C. Investigating the Incident

1. Conditions at the Site

Company B operated observation posts approximately two kilometers south of Kuwait's border in a desert environment of very coarse sand and no noticeable vegetation.[21] The winter weather here was cold at night and cool during the day, averaging lows of 0� to 5� C (32� to 41� F) and highs of 15� to 20� C (59� to 68� F).[22]

2. Interviews of Witnesses and Key Servicemembers

a. Medical Personnel

We interviewed several doctors and corpsmen about these Marines, including the 8th Marine Regiment's medical officer, the 2d Reconnaissance Battalion’s surgeon, and other 2d MARDIV medical personnel.

The 2d Reconnaissance Battalion surgeon was unaware of any 2d Reconnaissance Battalion Marines injured due to exposure to chemical warfare agent; however, he did recall the 3d platoon’s commander (one of the Marines this investigation identified) had acquired a condition then diagnosed as some form of infectious dermatitis.[23]

The senior chief at the 1st Battalion, 8th Marine Regiment’s aid station recalled an unidentified corpsman told him about two Marines from the 2d Reconnaissance Battalion who had blisters on their hands. As far as the chief knows, medical personnel sent the Marines to the 8th Marines Regimental aid station for their doctors to examine. The senior chief thought the blisters were the symptoms of some form of dermatitis, then a common ailment among servicemembers in the area.[24]

When questioned separately about this incident, the 8th Marines medical officer and the regimental aid station's senior corpsman stated they would know and remember if their personnel treated anyone for symptoms of chemical warfare agent exposure. To their knowledge, this never occurred; however, they treated several servicemembers at the various 8th Marine Regiment aid stations for various forms of dermatitis. The medical officer remembered a corpsman taking a group of Marines to a hospital at the 2d Force Service Support Group for symptoms resembling chemical warfare agent contamination. He does not think they were so diagnosed.[25]

We followed the 8th Marines' medical officer's lead by checking previous interviews with 2d Force Service Support Group medical personnel. We interviewed the executive officer of the 2d Medical Battalion; the commanding officer and senior medical officer, Company G, 2d Medical Battalion; a nurse with the 2d Medical Battalion; and the commanding officer, Company F, 2d Medical Battalion. None of them remembered treating 2d Reconnaissance Battalion Marines for injuries resembling those caused by chemical warfare agent exposure.[26]

The 2d MARDIV surgeon and the command master chief of the 2d MARDIV surgeon's office believe they would have been informed of any suspected 2d MARDIV chemical-related casualties; they knew nothing about these injuries.[27]

We also interviewed the Fleet Hospital 15 doctor who signed the medical treatment records of the corporal with blistered hands from 1st Platoon's third reconnaissance team. This doctor heard rumors several 2d Reconnaissance Battalion Marines were treated for chemical warfare agent exposure at his hospital, but he never treated any patients for such injuries. His notes on the corporal's medical records discuss only respiratory problems associated with oil well fire smoke. He did not specifically remember treating this Marine, but was sure he would remember treating a chemical warfare agent casualty.[28]

b. NBC Personnel

In July 1991 the Marine Corps Research Center published "Marine Corps NBC Defense in Southwest Asia," more commonly called the "Manley Report" for then-Captain Thomas F. Manley, who compiled the paper. This report is a contemporary analysis of NBC defense issues, such as training, doctrine, intelligence, individual NBC equipment, operational readiness, and major lessons learned, in the Marine Corps’s areas of operations during the Gulf War.[29]

To compile the report, Captain Manley interviewed several veterans, including the 2d Reconnaissance Battalion NBC officer and non-commissioned officer (NCO); and the 8th Marine Regiment NBC officer and NBC staff non-commissioned officer (SNCO). All these Marines would have been informed about an NBC incident (such as three to six Marines seeking treatment for blisters resembling chemical warfare agent wounds). None of these interviewees mentioned the incident involving Marines from the 2d Reconnaissance Battalion during their interviews with Captain Manley.[30]

The 2d MARDIV NBC officer remembered some details about the incident. Answering a question about Marines from the 2d Reconnaissance Battalion being overcome while digging in the sand walls of the man-made berm near Kuwait's border, he stated he heard speculation the blisters were due to chemical warfare agent exposure.[31] The 2d MARDIV NBC SNCO heard stories about Marines with blisters on their hands and knew no other details except the incident had occurred before the ground offensive.[32] A 2d MARDIV NBC officer heard a rumor one 2d Reconnaissance Battalion Marine developed an irritation caused by a chemical warfare agent.[33]  None of these individuals observed the injuries and we found no evidence to support the statements.

c. Command Personnel

We interviewed Marines at every level in the 2d Reconnaissance Battalion chain of command, including platoon commanders, a company commander, and battalion commander, as well as the 2d MARDIV assistant chief of staff for administration and assistant chief of staff for operations.

