Three years ago HSPH was retained by Kuwait to determine whether there were substantial public health impacts of Iraq's 1990 invasion and occupation of Kuwait and, if so, to -- (i) estimate the magnitude of such impacts, (ii) assess their causes, and (iii) determine whether cost-effective approaches of medical screening could be designed to facilitate early detection and treatment of affected individuals. The entire project is being conducted, funded and monitored under the auspices of the United Nations Compensation Commission (UNCC), which was set up to resolve claims against Iraq.
Results from the HSPH investigation formed the basis for Kuwait's final public health claims, which are among the first ever to seek compensation for the environmental and public health consequences of conflict between nations. The UNCC evaluated the claims, held hearings last September, and announced its compensation decision this week.
HSPH's investigation was led by Dr. John Evans, senior lecturer on environmental science in the Department of Environmental Health, and included three major elements -- a retrospective cohort study of 5,000 Kuwaitis whose health has been followed for 14 years; a probabilistic risk assessment of the likely mortality impacts of exposure to smoke from the oil fires; and a review of trends in morbidity and mortality data from Kuwait's Ministry of Health.
Phase I of the cohort study focused on individuals who were 50 or more years of age at the time of the invasion. Analysis of data for these older adults revealed that, in the 14 years since the liberation of Kuwait, rates of mortality have been appreciably higher among those who stayed in Kuwait during the invasion and occupation than among those who were outside of Kuwait during this same period. The comprehensive risk assessment suggests an average individual risk on the order of 2/10,000 may be attributable to exposure to smoke from the oil fires -- a level of risk which is roughly equivalent to that produced by smoking 20 packs of cigarettes. Across the entire population, this extra risk would correspond to roughly 100 premature deaths.
But this smoke exposure alone is not sufficient to explain the observed elevation in the mortality rates of those who remained in Kuwait during the occupation. A series of screening risk assessments for other contaminants -- such as volatile organic compounds, polycyclic aromatic hydrocarbons and metals from the oil lakes and marine oil spills; and depleted uranium -- indicated that population exposures to these compounds were unlikely to lead to appreciable risks to public health.
Research conducted by Professor Jaafar Behbehani (Kuwait University Faculty of Medicine) and his colleagues at Kuwait's Al-Riggae Center demonstrated that, in 1993 and also in 1998, rates of post-traumatic stress disorder (PTSD) were substantially higher among adults who remained in Kuwait during the invasion and occupation than among those who were outside of Kuwait.
Preliminary investigation of the data from HSPH's cohort of older adults supports the hypothesis that exposure to trauma may play a role in explaining the observed elevations in mortality among Kuwaitis who remained in country during the occupation.
The State of Kuwait's initial public health claims had been based largely on a preliminary analysis of trends in mortality and morbidity (as measured by hospital admissions) which suggested that morbidity and mortality rates among Kuwaitis had risen after the invasion and had remained elevated for several years.
Working with Dr. Mostafa El-Desouky of the Kuwait Institute for Scientific Research, the Harvard team critically examined the hospitalization and mortality data for the 1983 to 2002 period and found that these data alone did not provide compelling support for the assertion that the invasion and occupation of Kuwait had resulted in sustained and substantial increases in rates of hospitalization or mortality among Kuwaitis.
On the basis of Harvard's findings, the State of Kuwait revised its public health claims to seek compensation for premature deaths from exposure to the oil fire smoke, medical treatment costs and costs of loss of well being due to PTSD, and medical treatment costs for mine and ordnance victims.
In addition, Kuwait asked the UNCC for funding to support continued epidemiological and medical follow-up of the exposed Kuwaiti national population. Given the magnitude of the effect seen among older adults in HSPH's study and the lack of an entirely satisfactory explanation of the cause of these effects, it would seem essential to continue monitoring the health of this population and to expand the study to include individuals who were children and younger adults at the time of the invasion.
"While some might argue that global public health will not be advanced by a transfer of funds to Kuwait, it is important that international organizations such as the UN establish the precedent that public health impacts are fully compensable," said Evans. "It is well established that individuals may recover compensation for the loss of life, limb, or pain and suffering. But as our research shows, the most substantial public health impacts often result from small increases in individual risks spread across large populations. In these cases, the affected individuals may not be identifiable and, as a result, these impacts may be ignored. In their evaluation of Kuwait's claims, the UNCC has the opportunity to recognize and rectify this oversight -- making clear that public health impacts are fully compensable."
In addition to Dr. Evans, key researchers on the project included Douglas Dockery, professor of environmental epidemiology at HSPH, Jaafar Behbehani, assistant professor at Kuwait University Faculty of Medicine, James Hammitt, professor of economics and decision sciences at HSPH, and Roger Cooke, professor of mathematics at Delft University.
A summary of the report and list of contributing scientists is available at: http://www.hsph.harvard.edu/press/releases/kuwait/kuwait.doc
Press release in Arabic available at: http://www.hsph.harvard.edu/press/releases/kuwait/arabic_translation.pdf