There was A230, which was designed for use in very cold climates and specifically requested by the Soviet Army because its existing agents solidified in such conditions, rendering them ineffective. Then there was A232, which one might term the main Novichok agent. Designed as a VX replacement, it could be made from precursor chemicals that were not on the list of substances regulated by the Chemical Weapons Convention. This offered Russia a ready-made solution should the day come when it wanted to break out of the disarmament treaties. It was a way of retaining a dormant capability that the Russian state had pledged to give up.
Designed to fall from an exploding munition in a fine mist of droplets that could be inhaled or absorbed through the skin, A232 was created with a chemical signature that is almost impossible to detect with standard NATO equipment. The successful German intelligence operation had by 1998 however brought some A232 to the West, so Porton Down had examined actual samples and retained all the reference data. Alas, it was not the substance coming back from Salisbury. This left one more ‘production’ standard Novichok, A234.
This last formula had the advantage that it could be produced as a solid, then ground into powder. In some situations that could be used, for example via ventilation systems, to get A234 inhaled by the victim, in others it might be produced as a very viscose liquid. If this suggested some obvious possibilities as a poison for assassinations, that hypothesis fitted neatly with intelligence MI6 had received in the late 2000s, suggesting Russia had retained some small stocks of this agent for precisely this purpose.
It isn’t entirely clear whether scientists at Porton Down had ever synthesized their own A234, an activity that would have been allowed (in very small quantities) under the Chemical Weapons Convention, for example for the purpose of developing new filters for gas masks. Although they knew the chemical formulas for A234, some people have suggested to me that they may have refrained from making it for many reasons, not least cost, and therefore have never been able to carry out detailed studies on its properties. Others have implied that it was studied at Porton, though whether they made it or obtained some Russian A234 by clandestine means would be highly classified.
Whatever the truth, this was the substance that was coming up in their GC/MS testing. It had been found at the bench, and at Zizzi’s. Tests on blood and tissue from the Skripals now revealed the presence of A234 within their bodies too. The scientists also formed the view that it was a substance of great purity, something only a handful of labs in the world could have produced.
So if the experts were fixing on that obscure nerve agent, what did that mean for the patients in Salisbury Hospital? Asked this question, Dr Duncan Murray, the senior intensive-care consultant there, told me: ‘You don’t know the what I’ll term the kinetics of the agent: how long it takes to reach its peak effect; how long it’s going to last for; when things might start to improve… any metabolites of the drug that might have any long-lasting effects; and probably more the longer-term outcomes.’
The ‘metabolites’ he referred to are by-products of the body’s attempt to clear the poison. With some nerve agents these are well understood, sarin for example producing a complex acid so distinctive that it can be used as a marker for contamination with that agent. With Novichok A234 there was simply no idea what might happen as the body metabolized it, and whether this by-product might destroy the kidneys, brain, or some other vital organ.
Indeed even when I talked to the hospital’s Medical Director, Dr Christine Blanshard, in May 2018 about possible lasting effects she noted, ‘I think the honest answer is that we don’t know. And we have a total world experience of treating three patients for the effects of Novichok poisoning, and I think it’s safe to say that we’re still learning.’
Late on in that first week though, as the identification of A234 firmed up on the Wednesday and Thursday, these were not questions uppermost in the minds of the clinical team. They were struggling to keep the Skripals alive. To begin with this meant the Level 3 array of intensive care plus large doses of the standard three drugs used to treat this type of crisis: atropine, pralidoxime chloride, and diazepam.
The most important of these drugs, when dealing with nerve-agent patients, is atropine. It shields the body’s nervous system by limiting damage to acetylcholinesterase production. However, in order to do this, it is best administered quickly. Atropine has some other uses too, for crises rather more common than nerve-agent poisoning.
The paramedics who treated the Skripals on 4 March had, by serendipity, given them small doses of atropine. Suspecting an opioid overdose they had noted the pair had very weak heartbeats – and atropine is carried in many ambulances for use in such scenarios. So they administered what may have been life-saving medication to the Skripals based on a false premise of what had made them ill. ‘The doses given at the scene were small but significant,’ one medic told me, ‘after the nerve-agent diagnosis we flooded them with atropine.’
Another unknown was how much damage hypoxia, oxygen starvation, might have done to the brain. Doctors did not initially have a precise idea how long the Skripals had stopped breathing before the medics had arrived. Brain damage can occur within several minutes of such a crisis. Through scans of brain activity they became surer that the paramedics had performed a remarkable duty in this regard also, reaching the scene as well as supporting the Skripals’ breathing with great speed.
Other tests on the ward, such as those for kidney and liver functions, also showed some kind of normal activity. So as the patients entered their second week on Radnor Ward confidence started to rise, just a little. They were becoming, in the words of one of their consultants, ‘stably sick’. Every day survived was another day in the fight and Nick Bailey was showing that recovery was possible. He was sitting up, receiving visitors, and rallying even if some reported him a little confused and ‘not his usual self’. By 22 March he was well enough to be discharged.
Having got through the first couple of weeks with all their patients alive, the doctors began to think ahead to stage two of the fight. The medical literature had led them to believe that the ‘survival phase’ might last up to one month – that was the upper limit given for the active effects of the agent VX on the body, for example. But once that initial battle was over, and tests on Yulia’s organ functions were starting to give them confidence in that respect, a whole new stage began.
Production of acetylcholinesterase, the nervous system’s ‘off switch’, might take months to re-establish itself. Preparing for this eventuality they shifted ventilation from the mouth to the trachea (the windpipe, at the base of the neck below the voice box), which is less intrusive as well as allowing the patients to speak once the time comes to dial down their sedation, bringing them back into the world of the living.
This process was starting for Yulia at around the time that Nick Bailey was discharged. Having established that key organs appeared to be working, they looked for signs that the patient might be able to breathe with less help from the ventilator. They had begun scaling back her support in that regard just eight or nine days after the poisoning. And with the evidence that she could support her own breathing for a time, the medics started adjusting the drugs, as consultant Stephen Jukes explained: ‘We would begin to reduce the amount, literally taper the amount of the medications that [we] are using to a point where it’s no longer necessary and constantly review [the] response. If we worried that actually the response is damaging in some way or has potential to be damaging, we pause and perhaps backtrack. If things look stable, then we can slowly take away that support.’