MEDICINE AND WAR, VOL. 5.197-204 (1989) CONFERENCE REPORT
DLAWER ALA'ALDEEN MSC MBChB DTM&H
Physician, and Secretary, Kurdish Scientific and Medical Association, BCM Box 5952, London WCIN3XX
Abstract
Production and use of chemical weapons
Treatment of victims of chemical weapons-exchange of experience
Pathological and clinical effects
TreatmentScientific investigations
Collaboration with the United Nations system against use of chemical weapons
Biological weapons
Recommendations to the United Nations
A. To improve verification, protection and treatment against chemical warfare agent poisoning
B. Investigation of alleged violations of the Geneva Protocol of 1925 and the Biological Weapons Convention of 1972
C. The role of health professionals
D. International independent experts' committee on CBW
About the author
Abstract: The main objectives of an international conference in May 1989 on chemical and biological weapons (CBW) were: (1) To discuss and exchange information and experience of the protection and treatment of victims of the use of CBW; the investigation of allegations of use of CBW; the development of ways of collaboration between experts and the United Nations on issues of CBW; and the mobilization of public opinion against CBW. (2) To constitute a special committee out of the conference that could continue the work of the conference on the above issues and co-ordinate the viewpoints of experts and concerned bodies; further, this committee could offer its services to the Secretary-General of the United Nations, investigate allegations concerning the use of CBW, and report its findings to the Secretary-General and to the Conference on Disarmament in Geneva.
KEYWORDS Chemical warfare Gulf War Halabja Biological weapons
An international conference on chemical and biological weapons (CBW), which was held in Geneva on 24-27 May 1989, brought together specialists from 14 countries in the medical, toxicological, juridical, governmental, non-governmental and media fields. The conference was organized by the International Commission of Health Professionals for Health and Human Rights (ICHP). The conference programme consisted of individual presentations, discussions, and working groups.
Production and use of chemical weapons
Among the speakers on the first day were Dr Arnt Meyer-Lee (President of ICHP), Dr Ali Ali Kadhim (Secretary-General of the conference), Mr Theodore Zoupanus (Director of External Relations of the UN Office at Geneva), Dr E. Gunn (representative of the Director-General of WHO), Professor Martin Caplan (representative of the Pugwash Conference on Science and World Affairs). Professor Mohammed Gomau (chairman of the working group on juridical issues of the Geneva Conference on Disarmament), Mr Umesh Pal-wankar (International Institute of Humanitarian Law), Mr Igor Scherbak (Soviet delegate at the Conference on Disarmament). Professor Steven Rose (Open Univesity, UK) and Professor Jiri Matousek (USSR).
The speakers addressed various aspects of CBW. Stress was laid on the importance of holding such conferences to exchange information, participate in problem-solving, boost governmental efforts in negotiations, publicize these objectives, and re-affirm the important role scientists can play in issues of global peace.
The urgent need for a complete ban on research, development, stockpiling, and use of chemical and biological weapons was emphasized. Stress was laid on confidence-building among governments, unilateral initiatives, support for the UN efforts for disarmament, collaboration of scientists and other experts among themselves and with the UN, the study and anticipation of problems that may arise during destruction of stocks, and defining an acceptable approach to controlling the production of these weapons.
Highlighted also was the historical, political and social importance of the Halabja tragedy (where the Iraqi government used chemical weapons against its own Kurdish civilians) and the necessity of preventing similar tragedies from occurring again.
Grey areas in the Geneva Protocol of 1925 were discussed. The conference was reminded about the Paris conference of January 1989 which demonstrated the will of participating governments to abandon chemical weapons. However, a consensus had not been reached on the use of chemical weapons internally, within the boundaries of a member-state of the UN (as at Halabja and Bahdinan in Iraq), nor was consensus reached on the question of sanctions by the UN Security Council against violators of the Protocol.
Treatment of victims of chemical weapons-exchange of experience
The speakers on the next day were doctors who had first-hand experience in treating victims of chemical warfare, either in the field only minutes after an incident or later in advanced hospitals. Information they presented included that ten per cent of the fatal casualties of Iraqi chemical warfare against Iran were civilians; and that when Iraq used chemical agents against its own Kurdish population in Halabja, nearly all the fatal casualties were civilians.
