A. Background

1. Incident Report

In February 1998, investigators for the Special Assistant for Gulf War Illnesses, Medical Readiness, and Military Deployments interviewed Navy doctors and medical personnel about various issues. During these interviews, two nurses and one member of Fleet Hospital 15's administrative staff described an incident that occurred at the hospital in Al Jubayl, Saudi Arabia, in early March 1991.

According to a nurse on duty at the time of the incident, approximately 15 to 20 Marines from the 2d Reconnaissance Battalion came to the hospital seeking treatment for what she thought doctors diagnosed as symptoms of chemical warfare agent exposure. According to the nurse, hospital personnel admitted seven of these Marines for treatment and one had to be intubated due to a severe respiratory ailment.[2] The assistant chief of the hospital's Casualty Receiving Area and another nurse, both on duty at the time, made similar statements to our investigators regarding the treatment of these Marines.[3] None of these three persons treated these Marines nor were they present when the Marines were treated; however, the assistant chief of the hospital’s Casualty Receiving Area thought this incident was so significant that he photocopied the casualty receiving records, retained them, and later provided us those records for this investigation.

2. The 2d Reconnaissance Battalion

a. Organization

In December 1990 the 2d Reconnaissance Battalion, 2d Marine Division (MARDIV), Fleet Marine Force Atlantic deployed to the Persian Gulf as an operational component of the I Marine Expeditionary Force. The battalion's subordinate commands included a Headquarters Company and Companies B, C, and D (Company A was detached before January 1991). These companies’ personnel divided into 29 reconnaissance teams, of which 24 were motorized with 48 high-mobility multi-purpose wheeled vehicles (HMMWVs).[4] This narrative covers activities that occurred between February 4, 1991 and March 17, 1991.

The Marines involved in this investigation belonged to teams of Company B, which consisted of the company commander and three reconnaissance platoons. The reconnaissance platoons’ teams consisted of a team leader and five to seven Marines.[5] Six Marines from Company B reported experiencing the blisters we investigated. Figure 2 illustrates those Marines’ positions in the company's chain of command.

map of 2d Recobbaissance Battalian organization

Figure 2.  2d Reconnaissance Battalian organization

b. Mission

The 2d Reconnaissance Battalion supported the 2d MARDIV by conducting reconnaissance and surveillance of the areas forward of Coalition defensive positions. The battalion’s task was to identify enemy units south of the breaching sites and gaps or weaknesses in enemy defenses in those areas.[6] They accomplished this task by establishing observation posts along Kuwait's border and conducting reconnaissance patrols in that vicinity.

B. Sequence of Events

We primarily used veterans’ accounts, supported where possible by documented evidence, such as watch logs, unit chronologies, and Gulf War histories to develop this chronology. Figure 3 graphically depicts the time-line of these events.

timeline of events

Figure 3.  Timeline of events

1. Pre-Ground War Activities

On January 29, 1991, Iraq's units probed across the Saudi Arabian border three times, once in the 2d MARDIV's area of responsibility. This prompted the division commander to move the 6th Marine Regiment forward to provide a defensive front for the 2d MARDIV. At this time Company B was detached from the 2d Reconnaissance Battalion to support the 6th Marines, which they did by establishing listening and observation posts four kilometers south of Kuwait’s border. On February 4, 1991, the observation posts moved forward two kilometers to a man-made berm parallel to Kuwait’s border that concealed them from observers north of the position. Five days later, the 8th Marines relieved the 6th Marines. Company B remained in position (Figure 4).[7]

map of observation post locations on February 10, 1991

Figure 4.  Observation post locations on February 10, 1991

a. Symptoms Develop (February 4-14, 1991)

Between February 4 and 14, 1991, six Marines from Company B reported developing what they have described as bumps, blisters, or sores on their hands, ears, and necks. These Marines were from different teams and different platoons, and were assigned to different observation posts. Five Marines were from the 1st Platoon: one from the first reconnaissance team, one from the second, and three from the third reconnaissance team. The sixth Marine to report experiencing these symptoms was 3d Platoon's commander.[8]

The possibility of biological or chemical warfare was heavily emphasized during the Gulf War—Coalition forces expected Iraq’s forces to initiate chemical warfare.[9] Because of this expectation, the proximity of Company B's listening and observation posts to Iraq’s forces, and the obvious concern that the blisters could have resulted from some types of chemical warfare agent exposure, the company commander instructed these Marines to seek medical attention.[10]

At a rear area command post, corpsmen and various medical personnel examined the Marines. No one could diagnose a cause, but several speculated that the blisters formed because of something the Marines contacted while digging in the sand at the berm. Because of the threat of chemical attack, someone tested the Marines and their equipment for chemical contamination with a chemical agent monitor (CAM), a portable, hand-held device capable of detecting blister or nerve agent contamination on personnel, equipment, and elements of the surrounding environment (Figure 5 and Tab E). The CAM alerted for the presence of chemical warfare agent on one Marine's glove, so field medical personnel prepared the Marines for decontamination procedures. However, after the operator cleared the CAM and retested the glove, there was no alert. The CAM operator decided the alert had been a false detection and decontamination procedures were unnecessary.[11]

picture of a chemical agent monitor

Figure 5.  A chemical agent monitor

b. 8th Marines Regimental Aid Station (February 14, 1991)

