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

The Kuwait Oil FiresThe Kuwait Oil Fires

John S. Evans, Sc.D.John S. Evans, Sc.D.Harvard School of Public HealthHarvard School of Public Health

New England Chapter – Society for Risk AnalysisNew England Chapter – Society for Risk AnalysisBoston, MassachusettsBoston, Massachusetts

28 May 200828 May 2008

Public Health Impacts of Kuwait Oil Fires – 28 May 2008

The FiresThe Fires

More Than 700 FiresMore Than 700 Fires

First Fires –First Fires –

Air War ~ 17 January 1991Air War ~ 17 January 1991

Ground War ~ 23 February Ground War ~ 23 February 19911991

Liberation ~ 28 February Liberation ~ 28 February 19911991

Last Fire - 6 November 1991Last Fire - 6 November 1991

Oil Burned ~ 4 x 10Oil Burned ~ 4 x 1066 barrels barrels per dayper day

PM Emissions ~ 3 x 10PM Emissions ~ 3 x 1099 kg kg


The QuestionThe Question

Were there substantial public health Were there substantial public health impacts of Iraq’s 1990 invasion and impacts of Iraq’s 1990 invasion and occupation of Kuwait and the occupation of Kuwait and the ensuing Gulf War?ensuing Gulf War?

If so, how large were the impacts? If so, how large were the impacts? what were the causes? what were the causes?


The Hazards & Prior The Hazards & Prior AssessmentAssessment

Mines and OrdnanceMines and Ordnance

Environmental Environmental ContaminantsContaminants

Smoke from the FiresSmoke from the Fires Volatile Organic Volatile Organic

Compounds from the Oil Compounds from the Oil LakesLakes

PAHs and Metals from the PAHs and Metals from the Fires, Oil Lakes and Oil Fires, Oil Lakes and Oil SpillsSpills

Depleted Uranium from Depleted Uranium from Military OrdnanceMilitary Ordnance

Psychological TraumaPsychological Trauma

0.0

1.0

2.0

3.0

4.0

5.0

1986 1988 1990 1992 1994 1996 1998 2000D

eath

s/1,

000

p-y

rs

Kuwaitis

Non Kuwaitis


Our TeamOur Team Risk Assessment & Risk Assessment &

ValuationValuation

Dr. George GrayDr. George Gray

Dr. Andrew WilsonDr. Andrew Wilson

Dr. Josh CohenDr. Josh Cohen

Prof. Jim HammittProf. Jim Hammitt

Prof. Petros KoutrakisProf. Petros Koutrakis

Dr. Alan EschenroederDr. Alan Eschenroeder

Prof. Debbie BennettProf. Debbie Bennett

Expert JudgmentExpert JudgmentProf. Roger CookeProf. Roger Cooke

Dr. Jouni TuomistoDr. Jouni Tuomisto

Dr. Andrew WilsonDr. Andrew Wilson

Oswaldo MoralesOswaldo Morales

Marko TainioMarko Tainio

Delft, KTL, INE, Delft, KTL, INE, EarthtechEarthtech

Epidemiology & Medical Epidemiology & Medical Monitoring Monitoring

Dr. Abdulrahman Al-MuhailanDr. Abdulrahman Al-Muhailan

Prof. Jaafar BehbehaniProf. Jaafar Behbehani

Dr. David MageDr. David Mage

Louise HansonLouise Hanson

Prof. Douglas DockeryProf. Douglas Dockery

Martha FayMartha Fay

Prof. David ChristianiProf. David Christiani

Dr. Elpis SoteriadesDr. Elpis Soteriades

Dr. Rosalind WrightDr. Rosalind Wright

Prof. Allan HillProf. Allan Hill

Kadhema, Temple, KU, Kadhema, Temple, KU, KISRKISR


The PeopleThe People

About 600,000 Kuwaiti About 600,000 Kuwaiti NationalsNationals

Very Young PopulationVery Young Population

~ 25% >= 30 Years Old~ 25% >= 30 Years Old

Many Outside of Kuwait Many Outside of Kuwait During OccupationDuring Occupation

~50% in Kuwait in mid ~50% in Kuwait in mid February 1991February 1991

~95% Had Returned by ~95% Had Returned by mid October of 1991mid October of 1991

-1 2 0 -1 0 0 -8 0 -6 0 -4 0 -2 0 0 2 0 4 0 6 0 8 0

E astin g (k m )

