefirst large-scale use of a chemical compound inYpres, Belgium, on 22 April 1915, the beginning ofchemical warfare as we know it today, involved thedispersal of 180 tons of chlorine from over 5,700 can-isters by the German forces. During that war, thelist of chemical agents was expanded to includemustard, phosgene, adamsite, and cyanide.

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TACTICAL AND STRATEGIC USE OF CHEMICAL WEAPONS

Delivery of chemical agents can be accomplishedby a full range of weaponry. Liquid agents may bedispensed from land mines and spray tanks to ar-tillery projectiles, aerial bombs, rocket and missilewarheads, or even cruise missiles. This means thatall battlefield areas, from front lines to rear reserves,are vulnerable to chemical warfare attack, and thatmedical practitioners should be fully prepared totreat chemical warfare casualties from a variety oflocations. It is also important to note that, while thissection largely focuses on the use of chemical war-fare agents on the battlefield, medical personnelmust also be prepared for the possibility of isolatedand spontaneous chemical attacks on both militarypersonnel and civilians in areas subject to low-in-tensity conflict and isolated acts of terrorism.

To be effective, chemical agents must be effi-ciently dispersed over their intended targets. Mostapplications call for large-scale agent distributionover large target areas that are occupied by, or maybe of interest to, military units. For example, docu-ments recovered from the former German Demo-

cratic Republic called for Warsaw Pact forces toemploy heavy chemical warfare attacks early in anyconflict with the West.23 Considerable quantities ofan agent may have to be applied to ensure goodcoverage in the face of such factors as wind, heat,and agent volatility, and surprising the enemy soas to find them unprotected (eg, unmasked).

Chemical Agent Delivery Systems

The four methods of delivering chemical agentsare explosive release, bulk release, base ejection, andspray delivery (Figure 4-1). The most commonmethod is explosive release. Bursts from individualexplosive munitions are, effectively, point sourcesfor chemical warfare dissemination. Chemical war-fare artillery shells, which serve as smaller pointsources, could be laid down in a grid to cover a largearea. The same could be accomplished with fewermissiles, which carry larger payloads and havelonger ranges. Agents can also be delivered frommultiple explosive point sources using submuni-

Fig. 4-1. Four modes of chemical agent release, (a) Explosive-release devices are predominantly represented amongthe major chemical warfare arsenals. While some agent is lost to decomposition, their simplicity makes these theweapons of choice. Point-source explosives are single detonation devices, while line-source munitions release a se-ries of time-delayed explosions that lay agent toward the end of the trajectory, (b) Bulk-release munitions spill agentinto the airstream of the projectile, (c) Base-ejection devices are relatively uncommon owing to their cost and com-plexity. Like explosives and bulk-release devices, these munitions can be carried on longer-range missiles, (d) Spraydelivery can be used to achieve large-area coverage, such as that required for terrain denial. However, because ofaircraft vulnerability, spray delivery is generally limited to application on undefended territory or against a poorlydefended foe.

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tions to cover a larger area or, if detonated in se-quence, to lay down the agent along a trajectoryline. Such line deliveries may be delivered directlyover the target, or upwind of the target, preferablyperpendicular to the wind.

Bulk release, base ejection, and spray deliveryalso deliver chemical warfare agents along trajec-tory lines. In bulk release, the forward covering, or"skin," of a warhead is blown off, exposing agentto aerodynamic breakup by high-speed air flow. Inbase ejection, an explosive charge causes an inter-nal pistonlike action to force the agent out of theback of the warhead—either through small aper-tures, aerosolizing it, or into a high-speed airstreamfor aerodynamic breakup. Explosive, bulk release,and base ejection methods are primarily suited forthe dispersal of liquid chemical agents. For the fewsolid agents such as the tear gas CS and the inca-pacitating agent BZ (3-quinuclidinyl benzilate), ef-fective aerosolization is often achieved by pyrotech-nic munitions.

