Gas! GAS! Quick, boys!—An ecstasy of fumbling
Fitting the clumsy helmets just in time,
But someone still was yelling out and stumbling
And flound’ring like a man in fire or lime.—
Dim through the misty panes and thick green light,
As under a green sea, I saw him drowning.
In all my dreams before my helpless sight,
He plunges at me, guttering, choking, drowning.
—from “Dulce et decorum est,” by Wilfred Owen, a World War I poem depicting the horror of gas trench warfare
Nine days after the bombs of “shock and awe” rained down on Iraq, a shock wave shuddered through the desert warehouse where I was dead asleep on a cot. The explosion jolted me wide-awake along with hundreds of other sleeping soldiers. A clatter rippled overhead as roof tiles collided in succession like dominoes, and the concrete floor trembled.
“What . . . the FUCK . . . was THAT!?” a deep voice yelled.
“EVERYBODY OUT! NOW!”
Bodies everywhere erupted from sleep in the “The Cave,” our living quarters in an open-bay warehouse the size of an airplane hangar.
Shit, I thought. A Scud missile?! We’re under attack.
I fumbled in the dark under my cot for my chemical protective suit and gas mask, which I kept within reach at all times, yanking them on as I stumbled out of the dusty warehouse and into the cool, clear night. Outside was chaos and sensory overload: the buzzing generators and bright floodlights made it hard to think through my sleepy fog.
A river of masked soldiers, like extras in a sci-fi movie, streamed into concrete bunkers just a few steps from The Cave. I entered one the size of an airport shuttle, and we kept packing in bodies—twenty or thirty until we overflowed the space. Then I waited, in anticipation, hearing others around me sucking wind in their masks. Our base on the outskirts of Kuwait City was the nerve center for the United States during Operation Iraqi Freedom. We were a prime target. Were other bombs incoming?
After years building my foundational skills in the hospital and running the lab response side of germ-warfare defense, I sat poised on the front lines, crammed shoulder to shoulder, with other soldiers wearing M90 gas masks that would give some people nightmares, but they were our last line of defense against nerve agents and infectious viruses and bacteria spread by aerosol. I was here to protect these soldiers from the invisible living agents that could be unleashed by those bombs, which could take days to identify. For some that would be too late. This felt like the midterm exam of my career.
There was nothing I could do in the bunker but wait, think, and breathe, which was a struggle in and of itself. Sucking air into an M90 gas mask takes breathing power, and when you’re already out of breath it feels suffocating. The harder I breathed, the more claustrophobic I felt, and the deeper the panic set in. Shaking from adrenaline, I braced for the next bomb, fearing it would be filled with nerve agent—or worse.
We had reason to be afraid. Despite signing the 1972 Biological Weapons Convention, a worldwide treaty to end the production and storage of weapons-grade germs, Iraq had admitted in 1995 to developing and stockpiling tons of chemical and biological weapons for tactical use during the first Gulf War.1 Anthrax. Botulinum toxin. Aflatoxin, a poisonous toxin produced by mold. Iraq had also used chemical weapons against Iran during their war in the 1980s. There was no reason to assume that Iraq did not have them still, thirteen years after the 1990 Gulf War, “Operation Desert Shield/Storm.”
As part of its defense strategy and the culmination of our contingency protocol and smallpox vaccine efforts, the U.S. military had deployed me on an A-team of nine chemical and biological warfare experts. Working and traveling as our own independent unit, we had a mission to vaccinate troops against the biological agent presumed most likely to be used against us by Saddam Hussein: botulinum toxin. We transported hundreds of vials of treatments and antitoxins, a delicate arsenal of countermeasures that we had to keep cold at all times, lest they expire in the desert heat. We had a short timeline to disseminate these countermeasures to several military field hospitals and medical centers in Kuwait, and train medical personnel on how to administer them before the launch of the invasion force. The number of potential victims was staggering: around 130,000 American troops were dispatched during the initial invasion of Iraq. Our supplies would be enough to treat only a tiny fraction of them.
There are many ways to die at war, but I can imagine few ways more horrific than death by a nerve agent or botulinum toxin (bot). If you had to choose between the two, it’s a toss-up.
Nerve agents, as the name implies, attack our body’s nerve network, which buzzes in constant communication. Each nerve strand transmits messages throughout the body—“Breathe.” “Smile.” “Duck!”—through chemical “ferries” (signals) passed across channels from one neuron to the next. A single drop of VX liquid will penetrate the skin rapidly and trigger a flood of chemical transmitters into those tiny channels, causing hyperstimulation. Like the frantic writhing of a wasp after you spray it with Raid, the nerves go haywire, bombarded with unceasing messages that cause you to lose control of your body in all the worst ways: drooling, vomiting, losing bowel control, and ultimately seizing—before you stop breathing.2 The only bit of good news is that by the time you seize, at least you don’t know what’s happening.