During the Iraq-Iran war, 50 000 mild cases, 50 000 moderate to severe cases, and 5000 fatal cases of war gas poisoning were reported. 25-30 thousand of these were civilians; 10% of the moderate and severe cases were fatal; and 15-20% were Iraqi soldiers treated by the Iranians (the Iraqis were probably affected because of winds or indiscriminate use in militarily desperate situations).
Dr A. Fourukan, a field doctor, pointed out that from massive use of chemical weapons they had received up to 500 victims per hour, of whom 50-60 were comatose. In these circumstances, the most important measures were planning and organizing of evacuation, and proper management in the local unit. In Kurdistan local health staff were utilized, and the local nurses with highly organized management tended to be more effective than well-educated physicians.
Pathological and clinical effects
Assessment of the patient's condition was made by considering the extent of lesions, the parts damaged, the severity of nicotinic, muscarinic and central effects of nerve agents, and the results of laboratory tests. It was observed that muscarinic neurological symptoms appeared first, followed by the nicotinic and later the central nervous symptoms. The acetylcholinesterase blood-level was measured and if found to be reduced by more than 15%, the soldier would not be sent back to the battlefield.
Detection methods that were used effectively in Iran were colorimetry and gas chromatography. Para-nitrobenzyl-pyridium powder or paper were used in the field as an inexpensive method for detection of mustard (dichloroethyl sulphide) and nerve gases. High levels of thiodiglycol in the urine of patients suggested exposure to mustard gas (normal values, 0-5 ng/ml; exposure, 20-90 ng/ml;
maximum level detected prior to death, 333 ng/ml). The level of this breakdown product of mustard gas diminishes with time and becomes undetectable. However, when hydrochloric acid is added to the urine, trace amounts of thiodiglycol are converted back to mustard which is readily detectable.
Dr H. Sohrabpour had carried out a study on 35 Iranian combatants exposed to mustard gas, and this showed that the agent primarily affected the skin and the respiratory tract. Follow-up spirometry indicated that the respiratory effects were predominantly obstructive, although mixed obstructive and restrictive impairment of airflow or normal ventilatory function were seen in some heavily exposed patients. Autopsies showed heavy and haemorrhagic lungs. Almost all patients with a leucocyte count of less than 1000 died. Bronchial lavage and biopsies showed squamous metaplasia, suggesting a possible pre-carcinogenic effect of the mustard gas. Long-term sequelae seen in some cases are reduced lung compliance and shortness of breath.
Reviews of the clinical pictures and pathology of war gas victims were made by a number of European doctors whose medical experience had been with patients exposed at least 5-6 days earlier. They emphasized that on hospital admission prompt assessment of the victim's general condition is very important before deciding on what should be done.
Treatment
First aid and field management were designed to:
(a) Establish respiration.
(b) Distinguish between mild, moderate and severe cases (triage).
(c) Administer atropine to cyanotic patients (1-2 mg initially, evaluate respiration, and if no response is observed inject 10-20 mg intravenously over 5 minutes). Guidelines to dosage were control of respiratory secretions and mydriasis.
(d) Inject diazepam following the atropine, 10 mg intramuscularly, in all moderate and severe cases.
Skin lesions caused by exposure to mustard gas were generally treated by conventional open methods. Atypical effects of the gas were deep pigmentation and unusual exfoliative lesions. Some observations remained unexplained, such as blue discolouration of the skin in many of the victims and eosinophilic infiltration of lung alveolae in biopsies.
Decontamination of exposed parts of the body, clothes and equipment was best achieved with fuller's earth. Bleaching powder is an irritant, and should not be used. Water is essential for the toxic action of mustard gas and as water in the battlefield may also be contaminated, its use for decontamination was not recommended.
Based on animal experiments, Dr M. Balali, an Iranian scientist, has concluded that up to 20 mg of acetylcysteine or 25 mg of sodium thiosulphate administered 10 minutes prior to, or even up to the time of, exposure to mustard gas will provide some protection. Mice could not be protected when these substances were administered well before or late after exposure.