Spray delivery is more efficient than the otherthree methods in providing a very fine aero-solization (average droplet diameter = < 5 urn) ofagent, which can be inhaled far down into the lungs.This method is particularly suited to the deliveryof toxins, which require deep inhalation and whichdiffer from most chemical agents in that they are

solids and do not vaporize. Spray delivery requiresslow speeds and low altitudes, conditions that ren-der aircraft particularly vulnerable to attack. Spraytanks could also be mounted on trucks or boats, andunmanned aircraft could be designed to performthe task. The increased vulnerability of spray-de-livery systems makes their use more likely againstunarmed or poorly equipped opponents, or on care-fully targeted sites under cover of surprise. Spraydelivery could also be applied to closed ventilationsystems in more focal applications.

From a tactical military standpoint, explosivemunitions, the dominant mode of chemical agentdelivery, vary with respect to effective agent deliv-ery. Disregarding differences among chemical war-fare agents for now, Figure 4-2 describes chemicalagent dissemination with respect to explosive mu-nitions in further detail and illustrates importantconsiderations regarding the chemical agent dy-namics and toxicity. Explosion of a chemical agentshell, at ground level or some height over the tar-get site, generates two products: vapor and drop-lets. Droplets (average diameter range =100 urn to1 mm for pure agents) will fall to the ground in a finerain to coat the target surface with liquid.

Agent vapor, the greatest threat for inhalationalintoxication, derives from three sources. First, agentvaporizes from explosive burst energy. This will

Fig. 4-2. Agent vaporization increases inproportion to energy sources such as heatfrom explosive charges or from ambientheat (as measured by air or surface tem-peratures). Vapor persistence is then deter-mined by weather factors such as wind andhumidity. Hydrolysis rates are affectedby factors such as temperature and solu-bility. Agents show characteristic hydroly-sis rates in water, and water vapor, as de-scribed by humidity, may cause significanthydrolysis of vaporized agent. The vesicantLewisite, for example, shows relativelyrapid hydrolysis in water vapor, while thenerve agent VX is more resistant to hy-drolysis.

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vary with shell design and specific agent payload.Important shell design factors are shell casing thick-ness, shell casing material, and the agent-to-bursterratio. Second, additional vapor will be generatedas falling droplets vaporize. Heat from the explo-sion dissipates quickly, and ambient air tempera-ture is the most important factor in driving thisvolatilization. Third, the liquid coating of agent onthe ground evaporates, ground temperature beingan important factor. Vapor produced by the firsttwo, explosive energy and droplet vaporization, iscalled primary vaporization, while that rising fromthe ground is secondary.

Considering these phenomena, we can ap-preciate, for example, the differences in agent threat(liquid persistence and deposition vs vaporization)in scenarios wherein chemical agent shells aredropped on a desert area during different times ofthe day. The influence of wide environmental tem-perature fluctuations over the 24-hour cycle, com-bined with the agent used (see below) can make alarge difference: we can expect increased surfacedeposition and skin-contact threat during coolnights, and a considerably increased inhalationaltoxicity threat during the heat of the day.

Successful employment of chemical agents is in-fluenced by many variables. Most notable amongthese is the weather, in that the agent is transportedby the wind and air currents when released as avapor or an aerosol. Unfavorable meteorologicalconditions frequently preclude successful agentdeployment owing to the inordinately high num-ber of weapons used. Once deployed, the persis-tence of liquid contamination is affected by tem-perature, sunlight, wind action, and rainfall.

