Our thanks to Col. Dr. Torsten Sohns (MD) for this very important contribution to our baseline of understanding.

The Proliferation of Weapons of Mass Destruction: A Challenge for Decision Makers

Torsten Sohns

German Armed Forces Medical Academy

Neuherbergstrasse11, D – 80937 Munich

Summary: The proliferation of weapons of mass destruction (WMD)[1] and long-range delivery systems continues to be a matter of serious concern, as it can pose a direct threat to national and international security. WMD can be used not only in large-scale military attacks but also during civil wars or by terrorists and other criminal elements. Furthermore in their deployment area, armed forces may face risks in the civilian sector that are the result of the worldwide spread of nuclear technology and chemical industry. There will be fewer and fewer “clean, conventional” scenarios even when NBC weapons are not used. With this in mind, it is amazing how few resources have been allocated to prepare for these imminent dangers. In particular, the military medical services and the civilian health care systems of many countries are not appropriately prepared (manned, trained and equipped) for these dangers.

Key Words: biological, casualty, chemical, countermeasures, defense, medical, NBC, nuclear, radiological weapon, risk perception, terrorism, training

The views expressed in this article are the author's own and in no way reflect those of the German Ministry of Defense or of the German government.


1.1 Risk Estimation

When estimating risks we must look at two dimensions: first, the qualitative dimension that examines the characteristics of possible risks and, second, the quantitative dimension that allows us to estimate the probability of such an occurrence.

NBC risks are estimated as the product of the presence of nations, groups or unaffiliated individuals that desire NBC weapons and the probability that they possess them. In other words, a risk exists where these entities have access to NBC (nuclear, biological and chemical) weapons or agents. Additional risk factors include the means of delivery, in particular missiles with a long range, vulnerable targets and the potential damage that can be inflicted.

The risk becomes a threat once a nation, group or an unaffiliated individual has specific intentions of employing NBC weapons. Such intentions may be the result of international and sociopolitical constellations or the personal situation of a lone fanatic, all of which are factors that will not be discussed here.

In addition to the "classic" or "military" NBC risks arising from the presence of NBC weapons, from a medical perspective we must also consider other dangers with similar effects. As a result of the worldwide distribution and proliferation of nuclear and chemical technology, armed forces may face risks in the civilian sector, e.g., during peace support missions. Possible risks may arise from nuclear power plants, technical and medical radiation sources, depleted uranium, as well as chemical production facilities and stocks (e.g., phosgene, hydrogen cyanide, chlorine gas or insecticides). In the deployment area, safety standards may be lower than those in countries providing troops, and due to circumstances such as civil war, qualified control personnel at such facilities may be lacking. These risks include those resulting from explosions, fires and their associated by-products. Infrastructure disruption may also include neglect of hygiene measures, which could lead to an epidemic because of the reactivation of natural reservoirs. The indigenous population in the deployment area may be more resistant to such diseases than members of foreign forces.

1.2 Proliferation

The proliferation of WMD and long-range delivery means continues to be a matter of serious concern, as it can pose a direct threat to national and international security. Proliferation increases the number of possessors and thus the risk of these weapons being used.

The information presented in the chart below entitled "Reaching for the Bomb" was published in the German newsmagazine Spiegel citing a classified paper of the German Federal Intelligence Service of May 1997.

1.3 Risk Perception

Apart from nuclear weapons tests, few facts ever become public about NBC weapons and their dissemination. For this reason, the public and some decision-makers from many countries are unaware of the risks posed by the proliferation of WMD.

However, another group of decision-makers has access to classified intelligence information, which has increasingly contained reports on the dangers arising from the proliferation of WMD. Consequently, these decision-makers should be more aware of the risk potentials. It is thus amazing how few resources have been allocated in many countries to prepare for these possible upcoming dangers.

The 1991 Gulf War showed the consequences of poor risk perception. Suddenly and unexpectedly, a rogue country's covert NBC program posed a real danger. Recognizing the extent of the danger in Iraq has required years of in-depth investigations by the United Nations Special Commission (UNSCOM) and the testimony of high-ranking defectors.

