Disarmament Forum three. 1999
(Bulletin of the United Nations Institute for Disarmament Research - UNIDIR)

Examining Long-term Severe Health Consequences
of CBW Use against Civilian Populations
by Christine Gosden*, Mike Amitay +, Derek Gardener* and Bakhtiar Amin +

* University Departments of Biological Sciences and Medicine, University of Liverpool, UK; + Washington Kurdish Institute, Washington DC

http://www.unog.ch/unidir/3e-openforum.pdf

Hundreds of thousands of people have been killed or maimed and countless thousands are still suffering from exposures to chemical, biological and nuclear weapons. These include exposures during the First and Second World Wars, the Iran-Iraq War, the Tokyo subway attack, the "Anfal" campaign in Iraqi Kurdistan, and possibly during the Gulf War. Hundreds of thousands of survivors continue to suffer without help, essentially abandoned to face severe effects of weapons which are either carcinogenic (cancer-causing), teratogenic (causing congenital malformations) or neurotoxic (leading to profound neurological or psychiatric problems).

Real Threats

Exposure to chemical, biological or nuclear agents, either from military use or accidents, result in profound damage to people and the environment. Toxic residues from such weapons contaminate food and water supplies, cause sterility in people and animals, and can cause genetic damage spanning generations. Secondary consequences may spread across international boundaries, endanger millions, have effects on children yet unborn and on the fertility and health of future generations. The long-term implications thus differ from those posed by conventional weapons and defy responses planned for conflicts, terrorist attacks and accidents.

The sarin attack on the Tokyo subway system demonstrated the potency of such weapons, the difficulties in preventing their use and the inadequacy of the response system. Serious long-term neurological effects are now being reported not just among survivors, but also in the medical and emergency staff who responded to the incident. Unlike conventional arms, chemical and biological weapons attacks have deadly and disabling effects on emergency services personnel and persist in the environment. Such agents cannot be counteracted through conventional infrastructure and emergency responses.

Governments around the world now acknowledge the real threat of such weapons and the nightmare prospect of war and terrorism that destroy people and not buildings. Increasingly frequent industrial mishaps, train derailments, air crashes and other accidents have also resulted in exposures to a variety of highly toxic substances, and local jurisdictions have found themselves ill-prepared to respond. Emergency exercises in major cities and at defence establishments have exposed the inadequacy of current responses to the emerging threats. In the event of an attack or accidental exposure, governments must develop new strategies to care for and treat the victims. New understandings of how chemical and biological agents work and how to ameliorate their effects must be developed.

The Attack on Halabja and the Anfal Campaign in Iraqi Kurdistan

The populations of towns in Northern Iraq, especially the town of Halabja, are the largest civilian populations ever exposed to chemical and biological weapons. In 1988, the Kurdish inhabitants of Halabja were aerially bombarded with a cocktail of chemical and biological weapons, including mustard gas and the nerve agents sarin and tabun. The nerve agent VX and the biological toxin aflatoxin were also probably used. The people were drenched in these agents and their food and water were contaminated. About 5,000–7,000 people of the total population of 80,000 died as immediate casualties of the attack and a further 30,000–40,000 of the population were injured, many severely. No one has yet established exactly how many people died in the aftermath of the weapons attack, their ages or where or how they died. Nor is there any information about how many people now suffer long-term effects of the weapons or what the effect has been on the population structure as a result of infertility, foetal and infant deaths, and susceptibility to early mortality in vulnerable groups such as children, the elderly and pregnant women.

In addition to these victims in Halabja, there are further affected populations throughout Iraq attacked by Saddam Hussein from April 1987 to August 1988. Hundreds of tons of chemical weapons were used in attacks on Northern Iraq. It has been estimated that between 100,00–200,000 were involved in these attacks, but full medical and scientific studies of the weapons, the victims and the survivors have not been undertaken.