Botulinum toxin causes the opposite effect, paralysis, by blocking the chemical signal “ferries” leaving the nerve port. It starts with your head and moves down. First comes blurry or double vision. Next comes trouble swallowing. You might notice your voice sounds funny, or maybe you start choking. Your eyelids sag, your head droops, and your face looks dazed and zombielike as your facial muscles become slack. The worst part is that your mind stays alert, but you cannot speak. You are fully conscious as you suffocate.
Taking a bullet seems more appealing.
My team’s mission to protect our troops from this kind of horrific demise had begun months earlier back at Fort Detrick, Maryland. Dubbed the SMART-IND (Special Medical Augmentation and Response Team for Investigational New Drugs) team, our group was created by the army surgeon general in late 2002—a “dream team” of military infectious disease doctors, research nurses, and support technicians. With a short lead time to war, we launched something akin to the Manhattan Project of biodefense on the fringes of Fort Detrick in a double-wide trailer with lopsided floors and stained carpets, and without fanfare but with direct access to the senior military leadership. Our mission: to develop field-ready protocols—basically rules of engagement—governing the use of unlicensed vaccines and antidotes for biological warfare.3
Shortly after our work began, we received a gift. In record time all the work by Colonels John Grabenstein and Charles Hoke at the SARTF, Wyeth Pharmaceuticals, and the FDA paid off. By December 16, 2002, two lots of smallpox vaccine were approved for use with a new diluent. Now we had a licensed vaccine against smallpox. In short order the military did what it does best, vaccinating over five hundred thousand military personnel against smallpox, which knocked King Smallpox off his throne as the top threat. Similarly, the anthrax vaccination of the forces hobbled Queen Anthrax.
This left “bot” (botulinum toxin) as our top threat. We had a vaccine and treatments to defend against bot, but none were licensed by the FDA. We had to cut through the FDA red tape and teach others how to use these “investigational products,” but it’s not so simple adhering to the FDA’s requirements with incoming Scud missiles raining from the sky.
It might seem tempting to “lose” the paperwork somewhere in the desert. But ignoring the FDA’s rules was not a viable option and could cost us our careers. Gulf War Syndrome had dogged the military after the first Gulf war. Part of our mission was to prevent Gulf War Syndrome, Part 2.
Al Magill, our most senior doc on the team, had a Teddy bear personality, a playful smile, and a gift for telling senior leaders the truth in simple, unvarnished terms. He briefed our commanding general at Fort Detrick one afternoon, wagging his right index finger to emphasize the point: “Sir, whoever signs the 1572 [a form, signed by the lead investigator, that binds an investigator to protect human subjects] no longer works for you. They work for the FDA.” Meeting the FDA’s requirements was an impossible task in a war environment and the crux of our challenge. The general understood. He assured us that the in-country leader would get us what we needed to do this right.
Not only were we hog-tied with legal regulations, but our vaccines had been sitting in storage for decades. Decades! Like most medicines these products have a limited shelf life, and their effectiveness declines over time. Some of the products had problems we could work around. One botulinum antitoxin treatment had developed protein clumps that interfered with its usual intravenous delivery. We proposed injecting it into muscles as a preventive measure instead. Other instances were fraught with irony. The FDA did not want us to offer the botulism vaccine to soldiers because recent tests showed its protection in mice and guinea pigs had waned for some of the five serotypes in the vaccine. That made no sense to us trying to protect our soldiers and marines. Wasn’t partial protection still better than none at all?
I raised this question at a meeting with the FDA. “How, in good conscience, can you deny these potentially lifesaving products for our forces?” I asked.
The FDA department chief snapped back, jabbing her finger at me. “You can’t put that on us. We told you [the DoD] to make a new vaccine ten years ago.”
She was right. It was embarrassing and idiotic. Thirteen years after Operation Desert Storm, we were still talking about the same outdated bot vaccine. A newer one was in the pipeline but years away from becoming licensed. The army channeled money only to certain products and priorities, many of which were never on the radar for development for civilians.
After a brief hiatus, the FDA eventually relented, and the bot vaccine was back on the table.
Ironically, some of our fellow military members gave our team pushback and made us feel like stepchildren. Shortly before we shipped off to the desert, we were told that the lead medical general in-theater wanted to split us up and send some of us to work in a clinic in Qatar. We needed adequate numbers of team members. Splitting us up would guarantee mission failure. But even generals have bosses. The winds shifted again, and we learned that Vice President Cheney was tracking our mission. We were told our team would stay intact.
We nonetheless often found ourselves at odds with other high-ranking army officials. Before the invasion we met with the soldiers planning army operations (ops) deep in the bowels of the Pentagon. As my team members pitched our biodefense plan, the OPS guys didn’t take us seriously. “You know, Colonel,” one soldier said, “the time for good ideas has passed.”
Even though biological and chemical weapons had by then become household concerns nationwide, it was challenging to convey the devastating power of microbes to officers accustomed to more concrete threats: bullets, tanks, and bombs. At times it was almost comical. Take, for instance, the meeting when another paper-pushing colonel in the Pentagon shut down my teammates, three senior infectious disease colonels, as they briefed him on the Iraqi bioweapons threat and our team’s contingency plans for biowarfare.