Scientific investigations
European and Iranian scientists reported on the examination of unexploded bombs which contained the nerve agent Tabun. On close study of the Tabun, scientists detected phosphate compounds as impurities and chlorobenzene as a stabilizing agent. They also discovered silicon and calcium dust particles. It was thought that-these particles might serve as carriers (absorbants or adsorbants) for the chemical agents when inhaled and trapped in the bronchioles and alveolae.
The importance of the epidemiologist in investigating alleged attacks was highlighted by the report of Dr Howard Hu, a physician-epidemiologist, who had travelled to south-eastern Turkey to interview Kurdish survivors after Iraq's chemical attack in August 1988. The results of questionnaires and interviews on a large number of individuals and the evidence of eye witnesses were highly suggestive of a chemical attack.
Collaboration with the United Nations system against use of chemical weapons
On the third day stress was laid on the threat that CBW might pose to the global peace process, particularly when regarded as strategic weapons. Speakers pointed out the tremendous difficulties non-governmental organizations (NGOs) and fact-finding missions have had in investigating allegations of the use of CBW. Use or non-use of biological weapons is especially hard to verify, and the experience of investigating the yellow rain allegations was an important example of this.
The conference discussed extensively the best way to overcome a major problem of the UN and its experts: choice of laboratory for testing samples. One suggestion was to establish an international central laboratory as a UN body to handle CBW investigations as well as of industrial accidents and natural disasters. Another suggestion was to co-ordinate collaboration of national laboratories for these purposes.
Based on the Kurdish tragedy in Halabja and Bahdinan and on other allegations of the use of chemical weapons by the Iraqi government against its Kurdish population, which could not be investigated by the United Nations, proposals were made to create channels through which minorities' concerns in such countries could be voiced. Similarly, reference was made to the importance of this example which has shown the potential of these weapons for oppression of minorities, or as weapons of genocide.
Dr Rodney McElroy urged that a prohibition on the use of herbicides and tear gas in armed conflict should be included in the chemical weapons convention currently under negotiation in Geneva. Such a ban would strengthen the treaty, could prevent an escalation to more lethal agents, and would simplify verification of compliance. If the use of these chemical agents were not banned, another chemical warfare catastrophe like the defoliation the USA inflicted on Vietnam could occur.
Speakers recommended to the conference to call on the United Nations, international organizations, non-governmental organizations, and individual health professionals to use their influence within their fields and their capabilities to raise public awareness on CBW, and to use all possible means to ensure that a tragedy like that at Halabja is never repeated.
The conference moved on to discuss "the present situation with regard to the use of biological weapons". Speakers expressed their concern at the increased interest in many developed countries in biological warfare research. Since the signing of the Biological Weapons Convention in 1972 and the dormant years of the 1970s, renewed interest has been stimulated in certain military circles by the advances in genetic engineering and other biogenetic technologies. There is reason to worry that these techniques could be used to produce a new generation of biological weapons.
Biological weapons, like chemical weapons, are especially threatening to civilians. Armed forces can often be protected, but civilians, particularly the very young, the old and the sick are vulnerable. Research on these weapons in the name of defence is therefore difficult to justify. Defence research in this area can
only be acceptable if carried out by civilian agencies, and in an open and free manner with experiments and results made public immediately.
Recommendations to the United Nations
The extensive discussions of the working groups led to a set of recommendations to be presented to the United Nations Secretary-General. The conference adopted the recommendations in principle, and nominated an "International Independent Committee of Health Professionals and Scientists for Chemical and Biological Disarmament" to finalize them. The adopted recommendations were:
A. To improve verification, protection and treatment against chemical warfare agent poisoning
1. Provide special training on chemical weapons agents to medical and nursing staff.
2. Encourage the collaboration of international medical organizations, and in particular WHO, and also the Red Cross.
3. Provide facilities to an affected country from other governments and also from non-governmental organizations.
4. Give priority to chemical weapons victims' admission to hospitals around the world without any political hindrance.
5. Train and supervise combatants on the use of protective devices.
6. Provide facilities for civilian victims including health care, food and camping.
7. Establish an information centre and data bank, providing an encyclopaedia on chemical agents. Update of the 1970 WHO book on chemical and biological warfare agents and its distribution widely to all medical professions.
8. Consider the establishment of an international institute of chemical weapon agents in one of the places which has been attacked chemically.
9.Convene periodic meetings of specialists for exchange of information on an international basis.
