The Kuwait Oil Fires John S. Evans, Sc.D. Harvard School of Public Health New England Chapter – Society for Risk Analysis Boston, Massachusetts 28 May 2008

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 The Fires More Than 700 Fires First Fires – Air War ~ 17 January 1991 Ground War ~ 23 February 1991 Liberation ~ 28 February 1991 Last Fire - 6 November 1991 Oil Burned ~ 4 x 10 6 barrels per day PM Emissions ~ 3 x 10 9 kg

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 The Great London Fog December 1952 Air Pollution Episode Smoke Levels Rose to >1500  g/m Deaths Attributable to Smoke Baseline Mortality ~ 300 Deaths/Day Lawther noted that “No specific clinical syndrome was described…The effects on the health of the public …were among the old, sick and very young. This insult constituted the final intolerable stress in those with inadequate or severely-damaged cardiovascular and respiratory symptoms.” Only 1/3 of deaths were on days when death was “more likely than not due to smoke”

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 The Question Were there substantial public health impacts of Iraq’s 1990 invasion and occupation of Kuwait and the ensuing Gulf War? Were there substantial public health impacts of Iraq’s 1990 invasion and occupation of Kuwait and the ensuing Gulf War? If so, how large were the impacts? what were the causes? If so, how large were the impacts? what were the causes?

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 The Hazards & Prior Assessment Mines and Ordnance Mines and Ordnance Environmental Contaminants Environmental Contaminants Smoke from the Fires Smoke from the Fires Volatile Organic Compounds from the Oil Lakes Volatile Organic Compounds from the Oil Lakes PAHs and Metals from the Fires, Oil Lakes and Oil Spills PAHs and Metals from the Fires, Oil Lakes and Oil Spills Depleted Uranium from Military Ordnance Depleted Uranium from Military Ordnance Psychological Trauma Psychological Trauma

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 Our Team Risk Assessment & Valuation Risk Assessment & Valuation Dr. George Gray Dr. Andrew Wilson Dr. Josh Cohen Prof. Jim Hammitt Prof. Petros Koutrakis Dr. Alan Eschenroeder Prof. Debbie Bennett Expert Judgment Expert Judgment Prof. Roger Cooke Dr. Jouni Tuomisto Dr. Andrew Wilson Oswaldo Morales Marko Tainio Delft, KTL, INE, Earthtech Delft, KTL, INE, Earthtech Epidemiology & Medical Monitoring Dr. Abdulrahman Al-Muhailan Prof. Jaafar Behbehani Dr. David Mage Louise Hanson Prof. Douglas Dockery Martha Fay Prof. David Christiani Dr. Elpis Soteriades Dr. Rosalind Wright Prof. Allan Hill Kadhema, Temple, KU, KISR

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 Acknowledgement and Disclaimer Acknowledgement – This work was conducted for the State of Kuwait under the auspices of the UNCC with funds provided by the PAAC and with technical review and supervision by the Kuwait Institute for Scientific Research. Acknowledgement – This work was conducted for the State of Kuwait under the auspices of the UNCC with funds provided by the PAAC and with technical review and supervision by the Kuwait Institute for Scientific Research. Disclaimer – The views that are presented in this talk are those of the author and do not necessarily represent the official positions of the State of Kuwait or the Public Authority for Accounting for Compensation (PAAC). Disclaimer – The views that are presented in this talk are those of the author and do not necessarily represent the official positions of the State of Kuwait or the Public Authority for Accounting for Compensation (PAAC).