Cocktail of Weapons—Huge Range of Medical Consequences

We have as yet incomplete knowledge about the major long-term effects of chemical weapons, particularly when delivered in the potent and synergistic cocktail of the Halabja attack. What we do know is that chemical weapons have long-term effects. Genetic effects cause mutations in DNA and thus lead to cancers and congenital malformations, thereby giving rise to a new and continuing form of genocide. Mustard gas (although one of the first chemical weapons) is a very potent cancer-causing agent and is known to be toxic to embryos. Many pregnancies in Halabja are lost because of the heritage from these weapons and many women have suffered infertility as a consequence. In addition to the effects they have on stillbirths and childhood malformations and deaths, they continue to severely afflict the living. Mustard gas burns to the cornea have caused blindness; to the skin have caused skin cancers, pain and ulceration; and to the lungs have caused recurrent infections, asthma, bronchitis and pulmonary fibrosis so severe that lung transplants would be the only possible option for therapy. The nerve agents have caused severe neuropsychiatric disorders. There are as yet few effective treatments to oppose the destructive effects due to the advanced technologies of weapons of mass destruction and so it is imperative that advanced medical help is now provided for the victims.

Health Challenges

The effects of chemical and biological weapons, as well as nuclear exposure, differ from those of conventional weapons which have easily observable effects and for which there are effective treatments. In contrast chemical, biological and nuclear agents act silently, and many of the most severe effects are long term and strike without warning. Delayed effects such as the development of cancers following exposure may occur five to ten years later. Survivors of chemical, biological and nuclear attacks suffer devastating effects on all organ systems. They face a multitude of physical and neuropsychiatric problems. There are no known treatments, and conventional therapies may exacerbate their symptoms. Immediate responses by emergency services and national agencies may save lives, but do not address middle- or long-term problems. A major difficulty is how to treat rare cancers that are common in this population, such as those of the larynx and nasopharynx, which developed as a result of mega-dosages of carcinogenic and mutagenic mustard gas. There is no information either about methods for treatment of the neuropsychiatric effects of the nerve gases sarin, tabun and VX or the long-term medical effects on cardiac, respiratory, dermatological and ophthalmological systems of these weapons.

Pregnant women, young children and the elderly are at greatest risk from exposure to chemical weapons. There is an urgent need to treat this population so as to determine the best possible way of alleviating their suffering. Simple measures should be tested, such as the provision of folic acid to prevent birth defects; or iodine tablets and uncontaminated milk and food to prevent cancers of the thyroid, breast, bone and leukaemia.

Medical Infrastructure Deficient

The enormities of the health problems facing the population of Northern Iraq are magnified by an appalling lack of medical resources and infrastructure. Despite the fact that they were attacked eleven years ago, the survivors have received minimal, if any, humanitarian assistance. Regional doctors, trained mainly in the United Kingdom, are extremely frustrated by a severe lack of medicines, equipment and health support. Basic sciences laboratory facilities are inadequate and research capacities limited. The deans of regional medical colleges report a complete lack of up-to-date textbooks and journals. Communication between regional hospitals and with the outside world are difficult. There is even a shortage of pencils and paper for patient records.

Available drugs are often outdated or impure and there are major problems with equipment and supplies as basic as oxygen for surgery. Virtually no advanced treatment or diagnostic equipment exists in Northern Iraq. No transplants of any kind (kidney, corneal, liver, lung, heart) take place. Major medical infrastructure problems are exemplified for the care of those with cardiac failure (especially the young), where no cardiac drugs or analgesics are available, nor cardiac surgery. Renal failure leads to death as there is no dialysate available for the kidney dialysis machines. Patients with major medical conditions can be referred to Mosul or Baghdad, but even if they make the long, painful and expensive journey, they often die without treatment. Furthermore, many fear their lives will be at risk if they travel south into Iraqi controlled areas.

There is no plastic surgeon in the region to repair major mustard gas burns to the skin or congenital malformations such as cleft lip and palate. With no specialist paediatric surgeon or paediatric cardiology facilities, children with major chemical or biological weapons induced cardiac defects die through lack of treatment. While there are many doctors in Iraq, such as those presently working in general surgery, there is a need for specialist training, for instance in the area of plastic surgery to heal extensive mustard gas burns.

