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M ID DL E EA ST J OU R NA L OF I NT ER NA L ME DI CI NE • V OL UM E 2, I SS UE 3 27
MIDDLE EAST JOURN AL OF IN TERNA L MEDICINE VOLUME 5, ISSUE 4
M OD EL S AN D SY ST EM S OF C AR E
Case Report: Victims of the Long Term Effects of Chemical
Weapons on Health in Kurdistan of Iraq
ABSTRACT
Extensive exposure to chemical weapons such as mustard gas, nerve gas and
cyanide causes high mortality, morbidity, injuries, and chronic side effects in
vital organs, especially the respiratory tract.
Globally, chemical weapons have been documented as having been used since
429 BC, when they were used by the Spartans in the Peloponnesian War. In
the First World War (WW1) the use of chemical agents caused an estimated
1,300,000 casualties, including 90,000 deaths. Chemical weapons were heavily
used by Iraq against Iranian soldiers between1984-1986, then, against the
Iraqi Kurds in Sheikh Wasan and Balisan valley, during April 1987 and in
Halabja on 18th March 1988.
Reports suggested that as many as 2.9% of the Kurdish population have been
exposed to chemical weapons at some level.
This case report describes a Kurdish lady who was exposed to mustard gas
during a chemical attack in Sheikh Wasan in Iraq.
A forty eight years old woman wearing black clothes presented to our center
at 1999 complaining from shortness of breath (SOB). Her condition started 12
years ago when the Iraqi Government attacked her village Sheikh Wasan by
Chemical weapons which included Mustard gas and nerve gases such as Sarin,
Tabun and VX in April 1987. She described how the gas smelled like rotten
apples as it spread over the village. During the attack she suffered from sever
SOB, cough, skin burn and eye irritation and lacrimation. After several days
of being without medical care, she received some medical attention by local
medical staff in the area because the Iraqi authorities at that time refused and
prohibited them from management at the major hospitals. When she returned
to her home she found that several members of her family had died during
the exposure to chemical gases. Among the dead people were her parents,
two brothers, husband and son, in addition to other second and third degree
relatives. Since that time she has suffered from repeated attacks of cough
and SOB and wheezing that were increased by exertion and cold exposure.
The attacks were more severe with time and the SOB has interfered with her
daily activity and eventually she was suffering from SOB at rest and during
sleep that made her unable to sleep lying down. Moreover she was suffering
from severe depression since that time for which she consulted several doctors
but without improvement. In the end of 2001, she suffered from severe cough
and Hemoptysis associated with anorexia and loss of weight. She consulted
our center for this purpose and we asked for a medical care for her. Available
haematological and radiological investigations were done for her showing a
preliminary diagnosis of non-small cell lung cancer. . She was sent for further
investigations and treatment, but since then she has been disappeared and no
more information was recorded about her situation.
This is one example of many of those who suffered from the effect of chemical
weapons in Kurdistan of Iraq.
Key words: Chemical weapon, Mustard gas, shortness of breath, Cancer.
Kawa Dizaye
Correspondence:
Dr. Kawa Dizaye
Professor of Pharmacology
Hawler Medical University,
Erbil,
Iraq
Tel: 009647504452392
Email: dr_kawadizaye@yahoo.com
M ID DL E EA ST J OU R NA L OF I NT ER NA L ME DI CI NE • VO LU ME 2 , IS SU E 3
28 MIDD LE EAST JOURNAL OF IN TERNAL MEDICINE VOLUME 5, ISSUE 4
M OD EL S AN D SY ST EM S OF C AR E
Introduction
The use of chemical warfare agents dates back to 429 BC and various agents have been developed and used against populations
since that time. (Table 1 - below)
The NATO denition of a chemical agent is: A chemical substance which is intended for use in military operations to kill,
seriously injure or incapacitate people because of its physiological effects. (1).