Another important lesson of the Gulf War is that the improvisation and hasty measures resulting from insufficient medical preparations can have serious consequences. After Operation Desert Storm, thousands of soldiers complained of various vague health disorders, which they believe were, in part, the consequences of such hasty measures. Due to inappropriate medical documentation and missing scientific proof, veterans have not been able to substantiate their theory nor could experts submit conclusive evidence to the contrary. This is the dilemma of the "Gulf War Veteran Syndrome." Quite apart from personal suffering, there has been more than half a decade of bad press for the armed forces concerned. An end to public criticism and uncertainty is not in sight.

The USA provides an example of increased risk awareness and the willingness to act on the conclusions. Much more than in the past, its efforts are taking into consideration the dangers posed by the proliferation of WMD. For example, the budget planning for the US armed forces which despite cuts to the total budget provides for an increase from $ 462.3 to $ 610.8 million for NBC defense from 1992 to 2003.


2.1 Nuclear Weapons

In the new security environment, where yesterday's adversaries are today's partners, NATO's strategy for war prevention is no longer dominated by the prospect of nuclear escalation. However, the ability to maintain and restore the health of personnel exposed to a nuclear environment is part of a credible concept of the Alliance. Further, this ability is crucial in order to provide state-of-the art medical care for soldiers in every conceivable situation.

There are several thousand nuclear weapons still stationed in Europe, with an overwhelming proportion in Russia. At present the threshold for employing nuclear weapons is extremely high - in the West we talk of "weapons of last resort.” There is no guarantee that all possessors of nuclear weapons will keep this threshold as high in the future. A nuclear power may well change its strategy if it perceives its conventional armed forces are weak. There are temptations such as “a new generation of theater weapons ... with a low yield and limited side effects for the region and inhabitants outside the direct zone of military action.”

Furthermore, nuclear powers may use nuclear weapons as a means of retaliation against biological and chemical attacks. Since the Biological and Toxin Weapons Convention (BTWC) and the Chemical Weapons Conventions (CWC), nuclear weapons remain the WMD not outlawed by international law. If nuclear powers clash with a state brandishing BW and CW, as was the case in the 1991 Gulf War, preparations must be made to defend against not only hostile BW and CW, but also the collateral effects of friendly nuclear retaliation strikes.

In addition, we must consider that as a result of proliferation of nuclear technology the number of nations possessing nuclear weapons may further increase and that other possessors may not necessarily adhere to the Western policy of weapons of last resort. In addition to the five nuclear powers recognized by the UN Security Council (”P 5”) and the Non-Proliferation Treaty (NPT), two self-declared nuclear powers emerged in May 1998: India and Pakistan. These two powers rose from the ranks of the threshold countries, others may follow.

Particular attention should also be paid to the risk of terrorist groups and organized crime gaining access to nuclear weapons. In this context, existing nuclear potentials have to be considered not only in terms of the proliferation of knowledge, but also in terms of nuclear weapons changing hands. The specter of nuclear weapons changing hands may one day haunt us once a nuclear power becomes unstable, corrupt or extremist. Under these circumstances nuclear weapons may come under the control of civil war factions or may be passed on to rogue or extremist countries, terrorists or other criminals. For this reason stable nuclear powers, in particular a stable Russia with its huge arsenals, are essential for world security.

The risk posed by the use of nuclear weapons embraces a wide spectrum, with the erstwhile most threatening form, mass use, extremely improbable. The risk of locally restricted use is greater today, but so too is the possibility of extensive medical support. In contrast to mass use scenarios, the entire infrastructure would not be destroyed. For this reason, nuclear medical defense activities can no longer be portrayed as useless as was the case in doomsday scenarios. Since help is possible today, we are under a moral and ethical obligation to provide that help.

2.2 Radiological Weapons

“Radiological weapons” are part of the nuclear risk. These are weapons, procedures or methods, that disseminate radioactive substances; e.g., the conventional detonation of a container holding a radioactive substance. At multilateral arms control talks, such weapons are regarded as difficult to define and there is little chance of reaching consensus on this issue. In addition, their military value is unclear.

Nevertheless, recent reports indicate that such weapons could pose a real threat. UNSCOM uncovered evidence indicating that Iraq tried to develop radiological weapons. Other countries as well could have developed or be developing such weapons. In November 1995, Chechen terrorists were reported to be blackmailing the Russian government by threatening to contaminate Moscow with radioactive material, cesium-137.

