III. NARRATIVE^[1]

On August 27, 1997, the Special Assistant for Gulf War Illnesses published the original narrative detailing the circumstances surrounding the possible exposure to liquid mustard chemical warfare agent of a US soldier during the Gulf War.^[2] Since then the Presidential Special Oversight Board for Department of Defense Investigations of Gulf War Chemical and Biological Incidents (PSOB) and the General Accounting Office (GAO) have reviewed the narrative and provided comments to the Special Assistant. Both the PSOB and the GAO agreed with the original assessment based on information presented that an exposure to a chemical warfare agent was likely; however, both recommended additional investigation.

We investigated further as the PSOB and GAO suggested. New information about this incident includes reports on the location of the suspected bunker and when it was constructed. In the original investigation of this incident, we interviewed 11 people. For this follow-up investigation, we re-interviewed 4 people and conducted 20 new interviews. We identified 7 additional people to interview, but were unable to locate them. For the original narrative, we telephonically interviewed Colonel Dunn, the physician who examined Private First Class (PFC) Fisher and diagnosed the injury as an exposure to a chemical warfare agent; we interviewed him in person for this version. This narrative incorporates additional information obtained from PFC David Fisher.^[3] It also includes information obtained during interviews with medical and chemical warfare agent experts as well as with the soldiers who conducted the search and destroy mission with PFC Fisher.^[4]

According to a VII Corps message,^[5] PFC Fisher’s reported exposure to liquid mustard chemical warfare agent occurred on March 1, 1991, in a bunker located near the Iraq-Kuwait border.^[6] Figure 2 shows the general area where the bunker reportedly was located.

Figure 2. Location of reported mustard exposure incident

Reports on the bunker’s location vary, making its exact location difficult to determine; however, at the time of the incident, most of the reported locations were on Kuwait’s side of the border near Universal Transverse Mercator (UTM) coordinates QU 050 072. Figure 3 shows this location and others in detail. A VII Corps casualty report records another location for the bunker—on the Iraq-Kuwait border at UTM coordinates QU 003 023.^[7] We found no other information to support this location.

Figure 3.  Locations associated with the reported mustard exposure

PFC Fisher’s unit conducted a search-and-destroy mission centered on UTM coordinates PU 995 047.^[8] A VII Corps report to US Army Central Command (ARCENT) listed the location of the incident in Iraq "W [west] of PU 995 047."^[9] The unit’s mission was to destroy enemy vehicles and bunkers located within an area five kilometers east and west of UTM coordinates PU 995 047 and four kilometers north and south of the same coordinates—an 80 square kilometer area, shown as the shaded portion of Figure 3.^[10] PFC Fisher related he had checked out some 30 bunkers over three days before the diagnosis of his blister agent injury.^[11]

After medical personnel diagnosed PFC Fisher’s blisters as a chemical warfare agent exposure, two Fox vehicles went to find the bunker suspected of being the point of exposure. Although VII Corps reported to ARCENT that PFC Fisher would accompany the Fox vehicles to the suspect bunker^[12] when they searched the area, PFC Fisher did not accompany them to identify bunkers he had searched. ARCENT directed him not to accompany the vehicles, but rather to wait for a special chemical medical casualty team to examine him.^[13] The Fox vehicles searched the suspected area; one reported traces of distilled sulfur mustard and mustard-T mixture blister agent^[14] at a bunker located in Kuwait at UTM coordinates QU 050 072^[15] . The second Fox failed to detect the presence of any chemical warfare agent at the same location.^[16] An after action report noted the bunker at UTM coordinates QU 053 072.^[17] A VII Corps journal entry concerning this activity noted a Fox vehicle had a weak HD [sulfur mustard] reading at the suspected bunker at UTM coordinates QU 053 027,^[18] which may have been a transposition of the "072" portion of the coordinates.

According to an intelligence report, the suspected bunker was in an area recently occupied by Iraq’s 52^nd Infantry Division^[19] at geographic coordinates 29 56N 047 06E (UTM coordinates QU 031 136). At the time of the reported exposure, an officer who served with the 9^th Battalion, 227^th Aviation Regiment, was located at a tactical assembly area at geographic coordinates 29 57 06N 047 05 02E (UTM coordinates QU 010 150). He reported the bunker where PFC Fisher was exposed was one kilometer northeast of the tactical assembly area.^[20] We found no other information to support this statement.

PFC Fisher’s initial treatment by the medics in the 4^th Battalion, 8^th Cavalry Regiment (4-8^th Cavalry) aid station did not focus on his injury as chemical warfare-related. PFC Fisher himself originally thought a spider bite might have caused his arm’s redness and soreness. At 1:00 AM, March 2, 1991, he awakened for guard duty and radio watch and noticed redness on his upper left arm. He went to sick call at 8:00 AM; the medic diagnosed the blister as a possible heater burn and told Fisher to return to sick call in the afternoon.^[21]

• His company medic checked him, thought he might have a heater burn, and had him return at 1600, when more blisters had formed on the lower arm. At that time he was seen by CW2 [Chief Warrant Officer 2] Ahmed and CW3 [Chief Warrant Officer 3] Widhalm^[22] at the 4-8^th Cavalry aid station. They suspected he might be a blister agent casualty, decontaminated him with 0.5% chlorine solution, applied a local dressing, and evacuated him to C Co. [Company], 45^th Support Bn [Battalion].^[23]

