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 Medical Challenges in Chemical and Biological Defense for the 21st Century
677
Chapter 35MEDICAL CHALLENGES IN CHEMICALAND BIOLOGICAL DEFENSE FOR THE21
ST
CENTURY
ERNEST T. TAKAFUJI, M.D., M.P.H.*; ANNA JOHNSON-WINEGAR, P
H
.D.
;
AND
RUSS ZAJTCHUK, M.D., FACS
INTRODUCTIONPROLIFERATION OF BIOLOGICAL WEAPONSBIOTECHNOLOGYEnhanced PathogenicityAntibiotic ResistanceBioengineered Toxin ProductionGenetic WeaponryThe Human Genome ProjectNew Medical CountermeasuresMILITARY SCENARIOSSUMMARY
*
Colonel, Medical Corps, U.S. Army; Commander, Walter Reed Army Institute of Research, Walter Reed Army Medical Center, Washington, D. C. 20307-5100
 Director, Medical Chemical–Biological Defense Research Program, U.S. Army Medical Research and Materiel Command, Fort Detrick, Frederick, Maryland 21702-5012
 Brigadier General, Medical Corps, U.S. Army; Commanding General, U.S. Army Medical Research and Materiel Command, Fort Detrick,Frederick, Maryland 21702-5000
 
 Medical Aspects of Chemical and Biological Warfare
678
INTRODUCTION
Biological and chemical warfare has long con-cerned military planners, strategists, and tacticians.Experiences in the Persian Gulf War (1990–1991),the rising concern over terrorist groups and theirinterest in weapons of mass destruction, and thecontinuing difficulties with curbing the prolifera-tion of traditional chemical and biological weaponshave resulted in continuing modifications in poli-cies that would be employed in future scenarios.The use of such agents against the United States orits allies or both, including military and civilianpopulations, remains a distinct and perhaps increas-ing possibility.Recent events in the world, including the terror-ist attack with the nerve agent sarin in a subway inTokyo, Japan, in March 1995, have demonstratedboth the willingness of extremist organizationsto use these agents and the ready availability of deadly agents. Biological organisms continue to bereadily available throughout the world, obtainablein nature or through biological supply houses ormedical laboratories. Dangerous chemicals alreadyexist in local communities and in hardware and gar-dening shops.The current threat posed by weapons of biologi-cal and chemical origin has been discussed exten-sively in previous chapters of this textbook. Thischapter discusses three issues that will likely havea significant effect on chemical and biological de-fense in the next century:the global proliferation of biological weapons;the advances in technology, particularlybiotechnology, that will affect the develop-ment of weapons and their countermea-sures; andpossible changes in the future use
 
of chemi-cal and biological weapons by the enemythat will make delivery of medical care evenmore challenging.Efforts at counterproliferation will not be dis-cussed in this chapter. This should not be construedas a reflection of its reduced importance, for limit-ing the proliferation of weapons of mass destruc-tion continues to be a large effort of the UnitedStates government. Instead, emphasis is placed hereon the issue of biotechnology, for this is the areawhere medical personnel will find the greatest con-troversy and conflict. For the interested reader whodesires a more in-depth review of the subject of fu-ture prospects of biological weapons and prolifera-tion, we refer you to two excellent sources:
 Biologi-cal Weapons: Weapons of the Future?
and
 Director’sSeries on Proliferation
(see Recommended Readingat the end of this chapter).The potential exists for both (
a
) misuse of the bio-technology for refinement of current biologicalweapons and (
b
) development of new agents withadded potency. The profound impact that biotech-nology will continue to have on biological weap-ons and their countermeasures is of particular con-cern when put in the context of the worldwidedeployability of military forces, the potential useof genetic engineering for both peaceful and sinis-ter purposes, and continued attractiveness of bio-logical warfare as an option by adversaries in fu-ture conflicts.
PROLIFERATION OF BIOLOGICAL WEAPONS
The limitation and eventual elimination of bothchemical and biological weapons are two of thegreatest challenges facing the international commu-nity. Unfortunately, proliferation of such weaponsis continuing despite the best efforts of manynations, including the United States, to preventproliferation.
1
Biological weaponry is the most wor-risome issue because of the relative ease in devel-oping and mass-producing potent agents, thecontinuing difficulties in identifying enemy capa-bilities and limiting their development, and thepotential ability for adversaries to bioengineer anddeliver new organisms using the latest advances intechnology.On 23 February 1993, following the Persian Gulf War and the breakup of the Soviet Union, a panelof the U.S. House of Representatives Committee onArmed Services submitted a special report,
2
 