In this context, the Russian incidents of illegal trade in nuclear material are particularly worrying. German security authorities have registered more than 100 cases a year, since the collapse of the Soviet Union.

2.3 Further Dangers In Areas Of Operation

Further risks both to international crisis management and to humanitarian aid operations may be sources of radiation that are out of control, damaged or destroyed. For example, in the conflicts in the former Yugoslavia, some years ago, hospitals were targeted by the indigenous warring factions, without thought for potential sources of radiation. Lower safety standards may apply to nuclear facilities and to the handling and disposal of radioactive materials, in potential areas of operation.

Military forces throughout the world use depleted uranium for armor and armor-piercing ammunition, which presents additional health risks. An exception to this rule is Germany where the heavy metal tungsten is used instead of uranium. Recent research indicates that radiation induced harmful effects from depleted uranium (e.g., by exposure to shell fragments) have been underestimated in the past.


Biological weapons (BW) consist of biological agents and delivery systems. BW agents are reproductive microorganisms and toxins of biological origin that are produced for non-peaceful purposes, and, whose effects on physiological processes can result in death, temporary incapacitation or permanent damage. Epidemiology divides BW agents into pathogens of transmissible and non-transmissible diseases and toxins.

3.1 Special Properties Of Biological Weapons

The effects of BW agents can vary greatly. Pathogens and toxins can cause fatal diseases, as is the case with pulmonary anthrax or botulism, but are not necessarily highly contagious. Other pathogens, however, can produce communicable diseases, thus leading to the danger of epidemics. Such a danger is posed by plague or smallpox. Since systematic vaccination against smallpox has ceased, any resulting epidemic would be of considerable proportions and highly lethal, unless immediate quarantine measures and vaccination were carried out to prevent the infection from spreading. Other pathogens, such as Q fever, would only incapacitate, but not kill, their victims, unless they were immuno-compromised.

In 1970 an expert commission of the WHO published a model indicating that if 50 kg of anthrax spores were sprayed from an airplane over a major city with 500,000 inhabitants, 95,000 dead and 125,000 cases of illness would be expected. In a nutshell, this means for anthrax spores: 50 kg will kill one fifth of 500,000. These losses are comparable to those inflicted by an atomic bomb attack.

Differentiating between artificial and natural causes of illnesses and deaths is a special problem; diseases can emerge or re-emerge even under natural circumstances. The following descriptions of two outbreaks, which occurred in India and Africa, show just how difficult it can be to distinguish between artificially caused diseases and those that have their origins in a natural reservoir.

In September 1994, a century after the discovery of the plague pathogen, Surat in India witnessed an outbreak of a highly infectious, deadly, pulmonary disease, with a clinical picture similar to pneumonic plague. According to official records, this epidemic caused more than 50 deaths, the majority of which were young men. However, for several years there was no consensus as to whether it was the plague, and, whether the causative strain had been genetically manipulated. The local news spread suspicions that the epidemic was caused by the release of a biological warfare agent. At the close of 1996, a group of experts from WHO (along with specialists from the CDC in Atlanta, the Pasteur Institute in Paris and the Gamaleya Institute in Moscow), together with their Indian colleagues from New Delhi, succeeded in confirming the original diagnosis of pneumonic plague. The isolates were not identical with any of the known Yersinia pestis strains; thus scientists disagreed until 1997 as to whether the Surat plague strains had been genetically manipulated or were a natural mutation of the pathogen. Finally, they concluded that only ribotypes of Yersinia pestis characteristic to western India were involved.

Ebola is another disease that has emerged or re-emerged in recent years. The first reports of this viral hemorrhagic fever were reported in 1976 (318 people in northern Zaire and 284 in southern Sudan contracted the disease with mortality rates of 88% and 53%, respectively). Since that time, this puzzling fatal infectious disease has continued to re-emerge at irregular intervals. Although scientists are convinced that there is a natural reservoir for this pathogen, they have not yet been able to find it.

Should similar situations arise in the midst of a tense international political or military conflict, prompt work would be necessary to clarify the causes. Political and military decision-makers would urgently require a clear and firm medical assessment to evaluate the situation and decide on future actions, which could include grave military retaliation and escalation measures. In view of the extremely important role played by medical diagnostic capabilities, it is crucial that decision makers allocate the necessary resources to state-of-the-art medical biodefense capabilities.

