Opinion | Are Health Systems Prepared for Chemical Warfare in Ukraine?

As the war in Ukraine grinds on, the question is increasingly about the lengths the Russian army will go to prevail against Ukraine. The latest concern? Fear that Russia will begin using chemical weapons.

While it’s uncertain at this moment whether Russia will actually launch such an attack, one thing is clear: in a large-scale chemical attack within the current Russian-Ukrainian conflict, the prospect of any meaningful healthcare response is bleak.

Cause for Concern

In 1986, the Cooperative Threat Reduction (CTR) program was launched. The program, better known as the Nunn-Lugar Act, was created for the purpose of securing and dismantling weapons of mass destruction and their associated infrastructure in the former Soviet Union, including Ukraine. The workings of the CTR program have been openly discussed since its inception, and the program has operated in a number of Ukrainian labs for the purposes of biosafety and training.

Just recently, Russia brought a complaint to the U.N. Security Council to address its accusation that the U.S. and Ukraine are using the CTR program instead to develop chemical and biological weapons with intent to use them in the current Russian-Ukraine conflict. According to news reports of the White House’s response, Russia may have made this claim to “lay the groundwork” for its own use of such weapons against Ukraine.

How might such an attack work? Chemical and biological agents may be prepared in stealth, are easily concealed, and can be readily introduced into the air, water, or food supply. Chemical agents can be broadly classified as blistering/vesicants such as mustard, blood agents such as hydrogen cyanide, choking/pulmonary agents such as chlorine gas, incapacitating agents such as opioids, and nerve agents such as sarin or the Russian-made Novichok. In the modern era, chemical weapons development originated in the 1930s with the development of the nerve agents — organophosphorus cholinesterase inhibitors, each with particular potency.

Nerve agents are colorless and odorless, and the classic four include sarin, soman, tabun, and the American-produced VX. The V agents were at one time considered to be the most toxic agents ever produced and are ten times more toxic than sarin. Full-scale production of VX occurred in America in 1961 with the production of tons of the chemical agent. VX can kill a person rapidly after they have been exposed to an infinitesimal amount, specifically, the quantity needed to cover just two columns on the Lincoln Memorial on the back of a penny.

If a person is exposed to a nerve agent, a constellation of symptoms occur. Nerve agents block the action of acetylcholinesterase, and this leads to accumulation of the neurotransmitter acetylcholine. High levels of acetylcholine in the synaptic cleft causes overstimulation of cholinergic receptors. Symptoms related to excess accumulation of acetylcholine are divided into three groups: muscarinic, nicotinic, and central. Overstimulation of muscarinic cholinergic receptors causes pupil constriction, glandular hypersecretion, urination, defecation, sweating, and vomiting. Nicotinic symptoms are weakness and ultimately paralysis. Central nervous system poisoning will manifest as irritability, delirium, fatigue, lethargy, seizures, coma, and death by respiratory depression. Clearly, these symptoms should not be taken lightly.

Impact on Health and Healthcare

The use of chemical weapons in warfare present a particular problem to healthcare. Such weapons can create a complex mass casualty event where the treating personnel and the healthcare facilities may themselves be within the zone of conflict. Chemical and biologic attacks require intense and complex treatment, and in both types of attacks, treating personnel may themselves be at risk of becoming exposed and therefore decontamination may be required before the initiation of any supportive treatments. Emergency and medical providers would also need to have access to proper respiratory protection and hazardous material/chemically resistant suits, and in a widespread attack, in an ever-deteriorating war zone like Ukraine, such treatment capacity would be highly limited.

This wouldn’t be the first time Russia launched such an attack — the country has shown itself willing to use chemical agents in the past. In 2002, Chechen rebels took over a Moscow theatre and held 700 hostages, threatening to execute them. Russian authorities stormed the theater after using an incapacitating gas that may have been a mixture of remifentanil/halothane or the ultra-potent carfentanil in an aerosolized form. Carfentanil is a synthetic opioid that is approximately 10,000 times more potent than morphine — it is intended to be used as an anesthetic for large animals. The consequences of opioid overdose are well known. In many such cases, respiratory failure leading to death is the accidental consequence. In the Moscow Theater raid, opioids were specifically weaponized and death or injury was the specific intent. In the immediate aftermath of the Russian raid, at least 33 Chechens and 129 hostages died, the great majority of them from gas exposure and inadequate medical care. Russian authorities refused to release specific information on the nature of the gas exposure, significantly hampering the healthcare emergency response.

Russia has also seemingly used Novichok, the chemical nerve agent developed by the former Soviet Union and Russia. Novichok in certain variations may be even more potent than VX — possibly eight times as potent. Novichok has come to the attention of the public as an agent used in attempts to kill opponents of the Russian government. The most recent occurrence of this was the attempted assassination of Alexei Navalny in 2020. The use of Novichok as the poisoning agent was under dispute, but the immediate and subsequent treatment was tailored to treat nerve agent exposure and included large doses of atropine. Navalny survived but the treatment of just one individual required a labor intensive, organized, and sophisticated healthcare response. The widespread use of Novichok — or any other chemical agent in a war zone — threatens to be nearly universally fatal, potentially killing members of the public, Ukrainian military members, and exposed first responders.

Thus, based on prior history, there is a pattern and a willingness by Russia to deploy chemical and even biological agents while simultaneously projecting or deflecting attention. Indeed, the Russian government’s claim of biological weapons stored in Ukraine has served to galvanize further polarization of the war effort. Despite this, at the U.N. Security Council meeting on March 12, the High Representative for Disarmament Affairs, Izumi Nakamitsu, reported that the U.N. is “not aware of any biological weapons programs.” And to those who make note that there are biological research facilities in Ukraine, we must be clear: biodefense, including the production of medical countermeasures (diagnostics, therapeutics, personal protective equipment) is a vital component to bio-risk management and bio-preparedness. Medical countermeasures must be prioritized in shipments to Ukraine, in addition to standard resources. We would do well to remember that the healthcare response — and survival — will depend on it.

Gavin Harris, MD, is an assistant professor of infectious diseases and critical care at the Emory University School of Medicine in Atlanta. His clinical expertise and research interests include disaster preparedness and biosecurity, medical education and the care of critically ill patients, and scholarly work in military history and the history of medicine. Joel Zivot, MD, is an associate professor of anesthesiology/critical care at Emory University School of Medicine. His clinical expertise and research interests include care of critically ill patients in the OR and ICU, education, and scholarly work in bioethics, the anthropology of conflict resolution, law, policy, and a variety of topics related to anesthesiology/critical care monitoring and practice.