“Stop right there,” the colonel said, holding up his hands. My colleagues paused, confused. “Someone get me a tissue,” the colonel said dryly, clearly mocking our concerns about a bioweapon attack. “I think I’m going to cry.”
Our team leaders successfully explained their concerns, though, to Dr. Winkenwerder, the most senior physician in the DoD. Al Magill staged a battle scenario moving office supplies like chess pieces across a conference table representing an imaginary map of the Middle East.
“The problem, sir, is that the bad guys who want to do us harm are over here,” Al said, placing a pen on imaginary Iraq. He slid a second object just south of the pen, indicating Kuwait. “Here are our vulnerable forces.” He slid a third object to the other end of the world, over the United States. “The antidotes and the people who know how to give them [us] are over here,” he said. “Ten thousand miles away.”
Dr. Winkenwerder understood.
The next day, we learned we were going to war. Of the nineteen original members of the SMART-IND team, nine would deploy. We did not know who would draw the short straws or when they would be told. Not knowing was the hardest part.
The uncertainty had gnawed at me for the preceding two months of limbo as the team went on and off alert for possible deployment. I tried not to let on how I really felt and just dealt with it. At least we would have something definitive, I hoped, in the near future.
I distracted myself with standard prewar preparations: doctors’ appointments for prescriptions, packing and repacking my duffle bags, and updating my will. I needed a smallpox vaccine, but I worried about exposing my wife and sons, who have eczema, which could lead to severe or even deadly reactions if they had contact with the potentially contagious virus. So instead of spending what could be my last few days at home, I checked into a motel with stained carpets and a broken heater to wait out the period when the vaccine had the highest risk of spread. On my tenth night in the motel, I was half asleep when the phone rang.
“Mark,” the voice said, “you are one of the ones deploying. We’re sorry.” “Okay,” I mumbled, in a partial dream state but feeling the weight of the news. “I understand.”
Iraqi Freedom was not my first deployment. Years earlier I had deployed for nine months to Bosnia as the chief of Preventive Medicine for the U.S. forces. Although I put in a lot of miles in a Humvee on dangerous roadways and occasional hostile surroundings assessing our bases around the country, it was a peacekeeping mission.
The specter of war felt different.
I felt a strange cocktail of guilt and excitement. This was the adventure of a lifetime, an opportunity I looked forward to and had prepared for my whole career, but I hated leaving my family. My wife, Cindy, was six-months pregnant. Ten-year-old Luke was a baseball player, beginning to play the piano and the violin. Four-year-old Sean was still in preschool, a cuddly armful with a killer smile. I still held him every night as he fell asleep.
Because our team was a fringe element and not deploying with a massive military unit, Cindy lacked the support other military wives would have during a typical deployment. She was particularly upset that she couldn’t ask our church to pray for me, because we were told not to broadcast our activities—the old “loose lips sink ships” adage.
I feared I would miss the birth of my third son. I had bonded with his little form on ultrasound, and we had picked out a name, Daniel. I worried I might never meet him. At the same time, I had mixed feelings about the challenges of becoming a father for the third time. After ten years and two boys, I enjoyed the increasing freedom and felt some reluctance about changing diapers again but also guilty for feeling that way. In some ways deploying allowed me to escape dealing with my own reality back home.
The night before I was due to ship out, after we tucked the boys in, Cindy and I were lying in bed, talking quietly.
“I’m afraid I might not come back this time,” I said, choking on the words.
Cindy did not cry, but just held me. Strong as she is, physically and emotionally, she would later confess how hard it was to ignore a belief she had that whenever there is a new birth in the family, someone dies.
Before I left home, I sat down at my desk and typed up a note for Cindy on the computer with financial instructions and a spreadsheet of all our accounts and passwords. I sealed it in an envelope, placed it in our home safe, and told Cindy where to find it. On the envelope I wrote, “Open if I don’t return.”
We shipped out to the Kuwaiti desert in late February. The deploying biodefense team included some of the military’s finest infectious disease officers and researchers. Donald “Gray” Heppner led malaria vaccine research. Al Magill ran malaria drug research. Chris Ockenhouse was a gifted malaria lab scientist. Robert Kuschner, our team leader, was an expert on a range of diseases of military importance.4 Even though I was a department chief at the largest biodefense lab in the world, they all outranked me and were legendary in the military infectious disease community. As the junior physician on the team and with less research experience, I felt a little out of my league.
At Camp Doha, near Kuwait City, we set up our team headquarters in a one-room office, around 220 square feet, where all nine team members worked closely—literally and figuratively. Our office sat in prime real estate in the Command Center—the “Forbidden City,” as Gray Heppner, our philosophical team member who often quoted literature, called it. An island in a sea of warehouses with special access restrictions and isolated from the rest of the base by a closely monitored boundary of razor wire, the Command Center ran all in-theater military operations.
We had shipped ourselves a whole bunch of supplies: an industrial-strength printer for the paperwork and about twenty green footlockers set up as “go boxes.” These trunks contained a few hundred freezer bags prepackaged with everything needed to administer one treatment course of botulinum antitoxin: needles, syringes, intravenous tubing, IV catheters, and alcohol and gauze pads. If we got an emergency midnight call, we could grab the footlockers, hop on a chopper, and be ready to treat upon arrival within minutes.