The covert use of biological agents can be particularly attractive to civil war factions and clandestine operation forces. International crisis management operations are usually characterized by a lack of comprehensive military action. Currently, the verification of a biological attack is time consuming and difficult. The possibility of covert use renders the principle of deterrence almost ineffective. Biological agents could be used in and outside crisis areas. Members of the armed forces could be exposed regardless of whether covert use is targeted at the local population, allied units or directly at an armed forces contingent.

3.2 Limited Effectiveness Of Political Measures

The BTWC is the first multilateral agreement to comprehensively prohibit an entire category of WMD. Unfortunately, precise definitions and verification regulations are still in negotiations. Will a comprehensive verification regime be enough? Experience has shown that BW programs have continued despite agreements under international law.

The Geneva Protocol of 1925 only prohibited the first use of BW; the use of BW for retaliation, however, was not prohibited. Consequently, the Geneva Protocol failed to prevent BW programs, as shown by these examples.

Microbiological scientific work conducted in Germany after World War I was misinterpreted and exaggerated. Although historical evidence shows that Germany did not have a BW program, other governments feared that Germany would develop BW. They launched BW programs of their own to prepare for retaliation. Suspicions against Germany were harbored long before World War II.

For this reason France (early 1920s), then England (mid-1930s) and, finally during World War II, the USA and Canada developed biological agents to enable them to strike back. While the French BW program (anthrax, botulinum toxin, ricin, etc.) was still in the development stage at the time of the German invasion, England, the USA and Canada did possess operational biological agents (anthrax and botulinum toxin).

According to Alibekov[2], the Soviet Union began working on a typhus agent, following a secret decree issued by the Revolutionary Military Council of 1928. In the 1930s, the Soviet Union had at its disposal powdered and liquid forms of a typhus agent, which could be disseminated as an aerosol. It also experimented with Q fever, glanders and melioidosis on Solovecki Island in the White Sea. Alibekov adds that the Soviet Union attacked German troops with tularemia in the battle for Stalingrad in 1941 and Q fever in Crimea in 1943. Other sources report that plague, anthrax and cholera pathogens were also available towards the close of World War II.

Japan, which had not ratified the Geneva Protocol, embarked on an extensive biological program in the thirties and used dysentery, cholera, typhoid and plague pathogens in China during World War II.

Even the 1972 BTWC, which comprehensively bans all biological activities that are not justified for prophylactic, protective or other peaceful purposes[3], was unable to prevent continued work on biological weapons programs as the following examples show:

Although Iraq had been a signatory state of the BTWC since 1972, it carried out an extensive biological program which was gradually uncovered in the wake of the Gulf War, though not before 1991. Bending under the pressure of the Gulf War victors, Iraq acceded formally to the BTWC by depositing the instrument of ratification on 19 June 1991. However, its behavior has repeatedly raised doubts as to its adherence to treaties.

In 1992, twenty years after Russia signed the BTWC, President Yeltsin issued a decree admitting that Russia had been working illegally on BW and placed further activities in this field under threat of punishment.

Since then, however, accusations have continued to be leveled against Russia, especially by the USA. Vladimir Pasechnik and Kanatjan Alibekov, who defected in 1989 and 1992, claim they had previously worked as top scientists for a clandestine enterprise, Biopreparat, with more than 30,000 scientists and other staff. It was here that the Soviets conducted research and produced agents for their BW program. According to Alibekov, the Soviets even used BW (glanders) at least once between 1982 and 1984, during the Afghanistan war. Moreover, they produced enough biological agents to extinguish “...the entire population of earth several times ….” As far as the post-Soviet era is concerned, the Russian government has on several occasions strongly denied reports that it still has a biological warfare potential, but many questions remain unanswered. For instance, the whereabouts of former Soviet bio-ammunition are still unclear.

The effectiveness of the BTWC and the CWC treaties is highly dependent on political factors, such as the willingness of a government to comply and the confidence it has in the sincerity of its partners. In addition, the stability of a country and the degree of control the government has over military leaders, scientists and export industry play a major role. The progress in biotechnology also limits the effectiveness of the BTWC, by making it possible to produce biological agents in smaller facilities and with dual use technology. The risk of secret production and proliferation increases accordingly.