-8 0

-6 0

-4 0

-2 0

0

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4 0

6 0

8 0

1 0 0

Nor

thin

g (k

m)

B u rg anM in ag ish

U m m G u id a r

R au d h a ta inS ab riy ah

B ah ra

. .

..

K u w ait A irp o rt M e t S ta tio n


The MeasurementsThe Measurements

Equipment Had Been Stolen Equipment Had Been Stolen or Destroyed by Iraqor Destroyed by Iraq

No Measurements During No Measurements During First Several Months of FiresFirst Several Months of Fires

PMPM1010 Measurements at Three Measurements at Three Sites from mid-April through Sites from mid-April through December of 1991December of 1991

Typical Values ~ 300 Typical Values ~ 300 g/mg/m33

High Days 1000 to 2000 High Days 1000 to 2000 g/mg/m33

Reflect ALL SOURCES of PMReflect ALL SOURCES of PM

Time Series of PM at Mansouria

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PM c

once

ntra

tion

( g

/m3)

Ambient PM10 (Measured)

Ambient Average = 300


The ModelThe Model

US DOD Used HYSPLIT US DOD Used HYSPLIT Model to Estimate Exposure Model to Estimate Exposure of Allied Troopsof Allied Troops

HSPH Obtained Results HSPH Obtained Results through Freedom of through Freedom of Information RequestInformation Request

Values Vary Across Country Values Vary Across Country and By Dayand By Day

Typical Values ~ 10 Typical Values ~ 10 g/mg/m33 (in (in populated areas of Kuwait)populated areas of Kuwait)

High Days > 300 High Days > 300 g/mg/m33 (in (in populated areas of Kuwait)populated areas of Kuwait)

Model is Poorly DocumentedModel is Poorly Documented

Legend

Modeled TSP (ug/m3), Feb-Oct

1.9 - 8.5

8.5 - 15

15 - 22

22 - 28

28 - 35

35 - 41

41 - 48

48 - 54

54 - 61

61 - 68

0 25 50Miles


Why Worry About PM?Why Worry About PM?Time-Series StudiesTime-Series Studies

Following the London Fog of Following the London Fog of December 1952 it was December 1952 it was noticed that ~ 4000 excess noticed that ~ 4000 excess deaths occurred. During the deaths occurred. During the period of the fog, smoke period of the fog, smoke levels reached 4500 levels reached 4500 g/mg/m33 and averaged 1600 and averaged 1600 g/mg/m33. . The population of London was The population of London was ~ 10 million at the time.~ 10 million at the time.

In large cities around the In large cities around the world, numbers of deaths are world, numbers of deaths are higher on days with higher higher on days with higher levels of PM, all other things levels of PM, all other things being equal.being equal.

Such studies were first done Such studies were first done in London and New York, but in London and New York, but now have been repeated in now have been repeated in hundreds of cities. hundreds of cities.

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hang

e in

dai

ly m

orta

lity/

10 u

g/m

3 incr

ease

in P

M10

Pooled worldwideestimate- - - - - - - - - Worldwide literature - - - - - - - - - - - - -


Why Worry About PM?Why Worry About PM?Cohort StudiesCohort Studies

Mortality rates are higher in Mortality rates are higher in cities with higher levels of cities with higher levels of PM, all other things being PM, all other things being equal.equal.

The Six Cities study followed The Six Cities study followed the mortality experience of the mortality experience of ~ 8000 adults living in 6 US ~ 8000 adults living in 6 US cities with different levels of cities with different levels of PM for ~15 years.PM for ~15 years.