The actual botulinum antidotes and vaccines arrived separately in specialized cold containers called Vaxicools. The size of a large suitcase, these portable battery-powered refrigerators can hold up to four hundred vials of antitoxin.
Many things that we take for granted back home are nearly impossible to find in a war zone. Just picking up the vaccines and antitoxins at the airport required a 3:00 a.m. convoy, a search around the airport maze, and a lengthy negotiation with customs.
We also needed a secure location with a power source to keep the products cold. It seems so basic, but electrical outlets don’t sprout from the desert sand. We approached the on-base medical clinic, but we received a lukewarm reception. They had enough challenges with war casualty planning and caring for the routine sniffles, bumps, and bruises and wanted nothing to do with our products. Instead, we made nice with one of the third-country nationals who ran the medical warehouse to borrow some of their outlets for our freezer and the Vaxicools. The entire in-country supply of botulism countermeasures for our forces was kept alive by two electrical outlets in the warehouse. It was a perfect example of how the smallest detail could make or break an operation. A second fridge/freezer shipped to us disappeared in the “mail” on the way into the war zone, so we improvised and left most of the products in the Vaxicools, which were designed for transport, not for long-term storage.
The industrial-strength printer we brought was the single most important piece of equipment, spitting out thousands of pages of documents. One colleague estimated that if we had to treat the forces for botulism, the informed consent forms alone would weigh a ton or more.
Armed with medical products and the loathsome documents, in whatever limited time we had left, we were ready to launch our mission to train the U.S. docs in-country, thus multiplying the number of medical personnel who could assist us in responding to an attack with botulinum toxin.
We weren’t convinced that our in-country leaders took the threat seriously. Others in the medical “cell” in-theater called us “prima donnas.” We tried to get dedicated vehicles for our team, but we were rebuffed with empty promises. Ventilators that we thought were needed to save the most serious, paralyzed bot casualties never materialized.
When Bob Kuschner briefed the general about our mission—the same general who had wanted to split us up—Bob asked, “How many casualties are you expecting us to treat?” The general responded, “How many can you treat?” Bob provided a number. The general said, nonchalantly, “That’s fine.”
Though we worried about the worst-case scenario—a unit of hundreds of soldiers getting exposed to aerosolized bot—the simple things thwarted us daily.
One morning we planned to depart early in a three-vehicle convoy headed seventy kilometers north through the desert to Camp Udairi, Kuwait, which was the northernmost base near the Iraqi border. I did what I would do before any long drive—I checked the oil of my borrowed SUV. The dipstick was bone-dry. Shit! Really? I thought.
I refused to risk blowing my engine deep in the desert, but the base was an endless maze of warehouses, and it took some searching before I found the motor pool. The civilian employees there just shook their heads. “That’s a contract vehicle,” one said. “We can’t give you oil. It’s not our responsibility to provide oil for a contract SUV.” I thought, What kind of bullshit policy is this? but I said, “Are you kidding me?” “No.”
The irony of being denied oil, by my own people, in a nation built on oil, was not lost on me. This was ridiculous. I pointed out the many barrels of oil stacked around the motor pool that could easily fill a tank battalion and told them they were impairing our mission. Begrudgingly, the employee gave me two quarts.
Exiting the base, we deliberately ran the red light where some contractors had been killed by sniper fire a few weeks earlier. It was surreal, passing the large pink and tan box-shaped houses that dotted the city landscape before civilization disappeared in an endless sea of sand.
A two-lane asphalt road served as the main artery going north. We wondered why none of the other vehicles driving in either direction used it. It didn’t take too many spine-jarring potholes to figure out why, so we joined the others driving on the sand “highway.”
We passed a roadside vehicle graveyard, sand welling in the pockets of the “victims’” twisted metal, when I realized we were driving on the so-called highway of death. At the end of the first Gulf War, the Iraqis retreated north along this very same road while the U.S. Air Force strafed and bombed the vehicles. In the resulting chaos, the gridlocked vehicles and occupants became sitting ducks. I gazed on the ghostlike ruins and could almost hear the echoes of screams and explosions.
As we cruised along at up to fifty miles per hour across the desert, I felt like Mad Max. We felt the hot, gritty heat of the day, despite the vehicle’s air conditioning.
Camp Udairi, a vast tent city compound, emerged from the sand like a desert mirage. Our first order of business was a meeting with one of the operational units assigned to knock down the doors of potential biological weapon facilities in Iraq. The colonel in charge of this elite military unit had a very prominent bald forehead, giving him the nickname “Bullethead.” He invited us to join him at his tactical operations center inside an armored personnel carrier.
We clambered upward through a two-inch-thick tank portal, which opened into a small meeting room. Surrounded by walls covered with operational maps and communications equipment, our team lead, Robert Kuschner, briefed Bullethead on Iraq’s botulism threat and our antidotes and vaccines. We were all nervous, bracing for a chilly reception. Robert has a thin face, a shaved head, and a New York accent. He’s usually a polished presenter, but this time his words came out a little shaky. A lot was at stake. We had to convince Bullethead to let us vaccinate his elite team.