The serious deficiencies in health and medical infrastructure in Halabja and the three northern Governorates are exacerbated by United Nations sanctions and problems in implementation of Security Council resolution 986, which allows the sale of Iraqi oil in exchange for food and medicine. Northern Iraq has received only a very small part of the promised 13% entitlement of total medical supplies under resolution 986. The Iraqi regime, which oversees distribution of 986 supplies, rarely allows delivery of useful medicines and equipment requested by health authorities in Northern Iraq. The "Oil for Food" programme thus fails to meet the basic health needs of the population, let alone the special needs of chemical victims. As many doctors point out, Iraqi Kurdistan suffers from a double embargo — one by United Nations sanctions, the other imposed by the Iraqi regime on Kurdish regions. This situation continues to ensure steady deterioration of medical and other infrastructures.

Healing Halabja—Helping the World

Since visiting Iraqi Kurdistan and the town of Halabja in January 1998, Dr. Christine Gosden and the Washington Kurdish Institute (WKI) have conducted extensive consultations with regional doctors, officials, international experts and humanitarian NGOs. The result has been a proposal to develop a post-graduate medical programme in Iraqi Kurdistan for treatment and research of chemical and biological weapon exposures. The proposed structure would ensure that the humanitarian/medical response sensitively and ethically lays the groundwork for a stringent scientific process needed to determine the long-term affects of chemical weapons.

The proposed programme will facilitate development of strategies for conflict situation epidemiology, effective interventions, prevention, treatment and humanitarian aid. The model will facilitate cooperation between regional political authorities and administrative structures, and energize segments of civil society throughout Northern Iraq. The structure would integrate long-term international research and immediate health response efforts. Treatment and research programmes are also envisioned throughout Europe at research hospitals in Kurdish immigrant communities, as significant numbers may have faced exposure. Programmes among more accessible immigrant populations will provide critical patient databases for comparative studies with regional and control groups.

Working with physicians in Iraqi Kurdistan and international experts, Dr. Gosden and WKI have prioritized six "cornerstone" pilot treatment/research programmes:

· Cardiopulmonary; · Neuropsychiatric; · Cancers in children and adults; · Congenital malformations, infertility and infant death; · Medical disorders (including ophthalmological and dermatological.); and · Palliative care (treatment for the terminally ill).

Minimal international support and assistance from some local NGOs will help establish a rudimentary post-graduate structure at three university hospitals and a hospital in Halabja to undertake an initial detailed medical/demographic survey. Yet without substantial international assistance, medical treatment and research will not be possible, and the population will continue to suffer.

Conclusions

While there are many responses to the question of why there has been no rush to aid these people, if we continue to fail them and act as if they are beyond help, then the threats posed by chemical and biological weapons become much greater for all of us.

Even if we find it difficult to countenance providing humanitarian help, at least self-interest and the crucial issue of domestic preparedness should alert us to the relevance of this community for the wider population. For example, during the Gulf War, some American service personnel may have been exposed to a chemical cocktail. Their multisystem illnesses remain unexplained and have defied diagnosis and effective treatment. Additionally, as we have seen in both Northern Iraq and Chernobyl, these problems have affected not only local populations with immediate death, ill health and subsequent increases in the rates of congenital malformations and cancers, but have also had wider effects on millions of people hundreds of miles from the initial contamination. The Chernobyl accident has left a legacy of cancers, childhood malformations and genetic mutations, not just in Ukraine, but in countries throughout Europe. The environmental effects will persist for hundreds of years and the genetic damage will be passed on for generations. Therefore, no chemical, biological or nuclear exposure can be considered as a local problem.

The potency of the effects, such as the increase in aggressive cancers in the young which kill terribly and painfully ten years after the attack or children born malformed as a result of toxic effects, argues for renewed efforts for complete chemical and biological disarmament and the development of novel techniques to help and treat victims. Even if effective, the tools of disarmament to prevent the use of chemical and biological weapons would have come too late for the Kurds and others victimized by the Iraqi regime. But it is not too late to ease their massive suffering, and perhaps in the process, learn valuable lessons about treating victims of chemical and biological weapons.