The ACS study followed the The ACS study followed the mortality of ~ 500,000 mortality of ~ 500,000 adults for ~ 7 years living in adults for ~ 7 years living in 151 US metropolitan areas. 151 US metropolitan areas.


Back of the Envelope Risk Back of the Envelope Risk AssessmentAssessment

R ~ R ~ C M C Moo P P

Where Where is the risk coefficient ( is the risk coefficient (0.4% per 0.4% per g/mg/m33 PM2.5 cohort PM2.5 cohort (ACS)(ACS) or 0.1% per or 0.1% per g/mg/m33 PM10 time series) PM10 time series)

C is the concentration (300 C is the concentration (300 g/mg/m33 PM10 or PM10 or 10 10 g/mg/m33 PM2.5 due to PM2.5 due to firesfires))

MMoo is the background mortality rate (3/1000 p-yr or is the background mortality rate (3/1000 p-yr or 9/1000 adult-9/1000 adult-yryr))

P is the population (600,000 total OR P is the population (600,000 total OR 150,000150,000 adults) adults)

““Back of the envelope” screening estimatesBack of the envelope” screening estimates::

3535 deaths (2/10,000 risk among 150,000 adults) – using ACS cohort deaths (2/10,000 risk among 150,000 adults) – using ACS cohort coefficientcoefficient

116116 deaths – using Six Cities cohort coefficient deaths – using Six Cities cohort coefficient

00 deaths – if epidemiology does not reflect causal relationships deaths – if epidemiology does not reflect causal relationships


Key IssuesKey Issues

Exposure Level and Pattern --Exposure Level and Pattern -- Kuwait oil fire exposure level and pattern Kuwait oil fire exposure level and pattern is different than those of interest for most regulation, with background PMis different than those of interest for most regulation, with background PM10 10 levels in levels in Kuwait of 200 or 300 µg/mKuwait of 200 or 300 µg/m33, and PM, and PM2.52.5 increment due to fires averaging 10 µg/m increment due to fires averaging 10 µg/m33 with spikes of several hundred µg/mwith spikes of several hundred µg/m33. .

Should time-series or cohort studies be used to estimate risk?Should time-series or cohort studies be used to estimate risk?

Composition -- Composition -- Oil fire smoke differs in composition from typical urban Oil fire smoke differs in composition from typical urban aerosols in the U.S. and Europe. 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 -- Age-Structure of Population -- Kuwaiti population is far younger than Kuwaiti population is far younger than US or European populations.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 – Causation – Epidemiological studies may reflect association rather than Epidemiological studies may reflect association rather than causation due to various biases, failure to control for confounding, etc.causation due to various biases, failure to control for confounding, etc.


The Experts --The Experts --European ElicitationsEuropean Elicitations

Bert Brunekreef, Ph.D.Bert Brunekreef, Ph.D.Professor of Environmental Epidemiology, University of Utrecht, NetherlandsProfessor 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 Assistant Professor, GSF National Research Center for Environment and Health, GermanyHealth, Germany

Nino Kuenzli, M.D., Ph.D.Nino Kuenzli, M.D., Ph.D.Assistant Professor, University of Basel, Switzerland (now at USC)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, EnglandProfessor of Medicine, University of London, England

Ken Donaldson, M.D.Ken Donaldson, M.D.Professor of Medicine, University of Edinburgh, ScotlandProfessor 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), Head of Environmental Epidemiology, National Public Health Institute (KTL),

FinlandFinland


Rationale for Use of Expert Rationale for Use of Expert JudgmentJudgment

Scientific data may not speak for Scientific data may not speak for themselves; require careful interpretationthemselves; require careful interpretation

Scientific data may seem conflicting or Scientific data may seem conflicting or inconsistent; require judgmental synthesisinconsistent; require judgmental synthesis

In the absence of data, assumptions are In the absence of data, assumptions are necessary; requires judgment about necessary; requires judgment about plausibility of assumptionsplausibility of assumptions

Choice of and/or construction of models Choice of and/or construction of models may require judgments that are beyond may require judgments that are beyond the expertise of the risk assessorthe expertise of the risk assessor


The QuestionThe Question

How many deaths among the exposed How many deaths among the exposed Kuwaiti National population are attributable Kuwaiti National population are attributable to exposure to smoke from Kuwait Oil Fires?to exposure to smoke from Kuwait Oil Fires?