Furthermore, the rapid development of gene- and biotechnology in recent years has been beneficial, but it has also opened new possibilities to create genetically manipulated biological agents. The spectrum of potential biological risks is increasing and places ever greater demands on our biological medical defense capabilities.

3.3 Biological Risks Faced In The Recent Past And At Present

As we learned from UNSCOM, Iraq had admitted to producing anthrax and botulinum toxin for BW[4]. In addition, Iraq allegedly conducted a broad biological program, which included work on plague and gas gangrene bacteria, camelpox, rota- and enteric viruses, as well as on ricin and mycotoxins, especially aflatoxin. Further, Iraq declared that it had produced 10 kg of ricin, testing it once - without success - in a 155 mm artillery shell.[5] Despite years of investigations, UN experts have yet to discover the whereabouts of these BW or verify that they were destroyed.

Unveiling Iraq's biological capabilities in the Gulf War underscored, in retrospect, the correctness and necessity of the intensive NBC defense measures and the medical preventive measures of the coalition forces.

How great is the present risk of biological exposure to armed forces contingents? Are the UN troops stationed in the former Yugoslavia at risk from biological exposure? When analyzing this risk, we must consider that the parties to the war have accused each other of using BW to produce outbreaks of tularemia in northern Bosnia in early 1995. Tularemia pathogens are suitable for use in BW and have been weaponized in the past. On the other hand, tularemia is a naturally occurring disease in Bosnia and these allegations have never been verified.

3.4 Bioterrorism

Terrorists and other criminals, too, see biological agents as a suitable means for achieving their ends, as we have learned. Anthrax, salmonella, Yersinia pestis, botulinum toxin and ricin have all been acquired and produced for terrorist plans or even been used in attacks since 1980. [6]

The US FBI at any given time has about 50 to 60 ongoing investigations connected with bioterrorism. Extremists and other criminals have come to realize that they can terrorize others with the mere threat of employing BW agents. Of course, the response to such a threat requires a lot of time and effort before determining whether the threat is real or merely a hoax.

Again the USA sets an example of an increased awareness of biological terrorism and a corresponding program to protect the civilian population. The American government has created special Army and Marine Corps units (altogether some 500 men) to provide help in cases of NBC terrorism. For the 1996 Olympic Games, several hundred members of these special units were assembled in and around Atlanta in case of a terrorist attack. A systematic training program of the US armed forces was established for the civilian decision-making bodies and the police, fire departments, etc. of 120 major American cities. The Defense Department and Public Health Service have spent $262 million on a five-year domestic preparedness program. The Marine Corps Chemical / Biological Incident Response Force (CBIRF) was presented to the public on 30 April 1997 in an exercise on Capitol Hill in Washington.


Chemical weapons (CW) consist of chemical agents and delivery systems. CW agents are toxic chemicals, which are produced for non-peaceful purposes and whose effects on physiological processes can result in death, temporary incapacitation or permanent damage.

4.1 Limited Effectiveness Of Political Measures

The 1993 Chemical Weapons Convention (CWC) came into force on 29 April 1997. By January 1999, the Convention had been signed by 169 states. The USA, Russia and a small number of other states are declared possessors of chemical weapons. There are, however, suspicions that several other countries are also in possession of or developing chemical weapons, and have failed to declare these activities.

All state parties are allowed a period of ten years after the CWC's entry into force in which to destroy their chemical weapons. If, however, during the ninth year a state party realizes that it will not be able to complete this task within the specified time, the state party may make a declaration to that effect and apply for a five-year extension. This means that the overall time for destroying the chemical weapons may total 15 years.

Unfortunately, we cannot expect all possessors of CW to accede to the CWC. As we have seen with the BTWC, even signatory states to the CWC could violate it.

4.2 Chemical Risks Past And Present

The reality of chemical risks has been provided by the following recent events:

Iraq used CW agents against its own Kurdish population in 1988 in Brijini (proven by British NBC defense experts), in Halabdja (strong evidence) and in the war against Iran.

In the 1991 Gulf War, while no definite proof of the use of CW agents by Iraq could be established, the coalition forces nevertheless had to take extensive preventive NBC defense measures. From the NBC medical defense perspective, these included pretreatment with pyridostigmine. This treatment, in addition to many other factors, has been implicated as being responsible for aspects of the Gulf War Syndrome, although no scientific proof of this has been established yet.