• 429 B.C. - Spartans ignite pitch and sulphur to create toxic fumes in the Peloponnesian War (CW)
• 424 B.C. - Toxic fumes used in siege of Delium dur ing the Peloponnesian War (CW)
• 960-1279 A.D. - A rsenical smoke used in battle during China’s Sung Dynasty (CW)
• 1346-1347 - Mongols catapult corpses contaminated with plague over the walls into Kaffa (in Cr imea), forcing besieged Genoans to ee
(BW)
• 1456 - City of Belgrade defeats invading Turks by igniting rags dipped in poison to create a toxic cloud (CW)
• 1710 - Russian troops allegedly use plag ue-infected cor pses against Swedes (BW)
• 1767 - During the French and Indian Wars, the British give blankets used to wrap British smallpox victims to hostile Indian tribes (BW)
• April 24, 1863 - The U.S. War Department issues General Order 100, proclaiming “The use of poison in any manner, be it to poison
wells, or foods, or arms, is wholly excluded from modern warfare”
• July 29, 1899 - “Hague Convention (II) with Respect to the Laws and Customs of War on Land” is signed. The Convention declares “it is
especially prohibited… To employ poison or poisoned arms”
• 1914 - French begin using tear gas in grenades and Germans ret aliate with tear gas in artillery shells (CW)
• April 22, 1915 - Germans attack the French with chlorine gas at Ypres, France. This was the rst signicant use of chemical warfare in
WWI (CW)
• September 25, 1915 - First British chemical weapons at tack; chlor ine gas is used against Germans at the Bat tle of Loos (CW)
• 1916-1918 - German agents use anth rax and the equine disease glanders to infect livestock and feed for export to Allied forces. Incidents
include the infection of Romanian sheep with anthrax and glanders for export to Russia, Argentinian mules with anthrax for expor t to
Allied troops, and American horses and feed with glanders for export to France (BW)
• February 26, 1918 - Germans launch the rst projectile attack against U.S. troops with phosgene and chloropicrin shells. The rst major
use of gas against American forces (CW)
• June 1918 - First U.S. use of gas in warfare (CW)
• June 28, 1918 - The United States begins its formal chemical weapons program with the est ablish ment of the Chemical Warfare Service
(CW)
• 1919 - British use Adamsite against the Bolsheviks during the Russian Civil War (CW)
• 1922-1927 - T he Spanish use chemical weapons against the Rif rebels in Spanish Morocco (CW)
• June 17, 1925 - “Geneva Protocol for the Prohibition of the Use in War of Asphyxiating, Poisonous or Other Gases, and of
Bacteriological Methods of Warfare” is signed - not ratied by U.S. and not signed by Japan
• 1936 - Italy uses mustard gas against Ethiopians during its invasion of Abyssinia (CW)
• 1937 - Japan begins its offensive biological weapons program. Unit 731, the biological weapons research and development unit, is located
in Harbin, Manchuria. Over the course of the program, at least 10,000 prisoners are killed in Japanese experiments (BW)
• 1939 - Nomonhan Incident - Japanese poison Soviet water supply with intestinal typhoid bacteria at former Mongolian border. First use
of biological weapons by Japanese (BW)
• 1940 - The Japanese drop rice and wheat mixed with plague-carrying eas over China and Manchur ia (BW)
• 1942 - U.S. begins its offensive biological weapons program and chooses Camp Det rick, Frederick, Maryland as its research and
development site (BW)
• 1942 - Nazis begin using Zyklon B (hydrocyanic acid) in gas chambers for the mass murder of concentration camp prisoners (CW)
• December 1943 - A U.S. ship loaded with mustard bombs is attacked in the port of Bari, Italy by Germans; 83 U.S. t roops die in
poisoned waters (CW)
• April 1945 - Germans manufacture and stockpile large amounts of tabun and sarin ner ve gases but do not use them (CW)
• May, 1945 - Only known tactical use of biological weapons by Ger many. A large reservoir in Bohemia is poisoned with sewage (BW)
• September, 1950-February, 1951 - In a test of biological weapons dispersal methods, biological simulants are sprayed over San
Francisco (BW)
• 1962-1970 - U.S. uses tear gas and four types of defoliant, including Agent Orange, in Vietnam (CW)
Table 1: Chronology of biological and chemical weapons use and control, 429 B.C.–1998 (continued top of next page)
Source: (http://www.libraryindex.com/pages/1888/Proliferation-Weapons-Mass-Destruction-WMD-HISTORY-USAGE-
PROLIFERATION.html”)
M ID DL E EA ST J OU R NA L OF I NT ER NA L ME DI CI NE • V OL UM E 2, I SS UE 3 29
• 1963-1967 - Egypt uses chemical weapons (phosgene, mustard) against Yemen (CW)
• June, 1966 - The United States conducts a test of vulnerability to cover t biological weapons attack by releasing a har mless biological
simulant into the New York City subway system (BW)