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 The People About 600,000 Kuwaiti Nationals About 600,000 Kuwaiti Nationals Very Young Population Very Young Population ~ 25% >= 30 Years Old ~ 25% >= 30 Years Old Many Outside of Kuwait During Occupation Many Outside of Kuwait During Occupation ~50% in Kuwait in mid February 1991 ~50% in Kuwait in mid February 1991 ~95% Had Returned by mid October of 1991 ~95% Had Returned by mid October of 1991

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 The Measurements Equipment Had Been Stolen or Destroyed by Iraq No Measurements During First Several Months of Fires PM 10 Measurements at Three Sites from mid-April through December of 1991 Typical Values ~ 300  g/m 3 High Days 1000 to 2000  g/m 3 Reflect ALL SOURCES of PM

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 The Model US DOD Used HYSPLIT Model to Estimate Exposure of Allied Troops US DOD Used HYSPLIT Model to Estimate Exposure of Allied Troops HSPH Obtained Results through Freedom of Information Request HSPH Obtained Results through Freedom of Information Request Values Vary Across Country and By Day Values Vary Across Country and By Day Typical Values ~ 10  g/m 3 (in populated areas of Kuwait) Typical Values ~ 10  g/m 3 (in populated areas of Kuwait) High Days > 300  g/m 3 (in populated areas of Kuwait) High Days > 300  g/m 3 (in populated areas of Kuwait) Model is Poorly Documented Model is Poorly Documented

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 Why Worry About PM? Time-Series Studies Following the London Fog of December 1952 it was noticed that ~ 4000 excess deaths occurred. During the period of the fog, smoke levels reached 4500  g/m 3 and averaged 1600  g/m 3. The population of London was ~ 10 million at the time. In large cities around the world, numbers of deaths are higher on days with higher levels of PM, all other things being equal. Such studies were first done in London and New York, but now have been repeated in hundreds of cities.

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 Why Worry About PM? Cohort Studies Mortality rates are higher in cities with higher levels of PM, all other things being equal. Mortality rates are higher in cities with higher levels of PM, all other things being equal. The Six Cities study followed the mortality experience of ~ 8000 adults living in 6 US cities with different levels of PM for ~15 years. The Six Cities study followed the mortality experience of ~ 8000 adults living in 6 US cities with different levels of PM for ~15 years. The ACS study followed the mortality of ~ 500,000 adults for ~ 7 years living in 151 US metropolitan areas. The ACS study followed the mortality of ~ 500,000 adults for ~ 7 years living in 151 US metropolitan areas.

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 Back of the Envelope Risk Assessment R ~  C M o P R ~  C M o P Where  is the risk coefficient (0.4% per  g/m 3 PM2.5 cohort (ACS) or 0.1% per  g/m 3 PM10 time series) Where  is the risk coefficient (0.4% per  g/m 3 PM2.5 cohort (ACS) or 0.1% per  g/m 3 PM10 time series) C is the concentration (300  g/m 3 PM10 or 10  g/m 3 PM2.5 due to fires) C is the concentration (300  g/m 3 PM10 or 10  g/m 3 PM2.5 due to fires) M o is the background mortality rate (3/1000 p-yr or 9/1000 adult-yr) M o is the background mortality rate (3/1000 p-yr or 9/1000 adult-yr) P is the population (600,000 total OR 150,000 adults) P is the population (600,000 total OR 150,000 adults) “Back of the envelope” screening estimates: “Back of the envelope” screening estimates: 35 deaths (2/10,000 risk among 150,000 adults) – using ACS cohort coefficient 35 deaths (2/10,000 risk among 150,000 adults) – using ACS cohort coefficient 116 deaths – using Six Cities cohort coefficient 116 deaths – using Six Cities cohort coefficient 0 deaths – if epidemiology does not reflect causal relationships 0 deaths – if epidemiology does not reflect causal relationships