Because the command post medical staff was unable to determine a cause for the blisters, the Marines traveled farther back to the 1st Battalion, 8th Marine Regiment’s battalion aid station. Medical personnel again examined the Marines but could not diagnose a cause. The Marines stayed overnight, showered, and the next morning continued further back to a larger aid station operated by the 8th Marine Regiment.[12]

At the regimental aid station, medical personnel inspected the blisters. At least one Marine remembered having one of the blisters opened for closer inspection and cleaning. Further inspection of the blisters prompted one unidentified individual to speculate that the lesions could be the result of leishmaniasis, a parasitic disease spread by the bite of infected sandflies. This Marine recalled that medical personnel dismissed this explanation due to the absence of any other symptoms commonly associated with this condition, such as fever, fatigue, and abdominal discomfort.[13]

The Marines returned to duty. They were not incapacitated and their symptoms in no way hindered them from performing their daily tasks. Medical personnel had not diagnosed the blisters’ cause and advised only frequent daily hand-washing to treat the blisters. After approximately three to five weeks of daily washing, the blisters healed with no further complications.[14]

Little documentation describes the treatment of these injuries. In fact, after thoroughly searching medical records, unit histories, and watch logs, we could find only one reference to this incident. A 9:15 AM entry on February 14, 1991, in the 2d Reconnaissance Battalion's Watch Officer Log reads:

MSG [message] Received from "B" Co. 1.) Still maning [sic] OP [observation posts] F + D 2.) They have 6 people w/ blisters on hands and are being looked at by 8th MAR M.O. [medical officer] 3.) They wanted to know the status of their HMMWV alternator 4.) They also requested that LCPL [redacted] out of Combat Replacement Co return to BN [battalion].[15]

Company B rejoined the 2d Reconnaissance Battalion on February 18, 1991, as the unit prepared for the ground offensive.[16]

2. Ground War Activities (February 24-26, 1991)

The 2d Reconnaissance Battalion moved through the minefield breaching lane behind the 6th Marines on February 24, 1991, after which the battalion supported the 2d Battalion, 4th Marine Regiment during the final assault from Phase Line Horse to Phase Line Bear (Figure 6), providing navigational support and additional firepower with HMMWV-mounted machine guns.[17] All the Marines who experienced the reported symptoms were with the unit at this time and participated in these events unhindered by any ailments.[18]

map of movement of the 2d Reconnaissance Battalion on February 26, 1991

Figure 6.  Movement of the 2d Reconnaissance Battalion on February 26, 1991

3. Fleet Hospital 15 (March 11-17, 1991)

Between March 11 and 17, 1991, approximately one month after field medical personnel examined the Marines at the 8th Marines' regimental aid station, doctors at Fleet Hospital 15 in Al Jubayl treated three Marines from Company B, including the 1st platoon commander, for symptoms attributed to respiratory ailments, and another for a broken jaw. According to the hospital's admission logs, these were the only instances between February 10 and March 21, 1991, that anyone from the 2d Reconnaissance Battalion was admitted to this hospital. Two of the casualties eventually were medically evacuated.[19]

One of the Marines in the group treated for respiratory ailments in March was a corporal from 1st Platoon's third reconnaissance team who had developed blisters before the ground campaign. On this Marine's hand where the blisters were healing were minor scars. When doctors asked about them, the Marine recounted his treatment at the 8th Marines' aid station. It may have been unclear to hospital staff what caused the blisters, but doctors did not find the scars severe enough to require any treatment. Fleet Hospital 15 personnel later reported the treatment of these 2d Reconnaissance Battalion Marines to our office as a nuclear, biological, or chemical (NBC) incident. When questioned, both the Marine corporal and the 1st Platoon commander stated that they went to Fleet Hospital 15 in March 1991 for treatment of respiratory ailments they associated with inhaling oil well fire smoke, not chemical warfare agent exposure or the blisters that developed before the ground war.[20]

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 that 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 that 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 that 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 NCO. 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 that the blisters were due to chemical warfare agent exposure.[31] The 2d MARDIV NBC staff NCO 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 that 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 that 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, he 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 that 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.[68] 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.[69] 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.[70] The admission logs do not indicate anyone was ever admitted to the hospital for the treatment of chemical warfare agent exposure.

4. Civilian Medical Expert's Review

During our investigation, we asked a civilian 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. Five Marines viewed pictures of skin lesions caused by various conditions, including mustard agent exposure, and the Marines identified which ones most resembled their blisters. Pictures they selected included polymorphic light eruptions, leishmaniasis, urticaria, infectious folliculitis, Grover's Disease, and dermatomyositis.[71] None of the Marines identified the pictures of blisters caused by exposure to mustard agent.[72]

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

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