• November 25, 1969 - President Nixon announces unilateral dismantlement of the U.S. offensive biological weapons program (BW)
• February 14, 1970 - President Nixon extends the dismantlement efforts to toxins, closing a loophole which might have allowed for their
production (BW)
• April 10, 1972 - “Convention on the Prohibition of the Development, Production and Stockpiling of Bacteriological (Biological) and
Toxin Weapons and on Their Destruction” (BWC) is opened for signat ure
• 1975 - U.S. raties Geneva Protocol (1925) and BWC
• 1975-1983 - Alleged use of Yellow Rain (trichothecene mycotoxins) by Soviet-backed forces in Laos and Kampuchea. There is evidence
to suggest use of T-2 toxin, but an alter native hypothesis suggests that the yellow spots labeled Yellow Rain were caused by swarms of
defecati ng bees (CW)
• 1978 - In a case of Soviet state-sponsored assassination, Bulgarian exile Georgi Markov, living in London, is stabbed with an umbrella
that injects him with a tiny pellet containing rici n (BW)
• 1979 - The U.S. government alleges Soviets use of chemical weapons in Afghanistan, including Yellow Rain (CW)
• April 2, 1979 - Outbreak of pulmonary anthrax in Sverdlovsk, Soviet Union. In 1992, Russian president Boris Yeltsin ack nowledges that
the outbreak was caused by an accidental release of anthrax spores from a Soviet militar y microbiological facility (BW)
• August, 1983 - I raq begins using chemical weapons (mustard gas), in Iran-Iraq War (CW)
• 1984 - First ever use of ner ve agent tabun on the battleeld, by Iraq du ring Iran-Iraq War (CW)
• 1985-1991 - Iraq develops an offensive biological weapons capability including anth rax, botulium toxin, and aatoxin (BW)
• 1987-1988 - Iraq uses chemical weapons (hydrogen cyanide, mustard gas) in its Anfal Campaign against the Kurds, most notably in the
Halabja Massacre of 1988 (CW)
• September 3, 1992 - “Convention on the Prohibition of the Development, Production, Stockpiling and Use of Chemical Weapons and on
their Destruction” (CWC) approved by United Nations
• April 29, 1997 - Ent ry into force of CWC
• 1998 - Iraq is suspected of maintaining an active CBW program in violation of the ceasere agreement it signed with the UN Security
Council. Baghdad ref uses to allow UNSCOM inspectors to visit undeclared sites (CW/BW)
Table 1: Chronology of biological and chemical weapons use and control, 429 B.C.–1998
Figure 1: Classication of chemical weapon according to their mechanism of action
M OD EL S AN D SY ST EM S OF C AR E
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M OD EL S AN D SY ST EM S OF C AR E
About 70 different chemicals have been used or stockpiled
as chemical warfare agents during the 20th century and the
21st century. These agents may be in liquid, gas or solid form.
Liquid agents are generally designed to evaporate quickly;
such liquids are said to be volatile or have a high vapor
pressure. Many chemical agents are made volatile so they can
be dispersed over a large region quickly These agents were
designed specically to harm people by any route of exposure
and to be effective at low doses (2).
Chemical Weapons can be divided into lethal and
incapacitating categories (Figure 1).
A substance is classied as incapacitating if less than 1/100 of
the lethal dose causes incapacitation, e.g., through nausea or
visual problems. The limit between lethal and incapacitating
substances is not absolute but refers to a statistical average.
In comparison, it may be mentioned that the ratio for the
nerve agents between the incapacitating and lethal dose is
approximately 1/10. Chemical warfare agents are generally
also classied according to their effect on the organism. The
two major threat classes of chemical weapons are mustard
gas and the nerve agents, and this has not changed in over 50
years. Both types are commonly called gases, but they are
actually liquids that are not remarkably volatile. (3, 4).
It must also be remembered that possible new agents are
constantly being discovered, and also, that some chemical
agents may be used together as a mixture. From the medical
standpoint, toxins could pose similar problems to those
produced by chemical agents. (1)
Chemical agents in the modem sense were rst used in World
War I when chlorine gas was released, from large cylinders,
in a favorable wind.
The French were the rst to use chemical weapons during
the First World War, using tear gas. The German’s rst use of
chemical weapons were shells containing xylyl bromide that
were red at the Russians near the town of Bolimów, Poland
in January 1915 (5). Ofcial gures declare about 1,176,500
non-fatal casualties and 85,000 fatalities directly caused by
chemical warfare agents during the course of the war (6).