Bullethead’s posture, crossed arms, and frown suggested that he wasn’t buying what we were selling. I had a sinking feeling as Robert flipped through his printed slide deck. Just a couple of slides into the brief, Bullethead stopped Robert, and I feared our five minutes were up. Instead, he leaned over to his executive officer and said: “Hey, can you get Bill in here?5 He needs to hear this.”
A few long minutes later, I was surprised to see a familiar face. Bill and I had worked together at Fort Detrick three years earlier. “My God, I didn’t know you were here!” I said. “Great to see you!” he replied.
Bullethead warmed up considerably after that, and the tone of the meeting changed. By the time we left, we had exactly what we wanted: permission to offer our botulism vaccine and immune globulin to his soldiers on our next visit.
As we climbed down from the armored personnel carrier, the air had cooled, and the setting sun bathed the sand in a pink glow. I reflected on the amazing good fortune we had in the meeting. Maybe now we would be in business. The setting was peaceful in the moment, but I wondered what might lie beyond the horizon.
Our next stop was the Eighty-Sixth Combat Support Hospital (CSH) next door. In a few short days, when the bullets started strafing the sands, they would be the first mobile hospital to launch into Iraq. What we offered had direct relevance for their casualty preparations. The lead physician and twelve of his core medical staff listened attentively to my overview on how to recognize and treat botulism and smallpox. Government rules prohibited the physicians from giving the investigational bot treatment before they had been trained on the FDA regulations. So we left them cramming for an exam that would give them those credentials and then returned to our home base at Camp Doha. More intense training on the treatments would come on our next visit in a couple of days.
About five minutes from Camp Doha was a place called the Marble Palace, which was used for R&R. The sharp contrast with the desert gave it a Twilight Zone incongruity. An oasis of manicured grass and palm trees, the place had tinted windows under arches, marble floors, lounge chairs, tennis courts, putt-putt golf, and a swimming pool. It seemed like the furthest thing from war.
During a rare spell of down time, I sat by the pool and wrote a letter to Cindy:
I am suspicious that it is only a matter of time before something happens. I just saw that Pres. Bush & Tony Blair arrived in the Azores to “discuss” options. I believe there is only one option they’re discussing at this point, but you can read the papers as well as I & formulate your own conclusions. . . . By the time you get this, perhaps the war will already have started.
I am not too concerned about something like a scud attack from where I am, although there is that possibility, I am more concerned about getting hit by a car on post or some other stupid accident, like being in a Blackhawk that goes down in a sandstorm. . . . I hope you’re doing ok. I really miss feeling Daniel kick against your belly.
The next day, twenty minutes into the drive back to Camp Udairi, an alarm began beeping in the SUV. I looked back to see the emergency lights flashing on the Vaxicool that held a large supply of antitoxin we were transporting. Its temperature was rising. We had plugged the Vaxicool into the SUV’s cigarette lighter, which must have shorted out. This was a serious problem. The priceless vials inside would be worthless if we couldn’t maintain the proper temperature. Outside, the desert temperature was in the seventies and rising.
Chris Ockenhouse, an infectious disease doc with a long, thoughtful face and melancholy eyes, was in charge of the products. He rummaged around his backpack. “I think I have some batteries,” he said.
We popped them in and held our breath. To our relief, the beeping stopped, and the temperatures recovered until we reached our destination. Another crisis averted.
It was March 17, 2003, one day before the “shock and awe” bombing began, but we did not know it then. We could sense the tension building, though. As we cruised northwest toward Camp Udairi, we passed endless convoys of desert-tan camouflaged tanks, armored personnel carriers, and Humvees packed with soldiers and duffle bags headed in the same direction: the Iraqi border. The U.S. military was mobilizing—and it was a sobering sight. I felt a mixture of pride and fear for what lay ahead.
When we arrived again at Camp Udairi, I plugged my laptop into a projector in a dusty hospital tent where I would give my presentation. A dozen or so doctors and nurses assembled in folding chairs to learn how to recognize smallpox and botulism and how to administer treatment. I projected my slides onto the tan canvas wall of the tent.
As I was in midsentence describing the Iraqi bioweapons program, my voice was drowned out by a siren. Like the haunting air raid sirens of World War II, it slowly crescendoed to a wailing pitch. This was the first time I had heard the sirens, and despite the desert heat, it gave me chills. “It permeates your bones,” team member Gray Heppner said. We were under a Scud missile attack launched from across the border.
My audience and I instinctively tore open the Velcro flaps on our hips and pulled out our gas masks. Instead of ducking into the nearest bunker, as was protocol, I continued with my briefing, and my audience listened with rapt attention, even though I had to yell a little louder through the mask. I didn’t feel particularly afraid of the Scuds, though I was probably naive, but the haunting siren scared me. Moments later the ground quaked as a battery of Patriot missiles launched to intercept the Scuds. It was a beautiful sound. Someone was protecting us. I didn’t notice that one of my team members snapped a photo of me giving the brief through the gas mask. Behind me a photo of Saddam Hussein is projected against the canvas wall.