Similarly, the risk of CW exposure could not be ruled out for UN troops in the former Yugoslavia. As a precautionary measure, the NATO contingents were supplied with overgarments and antidotes.

The former Yugoslavian people's army produced CW agents. There was a major production facility in Mostar. In spring 1992, production facilities for chemical agents as well as ammunition for mustard gas and sarin were transported from the Bosnian city of Mostar to Serbia, presumably to Lucani.[7] In 1995, news reports alleged that the incapacitating CW agent BZ was used by Bosnian Serbs, when taking the Moslem enclaves of Zepa and Sebrenica. (German news agency, DPA, July 1995 and January 1996.)

At present, there is no guarantee that all chemical agents are in safekeeping. We cannot rule out the possibility that these stocks - as other types of weapons - may pass into the possession of one of the warring parties or fall into the hands of terrorists.

Substances used by the civilian chemical industry may also endanger armed forces personnel participating in UN missions in crisis areas. Here, it would suffiCe to mention only a few highly toxic substances such as phosgene, hydrogen cyanide, chlorine gas or insecticides. An incident that also occurred in the former Yugoslavia serves as an example: in 1992, Croatian media circulated threats announcing the detonation of chlorine gas tankers to prevent the Serbs from further attacks on Gradacac.

4.3 Chemoterrorism

Chemical terrorism, or chemoterrorism, is another aspect of CW risks. We are all aware that the Aum Shinrikyo sect used the CW agent sarin in terrorist attacks in Matsumoto (7 deaths) and in Tokyo (12 deaths and 5,500 injured). Another attempted assault at the Shinkaju Tokyo subway station and the release of hydrogen cyanide was prevented at the last minute.

As an additional element in the bombing of the New York World Trade Center in February 1993, the fundamentalist Islamic terrorists intended to use hydrocyanic acid. They loaded the car parked in the underground garage of the skyscraper with explosives and sodium cyanide. Their plan was for the hydrocyanic acid to kill any survivors of the explosion, as well as relief and law enforcement personnel entering the site. Fortunately, their plan was thwarted, because the terrorists had misjudged the course of the chemical reactions.

The plans and programs in the USA to fight bioterrorism also address chemoterrorism.


The risk of exposure to the effects of WMD is real. Weapons from each of the categories have been produced and tested. They are somewhere at someone's disposal. They have already been used in the recent past. Proliferation will augment the number of possessors and thus further increase the risk of these weapons being used.

The question is not whether, but when and where they will be used next.

We must first work to ensure that these weapons are not used. However, we must also enhance readiness for NBC defense.

In many countries, the public is not aware of these facts. Many decision makers have yet to fully perceive the risks involved and to take appropriate action.

The elimination of obvious shortcomings in biodefense capabilities, including medical biological defense, must be given high priority:

  • means for intercepting and destroying biological weapons,
  • aerosol detection and warning systems,
  • procedures for detecting biological agents,
  • preventing, diagnosing and treating BW diseases.

However, from a medical perspective, it would be ill advised to perform these remedies at the expense of nuclear and chemical medical defense. It remains, therefore, necessary to take preventive measures against weapons from each of the categories. Furthermore, retaliation with nuclear weapons may be the only viable option, especially where BWs are used. In the event of a nuclear strike, the medical services will have to deal with casualties arising from possible collateral effects.

In addition to the NBC risks arising from hostile action, medical services must be able to cope with other dangers, which may have effects similar to NBC weapons. In their deployment area, armed forces may face risks in the civilian sector resulting from the worldwide spread of nuclear technology (nuclear energy, technical and medical radiation sources, depleted uranium) and the chemical industry (production facilities and stocks of, for example, phosgene, hydrogen cyanide, chlorine gas or insecticides). There are likely to be fewer and fewer “clean, conventional” scenarios even where NBC weapons are not used.

Many countries have NBC defense experts and have equipped their forces with basic protective equipment, such as NBC protective masks. However, the forces of most countries do not have the capability to sustain operations in an NBC environment for more than a few hours and preserve their combat strength. This NBC defense capability, though, is precisely what is needed, not just tomorrow but today. It must be guaranteed throughout the entire operational spectrum by a balanced system [8] of NBC defense measures.