We asked two Company B platoon commanders about this event. The 3d Platoon commander was one of the Marines who experienced blistering on his hands. He believes he had leishmaniasis caused by an insect bite that created a sore on the back of his hand between the first and second knuckle. Over three to four days, more sores developed until they were on all fingers of both hands. The pain associated with these lesions equaled that of an insect bite. The sores healed over three to four weeks of daily, frequent hand washing. This Marine was not aware any other Marines in his platoon had developed this condition. Furthermore, this Marine does not believe his symptoms were related to those experienced by the other Marines because he recalls developing blisters in late January, before the company established the observation posts at the berm. He is included in this investigation because he belonged to Company B and experienced symptoms similar to the other Marines’.[34]

The 1st Platoon commander became involved in this incident almost a month after it occurred, but could not provide many details. He was able to confirm two 1st Platoon Marines had lesions on their hands, which he understood were caused by insect bites or contact with some chemical substance, such as motor oil or cleaning solutions. He confirmed the 3d Platoon commander also had these lesions.[35]

The Company B commanding officer could not remember this event. He was sure no Marines in his company were ever put on medication or light duty and speculated one or more Marines may have reacted to something in the desert and sought a medical opinion about its cause. He does not believe chemical warfare agent exposure affected any of his Marines.[36]

The 2d Reconnaissance Battalion commanding officer recalled Marines in Company B had problems with itchy hands but did not associate this with a chemical incident.[37]

US Army Field Manual 3-100, "NBC Defense, Chemical Warfare, Smoke, and Flame Operations" describes the principles of planning and executing NBC defenses. According to this document, the 2d MARDIV assistant chief of staff, G-1 (administration) would have prepared and maintained any NBC situation reports the 2d MARDIV generated.[38] She had no records of any chemical warfare agent casualties with the 2d MARDIV, but she directed us to the 2d MARDIV assistant chief of staff, G-3 (operations).[39] During our interview, the 2d MARDIV operations officer said he heard about Marines with blisters on their hands but knew nothing else about the incident.[40]

3. Analysis

a. Chemical Warfare Agent Exposure

Blister agents are chemical warfare agents that damage the eyes and lungs and blister the skin to the point of incapacitation or death. Blister agents are persistent and may be employed as colorless gases and liquids. The severity of a blister agent burn directly relates to the agent’s concentration and its duration of contact with the skin.[41]

We considered mustard agent exposure as a possible cause of these Marines' symptoms for several reasons:

1) Mustard Injuries

We initiated this investigation to assess the likelihood mustard agent exposure caused the blisters these Marines experienced. The following section compares expected symptoms and treatment of mustard agent exposure and the symptoms and treatment these Marines experienced.

a) Symptoms

The Marines had some difficulty describing their blisters in detail due to the interval that had passed since they had them. They described the blisters as up to the size of a dime (approximately two centimeters in diameter) with clear or opaque fluid. Some Marines remembered redness or inflammation accompanying the blisters; others did not.[46] The characteristic mustard blister  is dome-shaped, thin-walled, translucent, yellowish, and surrounded by reddened skin. Generally, it is 0.5 to 5.0 centimeters in diameter, although it can be larger. The blister fluid initially is thin and clear or slightly straw-colored; later it turns yellowish and tends to coagulate.[47]

Aside from the blisters, the Marines experienced few other symptoms. Several affected Marines remembered some minor itching associated with the appearance of the blisters,[48] but none remembered feeling a great degree of pain. In comparison, mustard blisters usually are very painful and cause damage comparable to first-, second-, or third-degree burns, depending on the agent’s concentration. At least one Marine experienced diarrhea and nausea,[49] common symptoms associated with mustard exposure.[50] The Marines speculated whatever caused these blisters was in the sand they dug at the berm.[51] If they were exposed to mustard potent enough to cause blistering and nausea, they also should have experienced ocular (eye) effects. We consulted an expert on this issue, and he thinks it is likely mustard of this potency within an arm's reach would have vaporized from body heat and affected the Marines’ eyes.[52] Over one minute, the threshold amount of vapor required to produce a skin lesion is approximately 200 milligrams per cubic meter, while as little as 12 milligrams per cubic meter will damage the eye.[53] None of these Marines experienced ocular effects.[54]

b) Treatment

The Marines noticed the blisters grew and spread across their hands over several days,[55] which is uncommon with mustard injuries.[56] It is common for secondary skin lesions to appear if a mustard casualty is not decontaminated immediately after contact with the agent, because the agent can spread from the back of the hand to the face, neck, and other areas of the skin. Mustard fixes to the skin within minutes of exposure, ensuring tissue damage if decontamination does not begin immediately after contact. By the time skin lesions appear, most of the agent has been absorbed, while the remaining unabsorbed mustard will have evaporated.[57] The Marines did not seek medical treatment until they noticed the blisters,[58] but this does not account for the blisters spreading over a period of days.