Later in the War they used mustard gas. Soon both sides were
using chemical warfare extensively leading to the introduction
of gas masks. The fear of the detrimental effects of chemical
warfare caused many countries to abstain from using it
and except for the use of poison gas by the Italians in the
war against Ethiopia (1935-36) and by the Japanese against
Chinese guerrillas (1937-42), chemical warfare was not
employed after World War I. This is not to say however, that
the militar y powers of the world did not continue to develop
new gases (7).
Chemical weapons were heavily used by Iraq against Iranian
soldiers between1984-1986, then, against the Iraqi Kurd Table
(2). In 1987-88 Iraqi forces launched chemical attacks against
approximately 40 Kurdish villages and thousands of innocent
civilians (8).
Initial scientic studies conducted by local doctors and
international specialists indicate that as many as 2.9% of the
population of almost four million people in northern Iraq have
been exposed to chemical weapon at some level between April
1987 and August 1988. In April of 1987, the regime attacked
the villages of Sheik Wasan and Balisan, using chemical
weapons for the rst time, killing more than a hundred people
Figure (2), mostly women and children. The worst of these
attacks devastated the city of Halabja on March 16, 1988. (9)
The attack on Halabja, a town of 80,000 to 90,000 people, is
the largest chemical attack against civilians in histor y (10).
The Halabja attack involved multiple chemical agents
including mustard gas, and the nerve agents SARIN, TABUN
and VX. Some sources report that cyanide was also used.
It may be that an impure form of TABUN, which has a
cyanide residue, released the cyanide compound. Most
attempts directed to developing strategies against chemical or
biological weapons have been directed towards a single threat.
The attack on Halabja illustrates the importance of careful
tactical planning directed towards more than one agent, and
specic knowledge about the effects of each of the agents.
More than 5000 people were killed during the attack on
Halabja, and more than 20,000 were injured (11).
Table 2: Documented Iraqi Use of Chemical Weapons on the Kurds
M ID DL E EA ST J OU R NA L OF I NT ER NA L ME DI CI NE • V OL UM E 2, I SS UE 3 31
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CO MM U NI TY C AR E
Figure 2: Samples of chemical weapon used in Balisan Vali in 1987.
Today at Balisan and Sheik h Wassan, 23 commemorative graves are representing 233 lost in the attack. The remains of the
dead were too difcult to separate and identify Figure (3).
Figure 3: Today at Balisan and Sheikh Wassan, 23 commemorative graves are representing 233 lost in the attack
M ID DL E EA ST J OU R NA L OF I NT ER NA L ME DI CI NE • VO LU ME 2 , IS SU E 3
32 MIDDLE EAST J OURNAL OF INT ERNAL MEDI CINE VO LUME 5, I SSUE 4
Unlike Halabja, the Balisan valley is far from the Iran border Figure 4. Injured survivors seeking treatment at hospitals in
government-controlled Arbil were taken away by the security forces -- and many were never seen again.
Residents of the villages recall that planes appeared, dropping canisters that spewed yellow dust. The dust was mustard gas,
but most civilians did not recognize the danger until symptoms appeared hours later. Many who did not die in the attacks were
permanently blinded; children and the elderly were particularly affected.
Extensive exposure to chemical weapons such as mustard gas, nerve gas and cyanide caused high mortality, morbidity, injuries,
and chronic side effects in vital organs, especially the respiratory tract (12).
Mustard a poisonous chemical agent is a cell poison that causes disruption and impairment of a variety of cellular activities.
Mustard is an alkylating agent, and once absorbed, its toxic effects result from chemical reactions with cellular constituents.
These biochemical reactions cause inhibition of mitosis, nicotinamide adenine dinucleotide (NAD) depletion, decreased tissue
respiration, and ultimately, cell death (13, 14,15).
Figure 4: Location of Balisan Vali and Halabja in northern Iraq
Mustard agent was produced for the rst time in 1822 but its harmful effects were not discovered until 1860. Mustard agent was
rst used as a CW agent during the latter part of the First World War and caused lung and eye injuries to a very large number of
soldiers. Many of them still suffered pain 30-40 years after they had been exposed, mainly as a result of injuries to the eyes and
chronic respiratory disorders (16)
Mustard agents are usually classied as “blistering agents” owing to the similarity of the wounds caused by these substances
resembling burns and blisters. It produces blisters and damage to skin, eyes, respiratory and gastrointestinal tracts. There is
usually erythema; vesication; bur ns and lung damage. Mustard gas also affects many other systems including haematopoietic
and immune systems. Haematological effects include leucopenia, thrombocytopenia, decrease in RBCs and sepsis. Secondary
infections of damaged tissue can occur easily. The most serious of the long term effects arise because mustard gas is
carcinogenic and mutagenic. In the respiratory system there are increased risks of chronic lung disease, asthma, bronchitis.