As a rule, combat troops have the best NBC defense capabilities. Nevertheless, they rely on medical services that have some of the worst deficits in NBC defense capability. Most medical services are capable of protecting neither medical personnel at work, nor patients during treatment and evacuation, nor sophisticated medical materiel against NBC exposure. This inability presents a major obstacle for military operations in an NBC environment and may seriously limit the options available to political and military decision-makers. The only options may be to do nothing or to retaliate with nuclear weapons.

To make matters worse, very few countries have a group of NBC medical defense experts, and when they do, this is a small group. Consequently, even these few nations have very limited NBC medical defense capabilities, i.e., the ability to maintain and restore the health of personnel when other NBC defense measures fail. Such a small group can seldom do more than provide the necessary advice to political and military decision-makers. Some of these groups may also be able to conduct high-tech laboratory tests, e.g., identify a limited number of biological agents. Normally, however, such a group and its budget are too small to cover the most urgent NBC related problems. In particular, there are shortfalls in the ability to provide NBC medical defense training for all military doctors, let alone guarantee an acceptable level of NBC medical defense readiness.

6. Recommendations

6.1 The Protective Triad: Political, NBC Defensive And Medical Countermeasures

At present, no strategy guarantees full protection against risks from WMD. There is no magic pill, no impregnable shield. The best possible defense is a joint approach in which political, NBC defensive and medical measures mutually complement and enhance one another:

1. The risk of an NBC attack should be ruled out, to the greatest extent possible, by political measures including disarmament and arms control. These measures are laid down in the Non Proliferation Treaty (NPT, 1970), the Biological and Toxin Weapons Convention (BTWC, 1972) and the Chemical Weapons Convention (CWC, 1993) and follow-on agreements. These treaties should be supplemented by export control measures for dual-use materials. Such materials should only be traded with countries that comply with the respective treaties and allow for inspections.

In cooperation with friendly countries, we must support the Russian government in converting the former Soviet military NBC research and production facilities. Some of their scientists ended up in difficult situations as the Russian defense budget was reduced. When scientists find themselves in a crisis of this kind, this can lead to considerable proliferation risks with unforeseeable consequences.

2. Political measures, however, do not offer complete protection. Therefore, the military and civilian technological activities (dual use problem!) of "rogue states," along with the activities of suspicious persons and organizations, must continuously be observed, analyzed and evaluated in an attempt to recognize activities conducted for non-peaceful purposes. This increases the chances of preventing the use of WMD and of developing effective countermeasures.

Should prevention fail, armed forces must be prepared to defend themselves by finding and destroying enemy WMD including incoming attack missiles. Throughout the entire operational spectrum, the armed forces must have a balanced NBC defense system at their disposal. This must be reflected by manpower, training and equipment.

NBC defense capability will protect personnel and materiel against NBC exposure. NBC defense

  • Prevents casualties, damage to materiel and facilities, and reduces the effects of NBC weapons,
  • Maintains or restores the operational capability of units affected by NBC weapons.

For medical services, this means that measures must be taken to protect medical personnel, patients and medical facilities against NBC exposure. In this specific area, medical services must catch up with a lot.

One of the benefits of being capable of protecting one's forces against WMD is that it renders such weapon programs less attractive. Moreover, in the face of the threatened or actual use of WMD, an NBC defense capability ensures that an acceptable spectrum of options is available to political and military decision-makers. This helps to keep the threshold of nuclear retaliation and escalation high.

Since NBC defense cannot guarantee complete protection against exposure, NBC medical defense capabilities must be available to maintain and restore the health of NBC-exposed personnel, clarify the causes of puzzling diseases and deaths, e.g., to distinguish natural from other outbreaks, advise political and military decision-makers.

Medical considerations must include not only the acute, often lethal effects of NBC weapons, but also the long-term effects of low-dose NBC exposure. This is a considerable increase in the qualitative and quantitative requirements placed on medical services.

6.2 Protection Of The Civil Population

Beyond military considerations, it must be remembered that in many countries the civil defense resources have been substantially reduced since the end of the Cold War. The management of situations involving NBC hazards in the civilian sector may require the armed forces' NBC medical defense expertise for it may be the only national resource available to decision-makers for appropriate advice.

