E. Subject Matter Experts' Opinions

1. Medical

At the time of the incident, Colonel Dunn concluded:

Later, in his testimony to the Presidential Advisory Committee on Gulf War Veterans’ Illnesses five years after the incident, Colonel Dunn stated:

We contacted an expert (a medical doctor) and asked him to review the circumstances surrounding Colonel Dunn’s diagnosis. He read the original narrative and viewed electronic copies of the photographs of PFC Fisher’s blisters, which the original case narrative did not include. He concluded

Based principally on Colonel Dunn’s clinical presentation of the incident, this medical expert believed the diagnosis of chemical warfare agent exposure was the most consistent with the information he reviewed. He stated the inconclusive nature of the urinalysis and MM-1 tests did not detract from the strong clinical chronology suggestive of a mustard exposure. While other causes cannot be completely ruled out, the expert stated that Colonel Dunn had suggested no likely candidates for further exploration. Taking all of this into consideration, including how the blisters appeared in the photographs, he concluded it is more likely than not, to a reasonable degree of medical certitude, PFC Fisher sustained an exposure to a sulfur or nitrogen mustard-type vesicant on March 1, 1991.[72]

2. MM-1 Mobile Mass Spectrometer

In 1993, a Chemical and Biological Defense Command[73] subject matter expert reviewed a copy of the MM-1 printout made during the Fox vehicle company commander’s test of PFC Fisher’s flak jacket. He reported the MM-1’s detections were at fairly high response levels and believed although the spectra taken did not verify the agent alarms, the high amount of oil and grease on the clothing may have prevented acquiring an actual spectrum for mustard chemical warfare agent. He concluded the incident was a mustard detection.[74]

He also reviewed the videotape and concluded it showed a spectrum verifying the alarm as HD (sulfur mustard).[75] Figure 7 [76] shows the spectrum data on the MM-1 screen as recorded on videotape. The MM-1 was in the surface monitor mode and had identified the blister agent, S-Mustard. "S-Mustard (HD)" is visible on the screen.

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Figure 7.  MM-1 screen showing spectrum for S-Mustard (HD)

In February 2000, we again asked this expert to review the videotape and ion relative intensity data we had extracted from it.[77] The analyst reviewed both and, believing the data showed the presence of sulfur mustard, stated:

After reviewing the videotape and associated ion relative intensity data, the CIA concluded mustard chemical warfare agent was not present on PFC Fisher’s flak jacket based on the absence of critical ions. They pointed out that several ions of medium-high intensity from a standard sulfur mustard spectrum are not present in the spectrum obtained from testing PFC Fisher’s flak jacket. For example, ion 59, ion 63, and ion 73 are missing. The absence of ions is a good indicator a target substance is not present. Of these missing ions, ion 63 is the most critical. Its presence is usually one-half to one-third the intensity of the most intense ion. Since ion 63 was not detected, the CIA concluded no detectable amount of mustard was found by the MM-1.[79]

F. Analyzing the Incident

1.  Likelihood of Chemical Agents in the Area

Is it reasonable to believe that a chemical warfare agent would be present in a bunker along the Iraq-Kuwait border?

The United States knew Saddam Hussein’s army had used chemical weapons in the Iran-Iraq war, knew his army had chemical weapons in its inventory in 1990, and expected to encounter these weapons on the battlefield.

In the underground bunker where he squeezed through a narrow doorway, PFC Fisher reported seeing ammunition—crates and many loose artillery projectiles in disarray, possibly due to earlier bombing.[80] PFC Fisher told one of the Fox vehicle commanders, "Everything inside the bunker looked like it had been deliberately messed up with broken items and everything in shambles."[81] However, he did not identify the munitions as chemical weapons and we found no evidence Iraq moved chemical weapons or chemical warfare agent into this area of the theater of operation.