Physical Properties of Chemical Agents

Toxicity mechanisms aside, the physical proper-ties of the agent itself and its formulation alsopresent similarly important threat considerations.Selection of agents and agent formulations can beused to effect differential impacts with respect todroplet size and liquid deposition, agent persis-tence, and agent volatility. The classic chemicalwarfare agents have a tremendous range of volatil-ity (Table 4-2), and volatility can be a determinantin deciding which agents will be used.27 Agents suchas hydrogen cyanide and sarin are relatively vola-tile; they present an immediate, but short-lived,threat. These agents are referred to as nonpersistent(ie, they vaporize rapidly after delivery). Alterna-tively, agents such as VX and sulfur mustard tend

TABLE 4-2

COMPARATIVE VOLATILITIES OFCHEMICAL WARFARE AGENTS

Agent Volatility (mg/tn3)

Hydrogen Cyanide

Sarin (GB)

Soman (GD)

Sulfur Mustard (HD)

Tabun (GA)

VX

1,000,000

22,000

3,900

900

610

10

Approximate amount of agent (in milligrams) that 1 m3 of aircan hold at 25°C.

Adapted from US Departments of the Army, Navy, and AirForce. PotentiaJ Military Chemical/Biological Agents and Com-pounds. Washington, DC: Headquarters, DA, DN, DAF; 12 Dec1990: Appendix B, Table B, pp 95-97. Field Manual 3-9. NavalFacility Command P-467. Air Force Regulation 355-7.

to fall largely in droplets, with less vaporization,and remain on exposed surfaces for a long time.These agents are called persistent.

Formulation is also used to manipulate the fateof the agent. Soman, VX, Lewisite, and sulfur mus-tard can be mixed with high-molecular-weightthickeners to increase droplet size and thereby de-crease primary vaporization. Such additives aregenerally used to promote efficient agent deposi-tion on the target site. Thickeners can also increaseagent persistence and may hamper decontamina-tion efforts.

Nonpersistent Agents

In tactical use, the threat of nonpersistent, vola-tile agents such as hydrogen cyanide or sarinis greatest to the respiratory systems of unpro-tected soldiers. A sudden, heavy bombardment ofthese agents may effect many casualties if un-masked soldiers are caught by surprise. When usedagainst an unprotected force, nonpersistent agentsare particularly effective in generating casualties,thereby creating breakthrough points in enemyfront lines. The successful use of nonpersistentnerve agent was demonstrated by Iraqi counterat-tacks against Iranian forces during 1988.23 Nonper-sistent agents can also be used to slow down the

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enemy by forcing him to wear protective equip-ment. Finally, they can also circumvent the enemy'sprotection against conventional high-explosivemunitions and may be used in night attacks to ha-rass the enemy.

Persistent Agents

Given favorable weather conditions, the use ofpersistent agents such as mustard and VX may posea threat for many days. Such agents can deny orinterfere with enemy occupation of terrain or useof equipment and, in theory, could be used defen-sively to protect vulnerable flanks. However, al-though they can slow down enemy movement, theycan also hamper the movement of friendly forcesthrough a contaminated area. Delayed casualtiesmay occur even among protected troops operatingin a contaminated area for an extended period.Hence, persistent agents may not be the agents ofchoice when occupation of territory by friendlyforces is imminent.

Chemical land mines may be used in conjunc-tion with military barrier systems to complicatebreaching or clearing the barriers by dispersingpersistent agent. The mines are typically based onhigh-explosive mine designs, with several poundsof agent being substituted for most of the explo-sive charge. High-explosive land mines will causecontaminated open wounds, primarily on lowerextremities, that must be properly decontaminated;this could be more difficult when persistent agentsare used.

Because of its action, sulfur mustard blisteringagent offers strategic benefits besides those consid-ered above. Sulfur mustard was used very effectivelyboth during World War I and during the Iran-Iraq Warto generate thousands of casualties. Although deathsamong unprotected sulfur mustard exposure vic-tims are relatively few,28 mustard injuries can tie upmedical treatment facilities with patients. Whilesurvivors of other agents stabilize relatively soonafter exposure, mustard lesions demand months ofmedical care. This was the fate of many thousandsof Iranian recruits, who were unprepared or poorlyequipped when they were exposed to sulfur mus-tard agent.