Next we prepared to vaccinate Bullethead’s elite team, but not everyone opted in for the botulism vaccine or antitoxin. That was their choice. We couldn’t make them volunteer, but the concept of not being able to require a potentially lifesaving measure still bothers me.
Set up in an empty ICU tent, we moved soldiers through the vaccination process like an assembly line: collecting medical histories, getting forms signed, and recording vital signs. Once all the administrative documents were done, we sent the soldiers behind a curtain, where our team nurse, Captain Jackie Carlin, was waiting, armed with syringes and long needles. No doubt some of the soldiers were surprised to find the petite brunette ready to give them the “Big Mac and fries.” Jackie earned her pay that night, enduring flirting from the younger soldiers as they dropped their trousers for injections in both buttocks. The sizable amount of fluid from the immune globulin made it considerably more painful than a typical shot and prompted the occasional “Mama mia” and expletives, followed by a sheepish, “Sorry ma’am.” We worked late into the night, monitoring vitals and keeping watch for adverse reactions. Around 1:00 a.m., we crashed on empty patient cots in the ICU tent.
Since the antitoxin injection had never been given in the muscles before, we needed to check on the soldiers around twelve hours after we gave it. So before we left the next day, we trekked across the sand from the CSH to the Battalion Aid Station, a single tent the size of a large teepee with a twelve-foot diameter. Five of us crowded into the tent with a couple of the soldiers at a time. There was little room for seven grown men as we maneuvered around a medical obstacle course—a stretcher, mountains of gauze, and a defibrillator—in a space fit for two. It could have been a scene from M*A*S*H, with soldiers dropping their combat trousers so we could examine their behinds. Sand rained down through the gap at the top of the tent and coated everything—including our hair and the soldiers’ butts. It was comical in retrospect, but I really wish I had taken a picture for the FDA regulators in their cubicles back home, so they could appreciate the challenges of giving investigational products in a war zone. Fortunately, the soldiers tolerated the antitoxin (and the situation) well. When we finished, we shook off the sand, packed up our papers, and headed to our SUVs.
As our convoy drove back toward Kuwait City, we hit a patch of soupy sand. Behind the wheel Gray Heppner floored it, but this only dug our spinning wheels deeper into what felt like quicksand. The hottest part of the day was approaching. We had no cell phone coverage, and we were too far from Camp Udairi to hike back. The batteries in our GPS had also died. As if on cue, the wind began to blow, stirring up clouds of sand.
I donned a respirator mask, and we got out of the vehicles and started wandering around stupidly, trying to come up with a plan. The sand swirling around us made us nearly invisible. We should have known better because a couple of days earlier a soldier, hidden by airborne grit in a sandstorm, lost one leg and had the other one mangled after being run over by a tanklike armored personnel carrier.
Suddenly, like a desert mirage, a massive tow truck emerged from the khaki fog. I have no idea how the driver knew we were there, but it seemed as if God had sent him. He deftly hooked us up to a cable and pulled us out of the mire, and we were on our way within minutes. Despite the dead GPS, we managed to find our way back to Camp Doha. We celebrated with a trip to the Green Bean, a little white trailer across the base that was the army’s answer to Starbucks. A vanilla Frappuccino never tasted so good.
That evening was the first night of shock and awe. Gray Heppner and I climbed up the stairs into the Tactical Operations Center, which was just thirty feet from our office in the headquarters. From the top of a massive amphitheater, we could peer through a large plate-glass window into the room where the bombing campaign was being orchestrated. The three-star general running the operation appeared surprisingly calm, although I suspected he wasn’t.
Seeing the attack unfold before me filled me with awe at the numerous individuals functioning as a seamless team. Like a colony of ants quivering in motion, around fifty staffers worked in concert, each with a unique skill: the operations cell, logistics, communication, movement readiness officer, medical evacuation, and air force liaison. Soldiers shuttled back and forth from one cell to another, up and down the stairs like a giant nerve network. The air felt electric. Different colored lights moved in all directions on three-story-high monitors, with each light signifying the movement of our military air attacks. Occasionally the lights flashed, or video feeds showed explosives launched by jets and drones, like a real-life video game.
In the next couple of days, all those forces we had seen driving on the sands toward Udairi launched into Iraq. Casualty counts began to climb. The pace of Scud missile attacks increased. At any time during the day or night, the low-pitched whirring sound of the base siren jolted us to attention. One afternoon, while I was carrying my lunch tray in the dining hall, the siren started to wail. The booming “big voice” on the loudspeaker announced: “TAKE SHELTER. THIS IS NOT A DRILL. MASK NOW.” A thousand Velcro flaps ripped open simultaneously as everyone automatically pulled out his or her gas mask. I dropped my tray and fell to the floor.
Another time we were sorting documents in the medical warehouse when the siren sounded. I reached for my mask. It was missing. I cursed myself for accidentally leaving it on my cot. I sat bare-faced breathing into my T-shirt while my colleagues laughed through their masks as they ribbed me with mock eulogies: “We knew him well . . .” I envisioned “drowning under a green sea” with the onset of nerve agent symptoms, like the choking chlorine gas victim in the famous World War I poem, “Dulce et decorum est.” I silently prayed for the “ALL CLEAR!” big voice.