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 Key Issues Exposure Level and Pattern -- Kuwait oil fire exposure level and pattern is different than those of interest for most regulation, with background PM 10 levels in Kuwait of 200 or 300 µg/m 3, and PM 2.5 increment due to fires averaging 10 µg/m 3 with spikes of several hundred µg/m 3. Exposure Level and Pattern -- Kuwait oil fire exposure level and pattern is different than those of interest for most regulation, with background PM 10 levels in Kuwait of 200 or 300 µg/m 3, and PM 2.5 increment due to fires averaging 10 µg/m 3 with spikes of several hundred µg/m 3. Should time-series or cohort studies be used to estimate risk? Should time-series or cohort studies be used to estimate risk? Composition -- Oil fire smoke differs in composition from typical urban aerosols in the U.S. and Europe. Composition -- Oil fire smoke differs in composition from typical urban aerosols in the U.S. and Europe. Should an adjustment be made for differential toxicity? Should an adjustment be made for differential toxicity? Age-Structure of Population -- Kuwaiti population is far younger than US or European populations. Age-Structure of Population -- Kuwaiti population is far younger than US or European populations. Do relative risk estimates from US/European studies apply directly? Do relative risk estimates from US/European studies apply directly? Causation – Epidemiological studies may reflect association rather than causation due to various biases, failure to control for confounding, etc. Causation – Epidemiological studies may reflect association rather than causation due to various biases, failure to control for confounding, etc.

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 The Experts -- European Elicitations Bert Brunekreef, Ph.D. Bert Brunekreef, Ph.D. Professor of Environmental Epidemiology, University of Utrecht, Netherlands Annette Peters, M.D., Ph.D. Annette Peters, M.D., Ph.D. Assistant Professor, GSF National Research Center for Environment and Health, Germany Assistant Professor, GSF National Research Center for Environment and Health, Germany Nino Kuenzli, M.D., Ph.D. Nino Kuenzli, M.D., Ph.D. Assistant Professor, University of Basel, Switzerland (now at USC) H. Ross Anderson, M.D. H. Ross Anderson, M.D. Professor of Medicine, University of London, England Ken Donaldson, M.D. Ken Donaldson, M.D. Professor of Medicine, University of Edinburgh, Scotland Juha Pekkanen, M.D., Ph.D. Juha Pekkanen, M.D., Ph.D. Head of Environmental Epidemiology, National Public Health Institute (KTL), Finland

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 Rationale for Use of Expert Judgment Scientific data may not speak for themselves; require careful interpretation Scientific data may not speak for themselves; require careful interpretation Scientific data may seem conflicting or inconsistent; require judgmental synthesis Scientific data may seem conflicting or inconsistent; require judgmental synthesis In the absence of data, assumptions are necessary; requires judgment about plausibility of assumptions In the absence of data, assumptions are necessary; requires judgment about plausibility of assumptions Choice of and/or construction of models may require judgments that are beyond the expertise of the risk assessor Choice of and/or construction of models may require judgments that are beyond the expertise of the risk assessor

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 The Question How many deaths among the exposed Kuwaiti National population are attributable to exposure to smoke from Kuwait Oil Fires? How many deaths among the exposed Kuwaiti National population are attributable to exposure to smoke from Kuwait Oil Fires? TOO HARD ! TOO HARD !  Decompose… Warm Up… Start with Easy Questions  Decompose… Warm Up… Start with Easy Questions  Work Toward the REAL QUESTION.  Work Toward the REAL QUESTION.

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 Mortality Impact of Permanent Decrease in PM 2.5 of 1 µg/m 3 in the US

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 Linking Evidence & Answers What evidence or theory suggests large values for this relationship? What evidence or theory suggests large values for this relationship? What is the highest plausible value? What is the highest plausible value? Tell us a little about your reasoning, the evidence, and theories that lead you to this value. Tell us a little about your reasoning, the evidence, and theories that lead you to this value. Can you tell us of scenarios that would yield higher results? Can you tell us of scenarios that would yield higher results? What evidence or theory suggests small values? What evidence or theory suggests small values? What is the lowest plausible value? What is the lowest plausible value? Tell us a little about your reasoning, the evidence, and theories that lead you to this value. Tell us a little about your reasoning, the evidence, and theories that lead you to this value. Can you tell us of scenarios that would yield lower results? Can you tell us of scenarios that would yield lower results?