B. Investigation of alleged violations of the Geneva Protocol of 1925 and the Biological Weapons Convention of 1972
1. While recognizing that the United Nations has provided: a permanent international panel of experts "on call"; permanent "kits" of analytical equipment with protective gear; a process for commencing investigation within 24-48 hours by direct request of the Secretary-General without a Security Council vote; and a group of laboratories around the world to analyse samples for investigations- yet there are practical difficulties and a periodic review of the United Nations procedures is urged.
2. The United Nations should consider establishing a laboratory for investigation of allegations of the use ofCBW. This laboratory could normally investigate environmental and toxic catastrophes, but would be available for investigation of allegations of use of CBW at short notice.
3. Mechanisms should be developed in the UN to respond to CBW allegations arising from armed conflicts other than those between states (e.g. armed insurrections, civil wars). These should be handled by the UN in the same manner as for conflicts between sovereign states.
4. The UN Security Council should deal with the use of CBW agents as a threat to peace and international security according to Chapter VII of the UN Charter.
C. The role of health professionals
1. Recommend that WHO, UNHCR and other UN organizations devise policies to treat CBW victims outside countries when such treatment is not available locally.
2. Encourage professional and scientific organizations to develop codes of ethics regarding: treatment of victims of CBW; duties of doctors, nurses, scientists, military personnel and other professionals to report suspected use of CBW to the UN Secretary-General; publication of biological and chemical defence research as open literature; and duty not to participate in research or development of new chemical or biological weapons.
3. Recommend that in cases where the UN cannot mount its own investigation (e.g. internal conflict), that it assists independent non-governmental organizations to investigate CBW allegations by helping them to obtain information, protective gear, testing equipment and logistical support.
4. Urge that UN organizations should devise policies and carry out programmes such as: UNICEF to consider implications for children and future generations; UNEP to study and publicize effects on the environment and ecosystems; the Human Rights Commission to consider policies regarding use of CBW in internal conflicts, and to define use of CBW as a crime against humanity and covered by the Convention on Genocide; UNHCR to plan for situations when use of CBW causes mass migrations; and UNESCO to mount a general educational campaign about the inhumanity of CBW.
D. International independent experts' committee on CBW
The conference recommended that a small committee be formed of CBW experts from around the world. This group should: articulate the purpose of involving health professionals and scientists in the debate about CBW; plan a process for involving health professionals and scientists in investigation, treatment and public debate about CBW; and consult with the United Nations and other international organizations on CBW issues, this to include investigation and treatment of victims.
E. Mobilization of public opinio1. The conference called on (a) the United Nations and other international organizations, (b) non-governmental organizations, particularly those representing health professionals and scientists, and (c) individuals with particular knowledge of chemical and biological weapons, to publicize by all possible means, including television, radio, newspapers, magazines and especially professional journals, the following issues:
(a) thepotentialconsequencesoftheuseofchemicalandbiologicalweapons
(b) information on the status of the international chemical and biological weapons conventions and negotiations
(c) current research on chemical and biological weapons in all nations, whether labelled as "offensive" or "defensive"
(d) documenting evidence of research, development, production, stockpiling or use of chemical or biological weapons
(e) ethical issues for health professionals, scientists or others about work on chemical and biological weapons.
A curriculum on chemical and biological weapons for use at all levels of education should also be developed, particularly for health professionals and scientists. In medical education, this curriculum should span pre-clinical and clinical disciplines.
2. The conference made a solemn appeal to the international public to remain vigilant so that an event such as the tragedy at Halabja is not repeated.
(Accepted 8 July 1989)
Dlawer Ala'Aldeen, a Kurdish doctor, graduated in medicine and worked initially in Iraq. He then studied tropical medicine and hygiene in London, and is currently doingresearch at the Clinical Research Centre, Northwick Park Hospital, on the development of a vaccine against menigococcal meningitis. As Secretary of the Kurdish Scientific and Medical Association (KSMA) and a member of the Working Party on Chemical and Biological Weapons, Dr Ala'aldeen is involved in the campaigns for chemical and biological disarmament, and for raising medical and humanitarian aid for the Kurdish victims and refugees of the chemical warfare in Kurdistan. He has had a number of medical and scientific papers published in Kurdish and in English. (Submitted June,1989)