One night in the “cave” warehouse, we had repeated alerts, and I had to don and doff my protective suit and mask repeatedly. I awoke in the middle of the night, surprised that I had fallen asleep with my gas mask on. I had grown so comfortable wearing it by then that I no longer felt the horrific claustrophobia.
After we gave the first round of vaccines, we faced a significant dilemma. The botulism vaccine, to be fully effective, requires three closely timed shots—an initial dose, followed by a second dose two weeks later, and a third six weeks after the first. But in that span of time, our soldiers dispersed all over the war zone. Was it worth hitching a ride on a Blackhawk into enemy fire to deliver a few booster shots? Our team leader felt obligated to do it, and we all worried about being chastised for not following through on the prespecified vaccine schedule. It was our duty, after all, to try and protect these soldiers. But dodging mortars in a combat zone to give a booster shot seemed absurd and foolish. Bullethead’s elite team was already on the move to undisclosed locations deep inside Iraq. We had no guarantee we could even commandeer a Blackhawk to get to them, much less find them. And the enemy was regularly shooting Blackhawks out of the sky. During one of our team meetings, I protested. As the junior member, my contrary opinion was dismissed, so I spoke with a more-senior member off-line, who agreed with me. He raised the issue at another meeting. Our leader eventually backed down.
We had to plan our activities not only around missions and battles but also around the local weather, which in Kuwait meant vicious sandstorms. Kuwait’s desert sand is a far cry from the grainy, white sand at the Jersey shore. It’s more like dried mud pulverized into brown talcum powder. It doesn’t take much to get it aloft. After a howling wind, suspended particles would hover in the air while an eerie silence settled over the camp. Everything in sight would be engulfed in airborne silt as thick as pea soup. It was so dense that I nearly turned into a speed bump for a Humvee one evening. By the time I saw the lights penetrating the sand fog, the Hummer was just a few feet away.
Even under clear skies on routine days, it was amazing how important little things mattered at war. An army “runs on its stomach,” and we became spoiled by the surprisingly good food. In addition to regular servings of burgers, baked beans, and steak, every lunch and dinner ended with a slice of pie, rotating from apple to cherry to pumpkin. One day the pie disappeared. No warning, no explanation. The replacement was a dry strawberry sponge cake.
“This is highly irregular,” we concluded. “Someone has to do something.”
Our two senior colonels weren’t taking this affront lying down. They marched into the kitchen and backed the sergeant first class in charge up against the wall. “Sergeant, what has happened to the pie? Do you realize what an important morale issue this is for the soldiers? We need our pie!” “Yes . . . yes, sirs,” the sergeant responded. “I’ll go see if I can find some more pie in the freezers.”
The next day the pie returned. We celebrated with an extra helping.
At this point, even with bullets and bombs flying, we still had one more set of hospital staff to train. One sunny morning five of us hopped on a Blackhawk for a ride to the Comfort, the navy’s hospital ship cruising in the Arabian Gulf. It was exhilarating lifting off from Camp Doha over the sea of tan warehouses below. We flew by the radio towers and spires in downtown Kuwait City and watched the desert recede as we headed out over the water.
The twenty-five-minute flight took us over shimmering blue water until a white rectangle appeared in the distance. As we approached, the rectangle grew into a massive white ship with a large red cross on its side. We touched down on the gray and white striped helipad and ducked out while the turning rotors above washed us with wind. The ship’s executive officer, dressed in brown khakis, showed us to our quarters where we would bunk for the night—patient beds again, in an empty hospital ward.
We set up our laptops and projectors in one of the ICUs and briefed the staff. Next we had a tour of the ship. Kyle Peterson, a navy infectious disease doc, showed us around the medical ICU and the isolation room. The capabilities on this ship would be the envy of any hospital director—multiple operating rooms, ICUs, an excellent lab, and a massive blood bank. Kyle was the first doc to report antibiotic-resistant Acinetobacter during Operation Iraqi Freedom from patients he cared for on this ship. Treating our battle-wounded soldiers infected with this difficult-to-treat bacteria would later prove a significant challenge for me on the wards of Walter Reed Army Medical Center back home.
Once our work was done, we had no way “off the island,” so we spent the rest of the afternoon lounging in the sun on a bed of thick rope on the helipad. The fresh sea air and singing gulls were a welcome contrast from the dusty desert. It was the high point of my deployment. I wondered whether I had joined the wrong branch of the military, because the navy docs seemed to have a pretty good deal.
After spending the night and wrapping up training with the medical staff, we had to wait for a ride back to land. Like the old television M*A*S*H* episodes, at this point in the war, choppers were in high demand, ferrying casualties from the front lines. When we finally heard the familiar WHOP-WHOP-WHOP of an incoming Blackhawk, we were ready to go. The Blackhawk touched down, and the rotors slowed but did not stop. Head down and crouching, I lined up behind my team members on the helipad feeling the rotor wash tussle our hats and uniforms. As I prepared to climb aboard, Bob Kuschner turned to me with three awful words. “KORTEPETER!” he yelled over the roar. “YOU’RE STAYING!”