Underscoring the importance of ambienttemperature and climate, we should note that per-sistence can change greatly with temperature;sulfur mustard volatility increases nearly 40-foldbetween 0°C and 40°C: from 75 to 2,860 mg/m3. Al-though always present, the threat of respiratory in-

toxication from sulfur mustard is considerably greaterat higher temperatures, although its persistence is re-duced.

Rapidity of action also factors into agent selec-tion. Volatile agents such as cyanide and sarin canact very swiftly, primarily via the respiratory tract.In general, nerve agent effects follow immediatelyafter exposure, culminating in seizures and deathwithin a few minutes of inhalation, cutaneous dos-ing, or both. Other agents, such as mustard,Lewisite, and phosgene act only after a delay. Forexample, both the blistering and the edematous ef-fects of skin exposure to sulfur mustard occur onlymany hours after exposure.

Choice of Agent and Delivery System

By selecting the appropriate agents, formula-tions, and delivery systems, a well-equipped mili-tary will be in a better position to achieve its tacti-cal objectives. U.S. Army Field Manual (FM) 3-10,Employment of Chemical Agents, discusses howchemical munitions could be used separately or in-tegrated with conventional weapons. Chemicalwarfare agents can be used to cause casualties, ha-rass the enemy, and hamper or restrict the use ofterrain. Although an offensive capability no longerexists, FM 3-10 provides useful information on howchemical warfare agents can be used on the battle-field.29 Brigadier General Augustin M. Prentiss, aChemical Warfare Service officer, describes in hisclassic 1937 book, Chemicals in War, the offensivetactical uses of chemical agents that were in placefollowing World War I.30

The most militarily significant effects of chemi-cal agents are through inhalation, in that mostagents are more toxic and faster acting by that routeof exposure. Almost without exception, modernarmies are equipped with protective equipment:masks to protect the eyes and respiratory tract, andprotective clothing to prevent skin contamination.However, the very act of donning protective equip-ment is an encumbrance. In hot weather, remainingin protective clothing for more than a few minutescan itself produce casualties. The mission-orientedprotective posture gear (MOPP) that the U.S. Armyissues, which was designed for use in the Europeantheater, can swiftly cause an active wearer to expe-rience heat stress and dehydration under desertconditions.31-32 The British protective counterpart,the MK 4 suit, keeps the wearer cooler by allowingperspiration to evaporate, although the heat stressproblem remains.33

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Detection and Protection

Adequate agent detection capabilities are essen-tial for successful chemical agent defense. AlthoughU.S. Army doctrine prescribes donning full MOPP4 gear if an attack is imminent or in progress, de-tection capabilities permit recognition of the trueagent threat and appropriate reductions to protec-tive posture (ie, MOPP 3 or even MOPP 2). Detec-tion capability for medical teams is essential to pro-vide warning that casualties are contaminated, andto avoid inappropriate assumption of high levelsof protective posture if they are not.

Well-equipped, well-trained troops who applyhigh levels of discipline in using protective equip-ment are not very likely to become chemical casu-alties. Most casualties will have sustained respira-tory injury due to failure to mask properly in timewhen under attack. We can speculate that as thelength of time spent in protective posture increases,the percentages of casualties with skin effects willincrease. Most of these effects will be from failures

in procedure when donning protective clothing andremoving contaminated protective clothing.

Among exposed populations, the range of agentintoxication effects can be expected to correlate withlevels of protective equipment, training, and disci-pline. The healthcare provider should anticipatethat poorly trained soldiers will show an increasedincidence of skin contamination by vesicants, forexample. There will also be a greater need for de-contamination. Civilian populations will generallybe the most vulnerable. Most will have little if anyprotective equipment, and no means of detectingthe presence of agent.

Even with protective equipment, the threat ofagent intoxication is greater for casualties with fa-cial, neck, or chest wounds that may compromisethe integrity of the protective mask seal. Based onwound descriptions, a retrospective analysis34 of2,021 casualties admitted to the Naval SupportHospital in Da Nang, Vietnam, found that maskfailure could have been expected to affect 34% ofthese patients.

