A time bomb for the 21st century

Chemical warfare is a growing threat, but we know very little about its long-term implications, argue Christine Gosden and Derek Gardener.

The 20th century provided a catalogue of weapons that could kill and maim on an unprecedented scale, whether biologically, chemically or radiologically. Amazingly, we do not seem to have learnt from the conflicts in which these weapons of mass destruction have been used, nor have we provided help, support and medical care to the exposed populations suffering immediate and long-term effects.

Chemical weapons, such as mustard gas, phosgene and chorine, were used in the first world war to gain military advantage by killing, maiming and terrifying troops in the trenches. There was no systematic follow-up, but it is known that many thousands died or suffered after the war ended, developing conditions such as lung cancer, pulmonary disease, heart failure or infertility.

The second world war saw large-scale manufacture of chemical weapons, including mustard gas and the nerve gases sarin and tabun, though these were never used in battle. Civilians who worked in the mustard-gas factories of Britain, Germany and Japan during the war have been shown to have up to eightfold increases in head, neck and lung cancers, and major pulmonary problems.

To the military mind, weapons of mass destruction (WMDs) mean death on a large scale with zero survivability. Their use is justified by the need to "shorten the war". Survivors are simply not playing the game. It was not until the use of nuclear weapons in Hiroshima and Nagasaki that cancers and birth defects in civilian populations induced by such weapons were acknowledged for the first time. The silent radiation that is the chilling sequel to the use of nuclear or radiological weapons will continue to kill for as many as 20 years after exposure. The dangers of such exposures are still being documented - they include cancer and congenital malformation. Some chemical weapons such as mustard gas and the biological toxin aflatoxin are thought to have similar results.

Since the second world war, there have been a number of attacks using WMDs, most recently the anthrax outbreaks in the US. The fact that these are thought to be the work of a loner has raised fears about the ease with which such weapons can be deployed.

But solid evidence of the effects of chemical and biological weapons is hard to come by. What information there is comes mainly from classified military documents that detail the effects of nerve agents on rats, mice and guinea pigs. In terms of humans, US experiments on about 1,400 male military volunteers in the 1950s and 1960s give some information, but this says nothing of the effects on women and children.

Scientists must make the most of information available from real-life incidents, such as the 1995 sarin attack on the Tokyo underground. This showed the vulnerability of emergency staff on site and medical staff at hospitals to such covert attacks. Sarin is colourless and odorless. Medical staff who were not wearing gas masks or protective clothing breathed in fumes of the nerve agent on the bodies and clothing of victims. Twenty per cent of victims with long-term neurological effects were members of the medical and emergency response team that tried to aid victims. Such information is vital if we are to protect victims of such attacks.

The largest group so far exposed to a WMD is the Kurd population of Northern Iraq. This population is so isolated, politically and geographically, that there has been a worldwide failure to recognise the scale of the attacks to which it was subjected, the terrible mixtures of weapons used, the effects on the population and the suffering of the victims as well as a failure to provide focused humanitarian and medical aid. The Kurds' experiences on the receiving end of chemicals and probably biological and radiological weapons as well, commenced during the 1980s Iran-Iraq war. A new cause of death was coined, "Anfalled". The "Anfal" was the system of ethnic cleansing used by the Iraqi government against the Kurds and resulted in the "disappearance' of more than 200,000 men and boys. It also had the advantage of allowing WMDs to be tested in hundreds of attacks on live subjects to improve their deployment against the Iranian militia. One single attack on the town of Halabja in the closing days of the Iran-Iraq war showed the world the effectiveness of Iraq's WMDs: 5,000 were killed and 40,000 injured as a direct consequence. The long-term effect of these attacks has been five-to-ten-fold increases in the incidence of cancers, congenital malformation and major medical disorders, causing terror among the surviving population. It is calculated that at least 250,000 people in the region have significant risks of suffering aftereffects, either from direct exposure or through exposure to contaminated food, water and environment.

It might be assumed that United Nations organisations would have undertaken systematic forensic testing, particularly as the attack on Halabja was the largest single attack using a WMD against a civilian population. But all UN organisations have respected the sovereignty of the Iraqi government, saying they cannot test attack sites until they are invited in. A UN special commission was set up with a mandate to investigate and monitor Iraq's arsenal of weapons of mass destruction, including mustard gas, sarin, VX, aflatoxin, botulinum toxin, anthrax and ricin, as well as potential radiological weapons such as irradiated zirconium bombs. However, its remit was taken to exclude investigating either what weapons were used or their medical effects.

But who should undertake medical treatment and research in such cases? Victims of chemical and biological attacks are likely to be suspicious of studies by commercial or military bodies - although the military would probably have a head start in at least having the most detailed knowledge of WMDs. Humanitarian aid organisations respond to emergencies, but studying the long-term effects of conflicts is not their province. In the absence of a change in UN policy, academics are in a unique position to help find routes by which international organisations can exercise their responsibilities and can make a significant contribution towards protecting civilian populations against WMDs and their effects.

We formed a collaborative academic/postgraduate medical institute for treatment in the region and to support research internationally in partnership with affected people. The obstacles are immense. Apart from the difficulties of getting to the region, the physical danger of working in an area where resources are so scarce that operations are often performed by lamplight, there are huge ethical issues.

Survivors of WMD attacks who require medical treatment need to be reassured that since they have already been victims of experimental attacks, they will not be subjected to further experimentation. Treatments should thus be evidence-based. But here we face a chicken-and-egg situation. Without more research, we cannot know how to treat people suffering from the long-term effects of these weapons or to protect against the immediate and short-term effects. One of the main problems of undertaking such research is that populations at risk are often displaced, dispersed or seeking asylum from torture and death. This makes systematic follow-up very difficult. Moreover, the detailing of attacks and the agents used are not uppermost in the minds of those fleeing for their lives. In Iraq, the most detailed information about the effects of the attacks may be in the hands of the government.

What evidence we do have, which has implications for those exposed to carcinogenic WMDs, shows that cancer and other risks increase with dose and that susceptibility changes with age. The question of who dies and who survives such attacks, short and long term, is important - is it the elderly, the young, pregnant women and their foetuses who are at highest risk? Some people may also be more at risk for genetic reasons. Other questions about susceptibility, survival and injury include whether activities such as sheltering in cellars, removal to the open air, wrapping with wet sheets and immediate attempts at decontamination by washing or jumping into lakes offer any protection.

Recent events in the US have awakened our fears about how unconventional weapons can be used in novel ways. Our preoccupation with finding rapid solutions for the problems of mass terrorism must embody aspects not only of conflict resolution but also of efforts to diminish the effects of weapons of mass destruction by understanding the impact they have and providing proper support for victims.

Christine Gosden is professor of medical genetics and Derek Gardener is biomedical science officer in the University of Liverpool departments at Liverpool Women's Hospital.