Four seats. Five bodies. Someone had to stay.
Tail tucked, I retreated to the edge of the helipad. As the Blackhawk rose, I blinked into the blast of air, stunned, and watched the helicopter shrink and vanish in the white-hot sky.
I had to fight back the tears. I’m not particularly superstitious, but this sudden separation from my team felt like a terrible omen. I could not shake the feeling that their chopper—or mine—was doomed. One of my colleagues snapped a photo of me from the Blackhawk, standing alone on the tarmac as they left me behind. This was the lowest point of the mission for me, and it shows on my face.
The same Blackhawk that picked up my teammates had delivered a brown body bag. I retreated into the alcove next to the helipad as the medical staff carried it in. Before sliding it into a storage refrigerator, a ship doctor unzipped the thick brown plastic to record some information. I caught a glimpse of the marine’s pale left hand, labeled with a paper tag.
The sight of that ghostlike, still hand amplified my dark premonition. Sullen, and not knowing when my ride would come, I retreated to the bowels of the ship, where I found a desk at a vacant nurse’s station. I found a ballpoint pen and white-lined paper and wrote an angry and sad letter to my wife, thinking it might be my last.
Soon enough a chopper came for me. Fortunately, I made it back to Camp Doha to reunite with my team and made a celebratory visit to the Green Bean for a latte.
After two months, teams searching for Saddam’s cache of biological and chemical weapons had come up dry. Perhaps Saddam’s army had destroyed them after all. Our team was no longer needed. It was time to go home.
I felt satisfied that we had accomplished what we were sent to do, and we did it in a timely fashion. Despite the blinding sandstorms, incoming Scuds, and regulatory nightmares, we had successfully deployed vaccines and treatments in the theater of war to protect the forces. But opinions of the team members varied. One said, “We were sent on a fool’s mission” with an impossible task and outdated vaccines and treatments. We were lucky, after all. The U.S. forces advanced without being attacked with chemical or biological weapons. We were prepared to treat botulism casualties in a small military unit; however, orchestrating a massive botulinum antitoxin response would have faced formidable challenges. We probably would have failed, at least in meeting all the FDA requirements. No doubt, we would have taken some of the blame.
Defending against bio agents on the battlefield remains a significant challenge. Because their use against our forces would likely be covert, we wouldn’t know we had been infected until soldiers became ill in droves. That would be too late. We need licensed countermeasures, but knowing which agent the adversary might reach for is a crapshoot. Research and development efforts continue, but it is unlikely we would ever create vaccines and treatments against all potential threats. If we are successful in licensing one countermeasure, our adversary may just reach for a different agent.
Some of our vulnerabilities from this deployment remain. A new, licensed botulism vaccine is years away. I would like to say that the next effort might be different, but I can’t. We would be reinventing the same wheel. Whoever does this before the next war would run up against the same regulatory challenges and mountains of paperwork that we faced. Institutional memories are short, and my colleagues and I who gained experience from this deployment have all moved on. The military still does not get any wider latitude for operational use than any civilian agency. Developing new countermeasures takes years, potentially decades, and there is no easy workaround. There is one bit of good news, though: we now have two licensed botulism antitoxins for the nation, which were first developed at USAMRIID.
I had mixed emotions about leaving the desert. I had really enjoyed the camaraderie with my teammates and knew I could never replicate the action and excitement of the deployment. My original concerns about being out of my league with my more-senior colleagues had long since abated, and we had become friends. However, I did not look forward to returning to the usual leadership frustrations back at USAMRIID, and my guilt over lacking enthusiasm about having another child also returned.
Landing at Dulles International Airport in Washington DC was bittersweet. I just picked up my duffle bags from baggage claim and said a quick goodbye to my teammates. At one moment we were a close-knit team operating on the fringe of the world, and in the next we went our separate ways. I took a quiet, lonely cab ride home.
Seeing my family brightened my spirits, though. Sean had made a card that said, “Welcome Home Daddy” in black marker. On the inside of the card, he wrote, “I can do my . . .” followed by a page of his alphabets, in different sizes and shapes in red marker. Luke wanted to show me he had a haircut. He drew pictures of “me before” and “me after,” where the first one looked normal and the second one frazzled with much shorter hair. Inside he wrote: “We are glad your back. At baseball I got hit by the pitch. Everyone is glad you came back.” Cindy had enlisted ten-year-old Luke to serve as her birth “coach” in case I didn’t make it back.
The next morning Cindy and I walked out to the front lawn with the boys. She handed me a pair of scissors to cut the yellow ribbon she had tied around the cherry tree in front of our house.
Ten days later whatever concerns I had about becoming a father again melted away as I held the squirming nine-pound, three-ounce gift as he entered the world. I enjoyed holding this little bundle against my chest as we both fell asleep each night. To this day he has the most infectious smile, and I am grateful for fatherhood each day.