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 Mortality Impact of Permanent Decrease in PM 2.5 of 1 µg/m 3 in US (Green) or Europe (Blue) Mortality Impact [% change in baseline mortality per unit of exposure (1 µg/m 3 PM 2.5 )]

The Sequence ExposureDurationEffectWindowUS(Baseline: 18 µg/m 3 ) MCMA(Baseline: 35 µg/m 3 ) Europe(Baseline: 20 µg/m 3 ) PermanentLong-termQ1Q2 One day 1 week Q3Q4Q5 One day 3 months Q6 Timing of Expression of Impact Q7 & Q8 Differential Toxicity Q9 & Q10 Public Health Impacts of Kuwait Oil Fires – 28 May 2008

Pre-Elicitation “Warm Up” Questions What are the key properties of an ideal epidemiology study for measuring long-term mortality impacts of PM exposure? What are the key properties of an ideal epidemiology study for measuring long-term mortality impacts of PM exposure? Similarly, what are the key properties of an ideal epidemiological study of short-term mortality impacts of PM exposure? Similarly, what are the key properties of an ideal epidemiological study of short-term mortality impacts of PM exposure? What factors need to be considered to decide whether epidemiology results should be viewed as causal? What factors need to be considered to decide whether epidemiology results should be viewed as causal?

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 The Answer Deaths Attributable to Exposure to Smoke from the Kuwait Oil Fires

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 The Answer Deaths Attributable to Exposure to Smoke from the Kuwait Oil Fires Expert * 5%50%95%Approach E61321TS A43263TS C<154426C F C B C D C Experts are listed in order of their median estimate of risk. Letter identifications are randomly assigned to experts.

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 Combining Judgments Should judgments be combined across experts? And if so, how? Should judgments be combined across experts? And if so, how? First, always present the full spectrum of individual judgments. Then – First, always present the full spectrum of individual judgments. Then –  Morgan and Henrion – combine only if between expert variation is less than within expert uncertainty  Cooke – combine based on performance on seed questions using a method reflecting both information and calibration

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 CalPUFF Model Harvard Used CalPUFF Model to Estimate Exposure of Kuwaiti Citizens Harvard Used CalPUFF Model to Estimate Exposure of Kuwaiti Citizens Computed Plume Rise From Thermodynamics of Oil Fires Computed Plume Rise From Thermodynamics of Oil Fires Used Improved Meteorological Data and Finer Grid Spacing Used Improved Meteorological Data and Finer Grid Spacing Accounted for Coastal Effects and Considered Plume Enhancement Accounted for Coastal Effects and Considered Plume Enhancement Values Vary Across Country and By Day Values Vary Across Country and By Day Typical Values ~  g/m 3 (in populated areas of Kuwait) Typical Values ~  g/m 3 (in populated areas of Kuwait) High Days  g/m 3 (in populated areas of Kuwait) High Days  g/m 3 (in populated areas of Kuwait)

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 The Epidemiology HSPH conducted a cohort study of 5000 Kuwaitis older than 50 on the eve of Iraq’s invasion. Information was gathered by questionnaire on health status, smoking, education, income, diet, exercise, location during the fires and exposure to trauma. The survival of those who were in Kuwait during the occupation was % lower than the survival of those who were outside of Kuwait during this same period. This difference was statistically significant and persisted after control for age, smoking, income and education.

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 Post Traumatic Stress Disorder The Al-Riggae Center conducted a study of ~2000 Kuwaitis in 1993 and a follow-up study of these same individuals in The Al-Riggae Center conducted a study of ~2000 Kuwaitis in 1993 and a follow-up study of these same individuals in Information was gathered by questionnaire on socio- demographics, exposure to trauma and symptoms of anxiety, depression and PTSD. Information was gathered by questionnaire on socio- demographics, exposure to trauma and symptoms of anxiety, depression and PTSD. In 1993 among adults rates of PTSD were higher among those who had remained in Kuwait during the occupation than among those who were outside of Kuwait. In 1993 among adults rates of PTSD were higher among those who had remained in Kuwait during the occupation than among those who were outside of Kuwait. Prevalence of PTSD By Location During Occupation Always Out In and Out Always In 14.4%(28/194)20.5%(168/819)25.2%(234/927)

