Editorial Column


Prof. Peter Blain

Consultant

Emergency Response Medicine for Public Health England

It is recognised that Heads of State and Government Leaders face many threats to their personal security. Recent events indicate there is also a growing threat of covert assassination or capability degradation using Chemical, Biological, or Radiological (CBR) agents. Publicized cases suggest this now a major challenge to close protection services.


CBR agents can be deployed in public or private settings and their use can be difficult to detect, diagnose or attribute. Standard medical training does not provide experience of the unique nature of CBR agents, their clinical effects and the required medical countermeasures. The conventional physician would struggle to identify and deal with a CBR attack.


State and non-state capacity to produce and deploy sophisticated cryptic methods of assassination or degradation are proliferating. The adversaries of many Leaders previously lacked knowledge of the potential of CBR agents, but information and expertise in manufacture and covert deployment are now more accessible. Protection service for Government Leaders must be augmented with a highly specialized defence capability to reflect the new threat whether it be external or internal in origin.


Recent incidents in the UK, and elsewhere, have added to the impression that the use of chemicals, toxins and other harmful agents is increasing both in conflicts but also to target individuals. The events in Salisbury involved a nerve agent (Novichok), an earlier assassination used a radioactive metal (Polonium) and still earlier one a biological toxin (Ricin). Something from each class of CBR agents has been deployed. On each occasion the agent responsible was identified, and any attempt at a covert attack, if that was intended, was uncovered by Government agencies. But if the Salisbury cases had been admitted and treated elsewhere, the identity of the poison may never have been determined, or a role even suspected, and the necessary treatments not provided.


The use of these agents is intriguing and, when considering the motive and intent, suggests the intent was a covert attack. Otherwise why select a rare, and very expensive, radioactive metal as the method of assassination? The polonium used was not identified by standard tests for radiation exposure and required the application of highly specialised analysis. Although, there were clinical findings suggestive of radiation exposure.

The murder of Georgi Markov, forty years ago, was even more theatrical but still an attempt to be covert. A modified umbrella was used to inject a micro pellet containing ricin into his thigh muscle during an apparently accidental prod of the tip on his leg.

These cases, and several others less publicised, have led to speculation that some unexpected deaths of prominent individuals may have been from unidentified poisonings with similarly little-known chemicals, toxins or radioactive materials sourced from an expanding range of potential threat agents, many identified in CBRN research programmes.


CBRN materials are seen as primarily military or, more recently, terrorist threats. Detailed knowledge about the nature and properties of CBRN agents is held predominantly by State defence agencies. As a consequence, the identity of medical countermeasures specifically effective in the treatment of CBRN exposed patients is also more likely to be available to those working in State organisations. This was demonstrated in the Salisbury cases where the use of novel and specific countermeasures reversed the widely anticipated fatal outcome. But would identification of the agent and the appropriate treatment have been more widely known outside of these agencies?


Poisons have a long and notorious history as methods of murder and execution and some dynasties specialised in their use (the Borgias favourite poison was Cantarella, probably arsenic based). In the past these poisons were recognised in societies as toxic compounds and include cyanide, arsenic and hemlock (used in the execution of Socrates). Others were natural compounds better known to specialists in plant or fungal toxins, or animal toxinologists. However, advances in synthetic chemistry and toxicology enable the production of novel compounds specifically designed to possess increased toxicity, evade detection and resist available countermeasures. The intention behind these developments was primarily for use in warfare and was the intent behind the development of the Novichok series and, no doubt, other synthetic ‘designer’ toxic chemicals, and genetically manipulated micro-organisms.

Training of health care professionals in the civilian sector includes very little about CBRN agents or relevant medicine. Military doctors are well informed and civilians working in emergency response, such as first responders and intensive care specialists, have extended part of their training to include CBRN agents alongside new pharmaceutical based agents (PBAs) (e.g. fentanyl analogues). The first responders and emergency and intensive care staff in Salisbury demonstrated the value of this training in their immediate management of the Skripals, and the two later casualties. But most hospital and family doctors would not be so cognisant in these scenarios.

Those individuals assessed as under a credible threat of attack, kidnap or assassination, because of their political roles, business positions or other achievements, usually have close physical protection graded to the assessed level of risk. Many also have a medical professional as part of their support team, who will respond to conventional medical emergencies and natural illness, but few of these practitioners have detailed knowledge of CBRN agents or other novel toxic compounds, especially those with the potential for covert use.


The solution is the application of the pillars of emergency medical protection – preparedness, resilience, response and recovery. Preparedness might be as simple as heightened awareness of the possibility and application of appropriate medical security protocols, but ideally would also include detection, identification and diagnostic capabilities incorporated into the support systems for the Principal. Resilience implies direct prophylactic protection such as a comprehensive vaccination programme, and the application of future health proofing technologies. Response depends on extended training of medical attendants and the physical protection team, and availability of validated medical countermeasures and other supportive medical interventions. The protection team should also have access to medical experts specialising in CBRN medicine for specific advice on the emergency management, investigation and diagnosis, and to contribute to the continued care during recovery. Accredited specialist expertise is in short supply around the world.


Companies currently produce CBRN related equipment and kit primarily designed and manufactured for military or civilian use, anticipating the probability of mass casualties. These businesses should be able to rescope their technologies to cater for a CBRN threat to an individual. Such bespoke design would attract a high premium. Businesses should consider the high value individuals at risk of a covert attack with CBRN type agents and specifically design equipment and countermeasures to mitigate the threat.


What does all this mean for the future? These latest incidents suggest there will be continuing use of novel agents to target high value individuals (HVIs) in response to political, financial or espionage issues. Those charged with protecting HVIs need to recognise the potential for use of CBRN agents to target the Principal, and their family, and take appropriate action, as discussed above, to mitigate the threat. This includes relevant specialist training for all involved, ensuring preparedness and resilience are strengthened, response protocols are frequently exercised, and specialist medical expertise is available for immediate expert advice and support in recovery.


It is intriguing to speculate why a novel chemical weapon, a radioactive metal and a biological toxin, or potent PBAs such as fentanyl analogues, were chosen to assassinate individuals. Most civilian health care professionals would not recognise a medical presentation due to these agents or be aware of the appropriate treatments, if any are available. So, it is possible these acts were intended to be covert. Or, alternatively, maybe they were to demonstrate ingenuity, skills and capability! Whatever the intent it seems fairly certain that even more exotic agents will be used in the future. CBRN used to be primarily a military concern at the State level, then terrorist groups developed an interest in the targeting of civilians and now there is individual targeting by State and non-State agencies.


Professor Peter Blain is a senior clinical professor and hospital physician with over 30 years’ experience in the application of medical knowledge to health security and operational issues.This includes the provision to Governments of expert advice on medical aspects of high-value asset protection.He is a recognised international expert in acute medical care and clinical toxicology, and provides high-level expertise in CBRN medicine, related sciences, and emergency response medicine to both UK and US Governments, and major international bodies and businesses.