RESPONDING TO THE THREAT: MANAGING CASUALTIES

The medical management of casualties, includ-ing triage, decontamination, and specific therapy,is discussed in separate chapters. However, severalpoints need emphasis under a discussion of con-cerns for the healthcare provider.

First, many of the early signs and symptoms pro-duced by chemical warfare agents may resemblethose of a variety of disorders, including stress.Among unseasoned troops, especially those withlimited experience in a chemical environment, psy-chological withdrawal or physical complaints ofpalpitation, gastrointestinal distress, headaches,dizziness, and inattentiveness will present difficultdiagnostic dilemmas for medical personnel on thebattlefield. A clinical awareness of the early signsand symptoms is critically important, but so is anawareness of the medical problems associated withstress. The potential for mass hysteria is also high,even among troops with full individual protection,and the horror of dying from a chemical agent at-tack is widespread. Apprehension will be a majorfactor in the confusion of battle.

To minimize such problems, continuous trainingis required so that soldiers are comfortable donningtheir protective equipment and operating in achemically contaminated environment. Similarly,soldiers must understand the rationale for takingthe nerve agent pretreatment, pyridostigmine, as an

added protective measure, not as a replacement formasking. Such training should involve medical input.

Second, the risk of chemical contamination ofmedical equipment and medical treatment facilitiesis an added threat, and precautions need to be takento ensure that patients are properly decontaminatedbefore being brought into designated uncontami-nated treatment areas. Frontline medics faced withmany casualties can only be expected to adminis-ter lifesaving procedures, such as opening the air-way or preventing further hemorrhage; decontami-nation can be expected to be minimal.

In rear areas, chemical decontamination of openwounds adds substantial complexity to otherwiseconventional wounds, which then require proce-dures different from those ordinarily established fordebridement. Some nations have adopted specialirrigation-suction devices to irrigate and cleanwounds, and air-flow protection methods to mini-mize the risk to hospital staff. The risk of woundcontamination may be higher with low-velocitywounds, when pieces of contaminated clothing ordebris may be carried into the wound and remaindeeply imbedded for a time; this may be a greaterproblem with persistent agents. Therefore medicalprocedures must be well defined, and healthcareproviders should regularly review the steps re-quired in handling a casualty.

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While chemical agents are an occupational haz-ard to the combat soldier, they are also a danger tothe emergency room and surgical staff, who mustrely on their hands and eyes to stabilize and treatthe casualty. Standard surgical latex gloves are notsufficient protection against chemical agents, andthey provide little protection against a vapor haz-ard. Should hospital-based medical personnel incritical specialties become casualties themselves, thehealthcare delivery system will be significantlycompromised. An improperly decontaminated ca-sualty may also pose a risk to other patients.

Third, the patient flow pattern in a chemical en-vironment will be substantially altered. Treatmentrates can be expected to be reduced because of thedecontamination procedures that must be in place.Injuries that will be seen will range from severe tominor, with the latter probably constituting themajority. With some agents, the effects of chemicalinjury may not be readily apparent until after a de-

lay, and this must be considered in the dispositionof the patient. Therefore, the process of medicalevaluation and observation may tax the holdingcapability of a facility.

Finally, the medical logistical requirements willbe increased. It has been stated that up to 40% moretransport is required to move a typical field hospi-tal in a chemical environment, and the fuel neces-sary to power air pumps, special filtration units, andair conditioners is an added requirement.35 Waterrequirements may also be increased in a chemicalenvironment. Medical treatment facility plannersshould recognize the importance of environmentalfactors within a chemical warfare theater. For ex-ample, the MOPP gear may not be designed for theclimatic conditions on the battlefield. Tests haveshown that perspiration compromises the ability ofthe battledress overgarment to protect the wearerfrom chemical agents36 and may actually predisposean individual to injury.32

FUTURE CONFLICTS IN A CHEMICAL ENVIRONMENT

From the standpoint of military strategy, two rea-sons are commonly cited for a combatant to employchemical weapons. First, they can be highly effec-tive when densely applied onto concentrated,largely immobile forces or populations. This factorlargely promoted their use against entrenched trooppositions during World War I. During the Cold War,military strategists anticipated similar intensechemical warfare bombardments from Warsaw Pactforces in the European theater. Second, chemical at-tacks can be initiated at lower levels to encumberan opponent with defensive equipment, or to cre-ate panic and disorder among poorly trained orunprepared troops. Application onto enemy troopsor civilian populations can also have a strong de-moralizing effect.