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 Post Traumatic Stress Disorder The PTSD persisted until at least 1998 – apparently due to a combination of new cases and cases in which symptoms continued to be present 5 years later. The PTSD persisted until at least 1998 – apparently due to a combination of new cases and cases in which symptoms continued to be present 5 years later. In 1998 there were still substantial differences in the prevalence of PTSD among adults who were in Kuwait and those who were outside of the country during the occupation. In 1998 there were still substantial differences in the prevalence of PTSD among adults who were in Kuwait and those who were outside of the country during the occupation. PTSD in 1993 PTSD in 1998 TOTAL YesNo Yes 46.0 % (122/265) 54.0 % (143/265) 18.9 % (265/1401) No 22.9 % (261/1136) 77.1 % (875/1136) 81.1 % (1136/1401)

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 The Role of Trauma Top figure shows mortality rate of participants in PHS by self-reported exposure to trauma. Bottom figure shows coronary heart disease morbidity rates of participants in PHS by self-reported exposure to trauma. The elevations among individuals attacked or arrested are statistically significant and those among individuals who witnessed violence are on the margin of significance. Both graphs present results after control for age, smoking and socioeconomic status.

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 Heart Attacks and PTSD Cumulative Incidence of MI Among PHS Study Participants Cumulative Incidence of MI Among PHS Study Participants PTSD defined by presence of symptoms in at least two of four groups – PTSD defined by presence of symptoms in at least two of four groups – Troubled by unwanted memories or vivid dreams Troubled by unwanted memories or vivid dreams Avoid things which remind you of the past Avoid things which remind you of the past Feel emotionally numb Feel emotionally numb Irritable or “on edge” Irritable or “on edge”

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 Kuwait’s Public Health Claim Deaths Attributable to Oil Fires PAAC’s approach was to limit its claims to those which were well supported by science and to be entirely open in its presentation of the state of the relevant science. PAAC’s approach was to limit its claims to those which were well supported by science and to be entirely open in its presentation of the state of the relevant science. On the order of 35 deaths among Kuwaitis were due to exposure to smoke from the oil fires (based on US DOD model and conventional regulatory risk assessment). On the order of 35 deaths among Kuwaitis were due to exposure to smoke from the oil fires (based on US DOD model and conventional regulatory risk assessment). This claim is likely to be quite conservative (i.e., understated) in view of the new air pollution modeling results and the findings of the expert judgment study. This claim is likely to be quite conservative (i.e., understated) in view of the new air pollution modeling results and the findings of the expert judgment study. The social cost to Kuwait of these 35 deaths is ~ 200 million US$ (based on a contingent valuation study done in Kuwait and extrapolation of VSL from the US and Europe). The social cost to Kuwait of these 35 deaths is ~ 200 million US$ (based on a contingent valuation study done in Kuwait and extrapolation of VSL from the US and Europe).

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 Daily Deaths in Kuwait -- 2 Aug 90 to 6 Nov 91 Daily Deaths Among Those In Kuwait (data from PACI and MOF files). Daily Deaths Among Those In Kuwait (data from PACI and MOF files). Oil Fires Started – mid-February 1991 Oil Fires Started – mid-February 1991 Death Rate Death Rate Before Oil Fires deaths/day Before Oil Fires deaths/day During Oil Fires – 0.47 deaths/day During Oil Fires – 0.47 deaths/day Correlation Between Deaths and Smoke Concentration ~ 0.6 (Weekly Averages) Correlation Between Deaths and Smoke Concentration ~ 0.6 (Weekly Averages) Not statistically significant Not statistically significant However, only 200,000 exposed people and a relatively short period of 248 days. However, only 200,000 exposed people and a relatively short period of 248 days.

Public Health Impacts of Kuwait Oil Fires – 28 May 2008

Current Ambient Air Pollution – A Less Obvious, But Perhaps More Severe, Problem Fixed Site Monitoring Khaldiyah & Um Al-Haiman PM10 ~ 100  g/m 3 annual mean Khaldiyah, Um Al-Haiman & Um Al- Aish PM2.5 ~ 45  g/m 3 annual mean 1/3 crustal Values Similar to MEXICO CITY !