In a 1995 interview,[82] Colonel Dunn speculated PFC Fisher might have encountered chemical warfare agent residue from weapons stored in bunkers (also called revetments) during the Iran-Iraq war because mustard is a very persistent agent. However, intelligence sources revealed the bunkers PFC Fisher’s unit searched were built in late 1990 after Iraq invaded Kuwait[83] and long after the Iran-Iraq war. Consequently, if PFC Fisher was exposed to liquid mustard while searching bunkers along the Iraq-Kuwait border, he encountered chemical warfare agent deployed in late 1990 or early 1991, not something left over from an earlier war.

However, in testimony to the Presidential Advisory Committee on Gulf War veterans’ Illnesses in July 1997, the Special Assistant to the Director of Central Intelligence for Persian Gulf War Illnesses Issues, discussed the possibility chemical weapons may have been present at 17 weapons storage sites along the Iraq-Kuwait border. He commented the CIA had assessed that Khamisiyah and An Nasiriyah were the only two sites within the Kuwait theater of operations where chemical weapons were stored during Desert Storm.[84] (PFC Fisher was never near either of these sites). The United Nations Special Commission echoed this testimony before the same committee. When asked if chemical weapons had been moved into Kuwait, the UN official, Charles Duelfer, stated, "We have seen no evidence of that and Iraqis have said that no movements took place…."[85]

During post-war munitions clearance operations in Kuwait, no chemical weapons were reported found in the US sector or indeed anywhere in Kuwait. According to the Defense Intelligence Agency, "During the three-year post-Gulf War ordnance clearing operations in Kuwait, chemical warfare agents were never detected."[86]

2.  Location of Possible Chemical Exposure

How confident are we regarding the location of the bunkers where PFC Fisher was possibly exposed to liquid mustard chemical warfare agent?

The bunkers PFC Fisher explored on March 1, 1991, are located approximately 100 miles south-southeast of the Khamisiyah-An Nasiriyah area. Based on the area covered by his unit’s search-and-destroy mission (80 square kilometers overlapping the Kuwait-Iraq border), it is possible they could have been in either Iraq or Kuwait, although reporting at the time of the incident consistently placed the suspected bunker on the Kuwait side of the border.

No one can pinpoint the exact location or time of PFC Fisher’s reported exposure to the chemical that caused his blisters. By his own estimate, PFC Fisher investigated more than 30 bunkers during the three-day search-and-destroy mission.[87] Reconstructing the details of the mission’s activities with Colonel Dunn after his diagnosis of exposure to a chemical warfare blister agent, the two narrowed the possibility to a bunker where PFC Fisher squeezed through tight passages, brushing against the bunker walls and doorways. Although PFC Fisher’s experience in that particular bunker seemed the most logical explanation for his exposure, it is simply his and the doctor’s best guess as to when and where the exposure could have occurred.

We have information about the two Fox vehicles sent to investigate the suspected bunker. A message from VII Corps to ARCENT indicated PFC Fisher was "OK…[and would] return to [the] scene to assist Foxes locate [the] site of possible chemical agent."[88] However, PFC Fisher did not accompany the Fox vehicles because higher headquarters wanted him available for Colonel Dunn’s examination.[89] The Fox vehicles reported they "found a bunker [with] traces of HD."[90] Because PFC Fisher was not with the Fox vehicles, we cannot be certain if they found the particular bunker he believed was the site of his exposure. Additionally, we have no confirming evidence, such as MM-1 printouts, about the Fox vehicle reports of HD in the suspect bunker.

3.  Medical Expertise

How well were the medical personnel trained regarding the identification and treatment of chemical warfare agent-related injuries?

Colonel Dunn’s credentials identify him as an expert in chemical warfare agent-related injuries. During Desert Shield/Desert Storm, Colonel Dunn was the US Central Command chemical casualty consultant, responsible for research and instructing US and allied physicians and medical personnel in chemical casualty care and medical protection against chemical warfare agents.