Special Inquiry of the House Armed Services Committee Intothe Chemical and Biological Weapons Threat 
. This re-port concluded that despite the decrease in abso-lute quantities of chemical weapons, the potentialdiversity and the frequency with which such weap-ons could be encountered were increasing. Thethreat had shifted to Third World scenarios, withdeployed U.S. military forces facing new threatsfrom chemical and biological weapons. Technologi-cal advances have increased the diversity of poten-
 
 Medical Challenges in Chemical and Biological Defense for the 21st Century
679
tial weapons of each variety. The report stated thefollowing concern, which goes to the heart of theproblems that the U.S. military medical depart-ments will face in the 21st century:
Genetic tailoring and the speed of technologicalinnovation create opportunities for the creation of exotic new agents which may be difficult to detector defend against.
2(p7)
In addition, the report of the House of Represen-tatives Special Committee alluded to 31 nations thateither possess or have the ability to develop an of-fensive chemical weapons capability, and 11 nationsthat either possess or have the ability to develop anoffensive biological weapons capability. The Spe-cial Committee realized that while it would be moredifficult for a country to mass-produce classicchemical warfare agents in large quantities with-out detection, it would be very easy for a countryor organized group to develop the technologicalcapabilities to produce other agents.
2
The former Soviet Union, long suspected of hav-ing an aggressive research and development pro-gram despite its participation in international agree-ments to curtail such development, has continuedto be a major factor in the global threat. Covert pro-grams continued, at least through 1992, despiteopen declarations to the contrary. With the dissolu-tion of the Soviet Union, concern has been gener-ated about the export of the scientific technologyand weaponry beyond its borders. Cooperation be-tween the Russian Federation and the United Statesis making progress in reducing this potentially dan-gerous situation.North Korea, Iran, and Iraq are three examplesof countries with biological warfare potential. NorthKorea has continued to have a program of coopera-tion with several countries in the Middle East, andthe prospect of biological weapons being used onthe Korean peninsula is a genuine concern. Iraq wasknown to have an active research, development, andweaponization program at the time of the Gulf War,although whether Saddam Hussein intended to usesuch weapons is controversial. If chemical weap-ons agreements are any indication of national com-pliance and intent, it should be noted that Iraq se-cretly constructed chemical warfare productionplants and imported chemical warfare technologyfrom the West in violation of the Geneva Protocol.
3
The use of chemical weapons on Kurdish forces hasnow been well documented.The Persian Gulf War and continuing prob-lems with Iraq resulted in the creation of a uniqueUnited Nations organization known as The UnitedNations Special Commission on Iraq (UNSCOM).
3
UNSCOM was established specifically by a UnitedNations Security Council resolution that spelled outconditions for cease-fire and the destruction, re-moval, or rendering harmless of chemical, biologi-cal, and nuclear weapons and ballistic missiles witha range greater than 150 km. UNSCOM unilaterallydefined the terms for its inspections of Iraqi facili-ties and has continued to direct and support com-pliance inspections.The United States has been active in its partici-pation in international efforts to specifically con-trol the spread of biological and chemical weapons.The Convention on the Prohibition of the Develop-ment, Production, and Stockpiling of Bacteriologi-cal and Toxin Weapons and their Destruction (alsoknown as the Biological Weapons Convention) andthe Chemical Weapons Convention have been dis-cussed in detail in other publications,
4,5
as have vari-ous confidence-building measures,
5
which have metwith limited success.It should be noted that UNSCOM activities arenot directly associated with the Biological Weap-ons and Chemical Weapons Convention agree-ments, although elimination of weapons of massdestruction continues to be a goal of most nations.It is plausible to assume that should internationalsituations arise in the future regarding proliferentswith biological warfare capabilities, the UnitedNations may again take actions similar to those ittook with Iraq.The “dual-use” issue, in which the technologiesused to develop and produce biological or chemicalweapons are very similar to those that would beneeded for human and veterinary healthcare researchand production and the agricultural industry, hascreated many challenges. The technologies involvedin pesticide dispersal, for example, could easily beadapted for the delivery of aerosols containing bio-logical agents. Verification inspections and confi-dence-building measures have had limited success,but efforts continue to strengthen the conventions.
BIOTECHNOLOGY
Since 1953, when James D. Watson and FrancisCrick identified the genetic code contained indeoxyribonucleic acid (DNA), discoveries in thefield of molecular genetics have skyrocketed. Break-throughs in genetic engineering have allowedgenes to be substantially altered and combined with
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