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 “Back of the Envelope” Risk Assessment Elements of Risk Assessment Elements of Risk Assessment Adult Population ~ 300,000 Adult Population ~ 300,000 Baseline Mortality Rate ~ 9/1000 p-yr Baseline Mortality Rate ~ 9/1000 p-yr PM2.5 Level ~ 30  g/m 3 PM2.5 Level ~ 30  g/m 3 Risk Coefficient ~ 0.4 % per  g/m 3 Risk Coefficient ~ 0.4 % per  g/m 3 Results Results ~ 300 deaths per year ~ 300 deaths per year

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 Risk Assessment – Toxicity May Depends on the Nature and Sources of PM

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 The Public Health Study Phase I – Medical Monitoring & Screening HSPH conducted medical monitoring and screening of about 5% of the participants in Phase I. In addition to the questionnaire information, the participants’ height, weight and resting blood pressure were determined. Venous blood samples were collected and analyzed for cholesterol & blood sugar and for the metals lead and mercury. The results indicate high levels of both hypertension and total cholesterol in this sample of elderly Kuwaitis.

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 The Public Health Study Phase I – Medical Monitoring & Screening The blood glucose and BMI values indicated high rates of obesity and diabetes among this sample of elderly Kuwaitis. The blood glucose and BMI values indicated high rates of obesity and diabetes among this sample of elderly Kuwaitis. Participation rates in the study were lower than anticipated, raising some concern about whether these results present an unbiased picture of disease in the population. Participation rates in the study were lower than anticipated, raising some concern about whether these results present an unbiased picture of disease in the population.

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 Blood Mercury Levels Tentative Results from Phase I Medical Screening Lognormal distribution 15% <= LOD (1  g/dL) Median ~ 5  g/dL GSD ~ 2.5 WHO and US EPA criteria: WHO PTWI = 0.5  g/kg-d or ~ 25  g/dL EPA RfD = 0.1  g/kg-d or ~ 5  g/dL Values regressed on fish consumption, gender and age: Women’s levels 3  g/dL lower than men’s. Local fish consumption important. All participants notified of results and provided with Arabic version of EPA/RfD guidance on mercury. Those with values above WHO criterion were notified in person by Dr. Behbehani and offered free re-testing of their blood.

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 Exposure Epidemiology PHS I & II Kuwait Longitudinal Health Study PM & VOCs Mercury in Fish Chemical Body Burden Integration & Interpretation Kuwait Burden of Disease Study Environmental Risk & Decision Analysis Kuwait National Center for Environment and Health MOH Vital Statistics KU Faculty of Medicine PAAC KISR KU Science & Engineering EPA MOH EPA Citizens NGOs Industry

Descriptive Epidemiology: Infant Mortality – “No Obvious Reversal”

Descriptive Epidemiology Adult Survival: 1950 to 2005 – “A Different Picture”

Descriptive Epidemiology Comparing Male & Female Mortality: 2001 to 2005 “Excess Mortality of Young Men”

Descriptive Epidemiology Life Tables MalesFemales Date IMR per q15 Life expectancy IMR per q15 Life expectancy At age 65At birthAt age 65At birth % % % % % % % % % % % % % % % %

Unique Natural Experiment Historically, epidemiologic studies linking specific war- related exposures (e.g., war-related trauma) to long- term physical morbidity have been challenging for a number of reasons Often difficult to examine direct linkages of the original experiences of war-related events given that most populations in this circumstance experience prolonged periods of armed conflict Even after the armed conflict, most endure prolonged economic crisis, lack of stable social systems and ongoing deprivation including displacement to other countries as refugees which may continue to impact health

Unique Natural Experiment The invasion of Kuwait by Iraq in 1990 resulted in the 7 month long Iraqi occupation of Kuwait After liberation, Kuwaiti nationals were encouraged to return and did not live in exile for long periods The physical and social infrastructure was restored in a comparatively short period of time Health and psychiatric care were made available to all Kuwaiti nationals

