Last week's chemical attack in Damascus killed hundreds of people, but thousands more received a non-lethal dose. What lies in store for these survivors?
Similar attacks by Iraqi government forces during the Iran–Iraq war in the 1980s offer clues, suggesting that survivors could face decades of health and psychological problems but that interventions can help – if they happen quickly.
The biggest single attack was in the Kurdish town of Halabja in northern Iraq, where at least 3000 people died and thousands more were severely hurt. The worst cases were caused by mustard gas, which causes blisters on the skin and lungs. It was not used in Syria (see "Wind and rockets key clues in Syrian chemical puzzle"), though President Assad is thought to have stockpiles.
Sarin, the likely culprit in Syria, was used too. Salah Ahmad of the Kirkuk Center for Torture Victims, which runs a rehab centre in Halabja, reports chronic neurological damage due to the nerve agent.
Long–term effects include restlessness, anxiety, disordered sleep, memory loss, cognitive impairment, depression and post-traumatic stress disorder (PTSD), according to Mahdi Balali–Mood of Mashhad University of Medical Sciences in Iran, who has studied Iranian chemical attack victims from the same conflict.
Profound guilt
There is a sarin antidote, atropine, but it needs to be given within minutes or hours in severe cases. No one knows how many Syrian victims may have received it.
Humanitarian organisation Médecins Sans Frontières says that clinics it supports in Damascus claim to have received around 3600 patients with neurotoxic symptoms on the day of the attack, and that they did treat people atropine.
Atropine can be effective weeks later in less severe cases, and MSF is trying to send more doses but there is no guarantee they will get through. It is in short supply throughout Syria.
Survivors will also have to deal with psychological trauma. Sarin can wipe out whole families, and this often leaves survivors with a profound sense of guilt, which can be debilitating.
Sad faces
Ahmad recalls a patient in Halabja who as a child was the only one of a family of 11 to survive the 1988 attack. As an adult, he "feels so bad he doesn't want to live", Ahmad says. "There were many survivors, but if you go to Halabja today you see a very different society. You see sad, depressed faces throughout the city."
A strong support network will be as crucial in Syria as emergency medical treatment, he says.
Two further incidents also reveal sarin's long-term toll. US soldiers exposed to low levels while destroying a weapons dump in Khamisiyah, Iraq, during the Gulf War of 1990-1991 had impaired memory, attention, visuospatial abilities and altered brain structure.
Many of the 5500 survivors of the 1995 sarin attack on the Tokyo subway report chronic memory and attention problems, and PTSD symptoms. Those exposed to intermediate levels have less grey matter in regions used for memory and cognition.
Journal references: Neurotoxicology, doi.org/cwpv2b; Annals of Neurology, doi.org/b75fxg
This article will appear in print under the headline "The survivors' tale"
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