Two important influences on the decision to em-ploy chemical attacks are weather patterns and userobjectives. Gas dispersal depends on wind speedand direction. If the attacking force is in close prox-imity to the target area, it must use protective gearin the event of wind shift. This handicap can beavoided, if the situation allows, when agents canbe delivered from a remote location by either air orlong-range artillery. The objectives of an attackermay also determine whether chemical warfare willbe employed and, if so, which agents are to be used.Thickened nerve agents and sulfur mustard denyfree access to terrain and are not likely to be usedby forces intent on occupation. Nonthickened nerve

agents are not persistent and could be used by amobile, advancing force.

Western powers had contemplated using chemi-cal weapons during World War II. Sir WinstonChurchill seriously contemplated resorting tochemical warfare should the defense of Britain havebecome desperate.37 Later in the war, U.S. militarycommanders also contemplated the use of chemi-cal agents to counter Japanese fanaticism, which,even during imminent defeat in 1945, caused ex-ceedingly high losses on both sides during islandwarfare (nearly 110,000 Japanese died in the battlefor Okinawa alone). These circumstances led theUnited States to resort to unconventional weaponry(the atomic bomb). With Germany out of the warand the death of President Roosevelt, who had op-posed any first use of chemical weapons, the use ofsulfur mustard and other agents was seriously con-templated during the summer of 1945.38 Based onrecent events and decisions, however, it is unlikelythat an offensive chemical warfare program wouldbe initiated by Western powers. This does not ne-gate the need for a strong defense posture, how-ever, as long as chemical proliferation continues.

Fanaticism shown by Iranian RevolutionaryGuard units may have precipitated Iraqi use ofchemical warfare agents at the end of 1983.Throughout the Iran-Iraq War, Iraq generally usedchemical weapons only when facing probable de-feat with conventional weapons.39 History suggests

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that a cornered and besieged enemy, confrontingtroops intent on inducing complete surrender, couldemploy chemical warfare agents as a final resort oract of vengeance. In 1937, Prentiss stated:

In the last analysis, war is not a sport, but a grimcontest between states for national existence. War

cannot be conducted by any code of sportsmanship,but only by the law of military necessity, howevermuch civilization may deplore the results.31(p699)

Therefore, the United States military must maintaina strong readiness posture in the face of a continu-ing chemical warfare threat.

SUMMARY

The military healthcare provider should be pre-pared to be the first to recognize military or civil-ian casualties of chemical warfare attack. This re-quires an informed understanding of the likelihoodof chemical warfare agent use or threat, and it re-quires the ability to clearly recognize agent-expo-sure symptoms against a varying background of un-related injury and stress behaviors. The healthcareprovider should be informed, to the fullest extentpossible, when to anticipate chemical warfare at-tack by hostile forces or terrorist activities. This re-quires consideration of an adversary with regardto political factors and motivation, chemical agentpossession or access, chemical warfare offensive

and defensive capabilities, and the strategic advan-tage to be realized through agent use.

When individuals suspected to have been ex-posed to chemical warfare agents are encountered,initial recognition of the type of agent used may befacilitated through an understanding of tacticalagent use, modes of agent dissemination, likelyroutes of casualty exposure to agent, and physicalagent properties and other factors determining thepersistence of these toxicants in the operating en-vironment. Finally, to protect both the injured andmedical personnel, casualty care must take placewithin a framework of decontamination both in thefield and in forward medical support facilities.

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