Mind-Body Paradigm Webster, Tonnelli and Sternberg 2002 linking psychological stress and affective states to disruption of key physiological mechanisms (e.g. neuro-endocrine and immune functioning, oxidative stress, autonomic response) and ultimately to disease expression

Major Salient Conditions: PHS I and PHS II MaleFemale

Number of Men and Women Reporting Witnessing Specific War-related Events

Number of Men and Women Reporting Being Victim of Specific War-related Events

Summary Measure of War-Related Trauma  Challenging to summarize mulitple items  Adopted modeling approach that places subjects on a continuous scale with higher scores indicating more severe trauma (Rasch modeling)  Divided this equally  no trauma  low trauma  intermediate trauma  high trauma

War-Related Stressor Score and Asthma Incidence: Adjusted Model Hazards Ratio (95% Confidence Interval) War-related Stressors NoneReference Group Low1.0 (0.6, 1.8) Intermediate1.4 (0.8, 2.4) High2.3 (1.3, 3.9) Adjusted for: age, sex, education, literacy, smoking, BMI, oil fire pollution

Multivariate Hazard Ratios of a 1-SD Increase in the War-Related Trauma Score Hazard Ratio (95% CI) Events (Person Years) Non-Fatal Myocardial Infarction1.21( ) § 186 (15021) Angina Pectoris1.59( ) § 33 (15875) Coronary Heart Disease *1.25( ) § 194 (14975) Adjusted for: age, sex, education, literacy, smoking, BMI, oil fire pollution * Includes MI and angina pectoris § P<0.01

PHS Phase II FatherMother Child N~1800 N~ yrs 4-7 yrs 0-3 yrs Public Health Impacts of Kuwait Oil Fires – 28 May

PHS Phase II -- Questionnaire Individual Characteristics Individual Characteristics Age, sex Age, sex Height and weight Height and weight Smoking Smoking Diet and exercise Diet and exercise Medical history Medical history Date of death Date of death (Deceased only) (Deceased only) Location Location During invasion, occupation and oil fires During invasion, occupation and oil fires Social/Psychological Current functioning Depression and anxiety Checklist Gulf War Syndrome Social network and support Coping strategies Traumatic events Before and After occupation During occupation Public Health Impacts of Kuwait Oil Fires – 28 May

PHS Phase II -- Biologic Markers Anthropometry Anthropometry Height, Weight, and Blood pressure Height, Weight, and Blood pressure Clinical Measures (fingerstick, 89% participation) Clinical Measures (fingerstick, 89% participation) Immediate reading Immediate reading Total cholesterol, HDL, LDL, triglycerides Total cholesterol, HDL, LDL, triglycerides Blood glucose (random) Blood glucose (random) HgbA1C (blood sugar control) HgbA1C (blood sugar control) C-reactive protein (systemic inflammation) C-reactive protein (systemic inflammation) Future genetic testing Future genetic testing Blood drops stored on specially treated filter paper Blood drops stored on specially treated filter paper Hair sample (60% of possible) Hair sample (60% of possible) Environmental metals (mercury) Environmental metals (mercury) Salivary cortisol ( “ Children ” only, 37% participation) Salivary cortisol ( “ Children ” only, 37% participation) Measure of stress response Measure of stress response Public Health Impacts of Kuwait Oil Fires – 28 May

Adolescence Prenatal Early Adulthood Older Adulthood Middle - Age Childhood Infancy Prenatal Accelerated Lifecourse Research Design PHS III PHS II PHS I Longitudinal Follow-up

The childhood shows the man, as the morning shows the day. John Milton, Paradise Lost (1667)

PHS Phase II & Possible Extensions FatherMother Child N~1800 N~1200 Interview Age yrs20-23 yrs16-19 yrs Interview Age Grand Child Grand Child Grand Child Grand Child Grand Child <16 yrs28+ yrs Recruit Siblings Recruit Children of Second Generation Public Health Impacts of Kuwait Oil Fires – 28 May

Public Health Impacts of Kuwait Oil Fires – 28 May 2008