During peacetime, the Medical Research Institute of Chemical Defense conducts a Medical Management of Chemical Casualties Course at Aberdeen Proving Grounds, Maryland. The curriculum involves five days of classroom and field instruction on recognition and medical management of chemical casualties. The course trains medical personnel (doctors, nurses, physician’s assistants, clinical scientists, and senior enlisted medical specialists). When Operation Desert Shield started, the Institute increased its course instruction at Aberdeen and at posts in the United States and Europe for units identified as ones about to deploy to the Middle East. Colonel Dunn testified he was certain course graduates were assigned at every location where a US unit was stationed.[91] It is reasonable to believe all the medical personnel involved in this incident were adequately trained to recognize and correctly treat this type of injury.

4.  Factors Affecting an Accurate Diagnosis

Even with adequate training, could the medics and doctors who attended to PFC Fisher have made a hasty or incorrect diagnosis?

The medical personnel who examined and treated PFC Fisher did not rashly diagnose him as a chemical warfare agent casualty. During his first sick call visit, they apparently did not suspect his injuries might have been related to chemical warfare agent—"heater burn" was the first diagnosis. This changed on his second sick call visit; the medics eventually thought the blisters were characteristic of a chemical warfare agent exposure. At that point, they decontaminated PFC Fisher and called in an expert, Colonel Dunn, to confirm or refute their diagnosis. By this time, two medics, two physician’s assistants, and a medical doctor had seen PFC Fisher. Colonel Dunn concurred exposure to liquid mustard chemical warfare agent had caused PFC Fisher’s injury. Based on interviews with the medical personnel involved in this incident, it appears they made their diagnosis carefully and deliberately. The photographs provide a historical record of the injury but shed no light on its cause. Although they are insufficient to conduct a detailed analysis, they confirm the blisters’ existence.

5.  Absence of Thiodiglycol

Could the diagnosis have been incorrect, since the urinalysis was negative for thiodiglycol, a mustard breakdown product?

Colonel Dunn was not surprised by thiodiglycol’s absence in the urine. He believed PFC Fisher’s exposure was so mild that the lack of a mustard breakdown product was not surprising. In addition, more than 40 hours passed from the time of the possible exposure to the time PFC Fisher provided a urine sample. If PFC Fisher had been exposed to liquid mustard, he probably would have eliminated through urination any trace of thiodiglycol from his system during that period. Thus, the absence of physical evidence, i.e., thiodiglycol in his urine, does not imply PFC Fisher had not been exposed to liquid mustard.

6.  Discrepancies in Test Results

How do we account for the apparent positive results from the Fox tests completed in Iraq and the negative results for those completed at the Chemical Research, Development, and Engineering Center (CRDEC) in the US? Were the tests conducted properly?

Two positive spectra for chemical warfare agent were reported: the MM-1 test of PFC Fisher’s coveralls and the two tests on his flak jacket. In the first case, the coveralls test printout conflicts with the Fox vehicle company commander’s recollection of the event. He recalled his MM-1 operator printed a spectrum for sesqui-mustard. The tape refutes this. No spectrum was obtained to provide high confidence of the presence of any of the chemical agents for which the MM-1 alarmed.

In the second case, while the company commander reported his Fox alerted for sesqui-mustard and lewisite on the flak jacket, the MM-1 spectrum did not indicate the presence of any type of chemical warfare agent, evident on the paper printout produced at the time (Tab G).[92] The second Fox, however, apparently obtained a spectrum for sulfur mustard. While a paper printout documenting this test is unavailable, the event was videotaped. According to the Fox Vehicle Program Management Office, the videotaped spectrum revealed that the presence of mustard on the flak jacket was only possible, but not probable. Data extracted and transcribed from the videotape showed the Fox spectrum did not contain a number of critical ions necessary to indicate mustard presence.

Finally, laboratory testing at CRDEC did not detect chemical warfare agent on either the flak jacket or the coverall swatch sent from Iraq.[93] However, it is possible the small amount of liquid mustard that might have been present on these articles dissipated through improper packaging or mishandling before CRDEC conducted the tests.

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