6.3 Continuity And Long-term Planning: The Only Way Forward

While it is quite normal for the perception of a particular risk to vary, the future availability of medical and other scientific capabilities is possible only with continuity and long-term planning. For day-to-day medical care, the type and frequency of diseases and injuries change very slowly in peacetime. In recent decades, the budgeting of the civil health care systems has not been seriously questioned. Moreover, there are thousands of competent physicians with the necessary knowledge and experience to administer prophylactic and therapeutic measures.

In NBC medical defense, the situation is quite different. Clinical pictures of relevance to NBC medical defense are uncommon. They are mostly encountered in connection with armed conflicts or terrorist acts, when the circumstances allow for only limited scientific evaluation. Only a small group of medical scientists is conducting research on the relevant clinical pictures; few countries have even one facility working in this field (“scientific islands”). Such facilities are usually just large enough to fulfil their personnel requirements for their own regular (small group of) experts. Unlike everyday clinical care, this field does not have thousands of experienced experts. In addition, fluctuations in risk perception have repeatedly led to reductions in NBC medical defense activities. In some countries, activities in an entire NBC discipline have even been cancelled altogether. The repeated discussions about the requirement for and benefits of NBC medical defense activities and, above all, the continual uncertainty of financing such activities have caused considerable insecurity. This has had devastating consequences for recruiting young scientific personnel. For example, in Germany there is no budgetary item specifically for financing NBC medical defense activities. This shortcoming must be urgently remedied.

NBC medical defense capabilities cannot be maintained or progress when responding to fluctuations in risk perception. Once lost, these capabilities cannot be reactivated in five or ten years, not even with huge amounts of money. All decision-makers must be warned that it is not possible to turn back down a one-way street.

6.4 Future Challenges

Armed forces of the future must have the capability to protect themselves against WMD, as well as from hazards similar to NBC exposure. Where precautionary measures fail, armed forces must be able to restore the health of those personnel who have been exposed. State-of-the-art equipment and procedures need to be in place. Armed forces, which do not have this capability, cannot honor obligations within an alliance. Nor will they be able to provide effective assistance should their own country find itself under NBC threat. As the threat from WMD increases, the availability of appropriate medical capabilities plays an increasingly important role in a country's defense.

Now is the time for decision-makers to allocate the resources necessary.


1. The terms "weapons of mass destruction" and "NBC weapons" are used interchangeably.

2. Ken W. Alibek, Stephen Handelman (Contributor) “Biohazard: The Chilling True Story of the Largest Covert Biological Weapons Program in the World – Told From Inside by the Man Who Ran It.” Random House Inc., New York, May 1999

3. BTWC, Article I: Each State Party to this Convention undertakes never in any circumstances to develop, produce, stockpile, or otherwise acquire or retain:

4 Microbial or other biological agents, or toxins whatever their origin or method of production, of types and in quantities that have no justification for prophylactic, protective or other peaceful purposes;

5. Weapons, equipment or means of delivery designed to use such agents or toxins for hostile purposes or in armed conflict.

6. In theory, 1 gram of botulinum toxin is enough to kill over 10 million people.

7. In theory, 1 g of ricin is enough to kill over 1000 people.

8. Cf. T. Sohns, "Defense Against Biological Terrorism" in T. Sohns, V.A. Voicu: NBC Risks Current Capabilities and Future Perspectives for Protection , Kluwer Academic Publishers, Doordrecht, 1999

9. See ASA 99-2.

10. The system includes seven elements: individual protection, collective protection, NBC medical defense, the hardening of defense materiel, NBC reconnaissance, decontamination, NBC evaluation and hazard forecast.

About the author: Colonel Sohns is a medical officer with the German Armed Forces. He has worked in the fields of medical planning and policy and of NBC medical defense. He is currently Deputy Commander of the German Armed Forces Medical Academy. Prior to this, he was assigned to the German Ministry of Defense and to NATO's Supreme Headquarters Allied Powers Europe (SHAPE).

For the Professional in Government and Industry with an interest in Nuclear, Biological and Chemical Defense, Disarmament and Verification; Emergency and Disaster Medical Planning; Industrial Health and Safety; and Environmental Protection