If field medical personnel believed mustard exposure caused these blisters, they did not treat the blisters as such. Treatment for mustard exposure includes cleaning the blistered skin to prevent infection and applying a topical antibiotic to the blisters and surrounding skin. If the casualty is to return to duty, medical personnel most likely would bandage the affected areas.[59] In this instance, the only treatment one Marine recalls was instructions to wash his hands regularly.[60] Field medical personnel did not treat these Marines as mustard agent casualties.

2) Chemical Agent Monitor Alert

The CAM alert indicates the possibility of a blister agent on the glove of one Marine.  However, the CAM's selectivity causes the device to alert to some non-chemical warfare agent vapors resulting in false positive detections.[61] Therefore, after the first alert, the CAM operator followed proper procedure by clearing the CAM before re-testing the glove.  For this test, did not receive a positive reading, indicating the first alert was a false detection.[62]

3) Source of Chemical Warfare Agent

Assessing the possibility of any chemical warfare agent exposure requires us to identify how the agent reached the point of exposure. Before the Gulf War, the US intelligence community[63] warned US forces Iraq not only had chemical weapons capabilities, but also had employed them against both its own citizens and against Iran.[64] After the Gulf War, the United Nations Special Commission on Iraq (UNSCOM) chemical and biological weapons inspections program identified, inventoried, and, in some cases, supervised Iraq's destruction of its chemical warfare agents and chemical weapons. During this program, UNSCOM determined Iraq’s only means of delivering mustard agent were 155mm artillery shells and aerial bombs.[65] The area where these Marines operated was in Saudi Arabia and never under Iraq’s control. These Marines did not receive in-coming artillery fire before the lesions developed,[66] and Iraq’s air force did not fly ground-attack sorties after January 25, 1991.[67] For this reason, we do not believe Iraq's forces delivered any chemical warfare agents to the area where these Marines operated.

b. NBC Incident Procedure

The standard procedure for reporting actual or suspected chemical or biological hazards is the NBC Warning and Reporting System. All units in an area of operations rely on this system to identify, assess, and limit the effects of chemical or biological attacks and determine the best course of action to complete their missions should such an attack occur. The most widely used report submitted in this system is an NBC-1 report, used to report NBC attack data. The Marines involved in this investigation never witnessed an NBC attack; however, their unit would have submitted an NBC-4 report (used to report possible NBC detections) if the unit NBC personnel believed chemical warfare agents had contaminated these Marines.[68] Our investigators never located an NBC-4 report for this incident, nor do we believe one was ever filed. Fleet Hospital 15 and the 2d Reconnaissance Battalion never filed an NBC report, and no Marine Corps unit histories note this event. Furthermore, the Fleet Hospital 15 admission logs provided by the veterans who reported the incident do not document the admission of anyone for symptoms resembling those described. This indicates no one who treated these Marines within the 2d Reconnaissance Battalion or at Fleet Hospital 15 thought the Marines had been exposed to chemical warfare agents.

c. Fleet Hospital 15 Casualty Receiving Records

When Fleet Hospital 15 personnel reported the treatment of these Marines to us, they provided us a photocopy of a 20-page hospital admission log that recorded the names, units, diagnoses, and dispositions of everyone admitted to Fleet Hospital 15 between February 10, 1991, and March 21, 2001. According to this log, 2d Reconnaissance Battalion Marines were only admitted to the hospital twice, either for asthma or a broken jaw.[69] The admission logs do not indicate anyone was ever admitted to the hospital for the treatment of chemical warfare agent exposure.

4. Medical Expert's Review

During our investigation, we asked a medical expert who specializes in chemical warfare agent casualty identification and treatment to evaluate the six Marines. This independent medical expert has several years’ experience in this field and once taught emergency department physicians and nurses in communities surrounding the eight US chemical weapon facilities how to assess, decontaminate, and treat chemical warfare casualties. In December 2000, almost 10 years after the Gulf War ended, he evaluated the Marines using information gathered by our investigators and through his own interviews with the Marines, three in person and one over the telephone. For the two remaining Marines, the medical expert relied on our interview notes to make his assessment.

During their interviews with the medical expert, the Marines described the blisters to the best of their ability and discussed their environment, clothing, and activities at the time the blisters appeared. The specialist showed five Marines pictures of skin lesions caused by various conditions, including mustard agent exposure, and asked the Marines to identify which ones most resembled their blisters. Pictures they selected included polymorphic light eruptions, leishmaniasis, urticaria, infectious folliculitis, Grover's Disease, and dermatomyositis.[70] None of the Marines identified the pictures of blisters caused by exposure to mustard agent.[71]

The medical expert could not identify with any degree of certainty what might have caused each Marine’s blisters. However, he listed several reasons why it is unlikely mustard agent exposure caused these Marines’ blisters:


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