Permanent impairment of vision may occur and eye damage may be severe, leading to blindness. Skin lesions and bur ns may
be severe with persistent changes and hypersensitivity to mechanical injury. Carcinogenic and mutagenic effects can result in
cancers, Carcinogenic and mutagenic effects can result in cancers, congenital malformations and infertility. Long term effects
(mutagenesis, carcinogenesis, eye, skin, lung, fertility) etc are dose and route dependent (17, 18, 19).
M OD EL S AN D SY ST EM S OF C AR E
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MIDDLE EAST JOURN AL OF IN TERNA L MEDICINE VOLUME 5, ISSUE 4
Case report
This case report describes a Kurdish lady who was exposed to mustard gas and
nerve agent during a chemical attack in Sheikh Wasan and Balisan vale in Iraq.
Figure 5: Badriya Saed Khidir
A forty eight year old woman wearing black clothes presented to our center at
1999 complaining from shortness of breath (SOB). Her condition started 12 years
ago when the Iraqi Government attacked her village Sheikh Wasan by Chemical
weapons which included Mustard gas and nerve gases such as Sarin, Tabun and
VX in April 1987. She described how the gas smelled like rotten apples as it spread
over the village.
During the attack she suffered from severe SOB, cough, skin burn and eyes
irritation and lacrimation. After several days of being without medical care, she
received some medical attention by local medical staff in the area because the Iraqi
authorities at that time refused and prohibited them from management at the major
hospitals. When she returned back to her home she found that several members
of her family have died during the exposure to chemical gases. Among the dead
people were her parents, two brothers, husband and son, in addition to other second
and third degree relatives. Since that time she has suffered from repeated attacks
of cough and SOB and wheezing that were increased by exer tion and exposure to
cold. The attacks were more severe with time and the SOB has interfered with her
daily activity and more recently she was suffering from SOB at rest and during
sleep that made her unable to sleep lying down. Moreover she was suffering from
severe depression since that time for which
she consulted several doctors but without
improvement.
In the end of 2001, she suffered from
sever cough and Hemoptysis associated
with anorexia and loss of weight. She
consulted our center for this purpose
and we asked for medical care for her.
Available haematological and radiological
investigations were done for her showing
a preliminary diagnosis of non-small
cell lung cancer. She was sent for further
investigations and treatment, but since
then she had disappeared and no more
information was recorded about her
situation.
On the 17th of March 2009 I visited the
area which were exposed to chemical
weapon in 1987. In Balisan I asked about
a woman called Badriya Saed Khidir and
they showed me her grave saying she had
passed away several weeks before. She
died while her eyes were lled with tears
crying for the fate of her son, her parents,
her two brothers and her lovely husband.
Another victim was a baby girl. Her
family named her Chemia (Chemist)
because she was borne on 16th April 1987
on the day of the attack in Sheikhwasan.
She died after three months from the
exposure to chemical attack.
These are two examples of the many
who suffered from the effect of chemical
weapons in Kurdistan of Iraq.
References
1-NATO. Handbook on medical aspects of
NBC defensive operations (1996)
2-Blodgett Brian, Germany’s Use of
Chemical Warfare in World War 1
(1999)Available:http://members.tripod.
com/Brian._Blod. gett / Chemical.htm
3-http://en.wikipedia.org/wiki/Chemical_
warfare
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Environmental Health Perspectives
Volume 107, Number 12, December 1999
4- Gordon M. Burck and Charles C.
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M ID DL E EA ST J OU R NA L OF I NT ER NA L ME DI CI NE • VO LU ME 2 , IS SU E 3
34
MIDDLE EAST JOURN AL OF IN TERNA L MEDICINE VOLUME 5 I SSUE 4
Figure 6: Grave of Badriya Saed Khidir
Figure 7: The author visiting the grave of Badriya Saed Khidir
M OD EL S AN D SY ST EM S OF C AR E
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M OD EL S AN D SY ST EM S OF C AR E
MIDDLE EAST JOURN AL OF IN TERNA L MEDICINE VOLUME 5, ISSUE 4
Figure 8: A family escaping from area exposed to chemical weapon in Balisan Vale
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