CW2 Ahmed related Fisher came to him with "a big blister on the deltoid of his arm,"^[24] which CW2 Ahmed said he treated with calcium hypochlorite. CW3 Widhalm examined PFC Fisher’s blisters and stated, "It was a textbook picture straight from the photos shown in the chem school."^[25]

The assistant non-commissioned officer in charge (NCOIC) of the 4-8^th Cavalry aid station and another medic working there took PFC Fisher through the decontamination procedures. The assistant NCOIC indicated he knew of no urine or blood tests taken while PFC Fisher was at the aid station.^[26] Medical personnel evacuated PFC Fisher to the 45^th Support Battalion for further treatment.

• At C Company, 45^th Support Battalion, Private Fisher was treated by [the senior medical officer], MAJ DeClue, who confirmed the clinical diagnosis of blister agent exposure, photographed the blisters, applied a topical antibiotic and gauze dressing, and returned him to duty with follow-up at his unit. Private Fisher remains in full duty status.^[27]

Before hostilities, three two-man teams of medical experts had deployed to the Kuwait theater of operations from the US Army Medical Institute of Chemical Defense. One team each was assigned to VII Corps, XVIII Airborne Corps, and the US Marines in-theater. Colonel (Doctor) Michael Dunn and another doctor, a pulmonary specialist, made up the VII Corps team.^[28] On PFC Fisher’s diagnosis and treatment as a chemical warfare agent casualty, Colonel Dunn’s team was notified to examine PFC Fisher’s injury.^[29]

• I examined him and interviewed CW2 Ahmed and CW3 Widhalm on 3 March at 1100. Private Fisher had two blisters, about 2 centimeters (cm) diameter each, on the left upper arm, and another two blisters, 1 to 2 cm in diameter, on the lateral left forearm, each surrounded by a narrow margin of erythema, or reddening. The roof of one upper arm blister had broken and the other three remained fluid-filled. Private Fisher felt fine except for mild local pain that did not interfere with his duty performance. The skin area was photographed and a urine sample was saved in preservative for later analysis for thiodiglycol, a mustard [agent] breakdown product.^[30]

When confronted with this apparent chemical warfare agent exposure, Colonel Dunn reviewed PFC Fisher’s activities before his first symptoms appeared. Colonel Dunn indicated in several interviews PFC Fisher’s blisters could have been caused by something other than mustard, such as poison ivy or other "skin sensitizing contact dermatitis provokers."^[31] However, in the absence of these causes and with the possibility that US soldiers might encounter chemical warfare agents in Iraq, he agreed with the clinical diagnosis of blister agent exposure.

When Colonel Dunn interviewed PFC Fisher to determine where and when his exposure might have occurred, he learned PFC Fisher had entered several bunkers on a search-and-destroy mission. PFC Fisher entered one particular bunker by squeezing through the doorway and passageway^[32] , where he recalled contacting many surfaces in the tight passages, thus soiling his clothing and equipment.^[33] Exiting the bunker, he again brushed against the wall and doorway.^[34]

Colonel Dunn concluded an exposure to liquid mustard chemical warfare agent while exploring enemy bunkers caused PFC Fisher’s skin injury. Colonel Dunn believed the sequence of events was consistent with this conclusion, particularly the eight hours between exposure and the first symptoms’ appearance. He concluded no other corrosive or skin-toxic chemical compounds that reasonably could be expected to be on the Gulf War battlefield show this eight-hour latent period between exposure and blisters’ appearance.^[35]

In a 1995 interview, Colonel Dunn reviewed the possible causes of PFC Fisher’s injury. He stated there were two possibilities. One possibility was PFC Fisher may have gotten into something on the battlefield other than mustard, for example, waste products usually associated with motor pools or possibly rocket fuel. All sorts of things might have caused blistering. Alternatively, PFC Fisher was, in fact, exposed to mustard chemical warfare agent. Colonel Dunn concluded that all of the information available at the time led to the diagnosis that the injury was clinically consistent with a mustard exposure, but that it was unproven and unconfirmed.^[36]

In a 1999 discussion with Colonel Dunn of possible causes for PFC Fisher’s blisters, he stated

• I was also asked could this represent exposure to something other than mustard … and I said, "Yes." [T]here [are] several other things that can cause skin blisters after a symptom-free latent period of many hours. The commonest one … is poison ivy and there are a few other skin sensitizing contact dermatitis provokers …. So, in the absence of any of these other well known potential causes of skin blisters after a latent period of time and with a hint of the positive Fox vehicle spectrum, we concluded that on clinical grounds this appeared to be a mustard exposure.^[37]

Colonel Dunn went on to explain that the universe of things that can cause skin to redden and blister six to eight hours after exposure is rather limited. Chemical warfare agents, some skin sensitizing agents and some plants like poison ivy can cause blisters such as PFC Fisher’s. In the absence of evidence for other things that seem likely, given the location, he believed mustard was the most likely, especially considering the latent period.^[38]

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