TOO HARD !TOO HARD !

Decompose… Warm Up… Start with Easy Decompose… Warm Up… Start with Easy QuestionsQuestions

Work Toward the REAL QUESTION.Work Toward the REAL QUESTION.


Question Setting Exposure

(Effect Interval) Change Pollutant Composition Baseline

1 US Long-term 1 μg/m3 PM2.5 Ambient 18 ug/m3

What is your estimate of the true, but unknown, percent change in the total annual, non-accidental mortality rate in the adult U.S. population resulting from a permanent 1 μg/m3 reduction in long-term annual average PM2.5 (from a population-weighted baseline concentration of 18 μg/m3) throughout the U.S.? To express the uncertainty associated with the concentration-response relationship, please provide the 5th, 25th, 50th, 75th, and 95th percentiles of your estimate.

5% :____________ 25%:____________ 50% :____________ 75%:____________ 95%:____________

Mortality Impact of Permanent Mortality Impact of Permanent DecreaseDecrease

in PMin PM2.52.5 of 1 µg/m of 1 µg/m33 in the US in the US


Linking Evidence & AnswersLinking Evidence & Answers

What evidence or theory suggests What evidence or theory suggests large valueslarge values for this for this relationship?relationship?

What is the highest plausible value?What is the highest plausible value? Tell us a little about your reasoning, the evidence, and Tell us a little about your reasoning, the evidence, and

theories that lead you to this value.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 What evidence or theory suggests small valuessmall values?? What is the lowest plausible value?What is the lowest plausible value? Tell us a little about your reasoning, the evidence, and Tell us a little about your reasoning, the evidence, and

theories that lead you to this value.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?


Mortality Impact of Permanent Mortality Impact of Permanent DecreaseDecrease

in PM in PM2.5 of 2.5 of 1 µg/m1 µg/m33 in US in US (Green)(Green) or Europe or Europe (Blue)(Blue)

US EU US EU US EU US EU US EU US EUExpertA ExpertB ExpertC Expert D ExpertE ExpertF

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ort

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un

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re (

1 µ

g/m

3 P

M

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The SequenceThe Sequence

ExposureExposureDurationDuration

EffectEffectWindowWindow

USUS(Baseline:(Baseline:18 µg/m18 µg/m33))

MCMAMCMA(Baseline: (Baseline: 35 µg/m35 µg/m33))

EuropeEurope(Baseline: (Baseline: 20 µg/m20 µg/m33))

PermanentPermanent Long-Long-termterm Q1Q1 Q2Q2

One dayOne day 1 week1 week Q3Q3 Q4Q4 Q5Q5

One dayOne day3 3 montmont

hshsQ6Q6

Timing of Expression of Timing of Expression of ImpactImpact Q7 & Q8Q7 & Q8

Differential ToxicityDifferential Toxicity Q9 & Q10Q9 & Q10



Pre-Elicitation “Warm Up” Pre-Elicitation “Warm Up” QuestionsQuestions

What are the key properties of an ideal What are the key properties of an ideal epidemiology study for measuring long-epidemiology study for measuring long-term mortality impacts of PM exposure?term mortality impacts of PM exposure?

Similarly, what are the key properties of Similarly, what are the key properties of an ideal epidemiological study of short-an ideal epidemiological study of short-term mortality impacts of PM exposure?term mortality impacts of PM exposure?

What factors need to be considered to What factors need to be considered to decide whether epidemiology results decide whether epidemiology results should be viewed as causal?should be viewed as causal?


The AnswerThe AnswerDeaths Attributable to Exposure to Smoke from the Kuwait Oil FiresDeaths Attributable to Exposure to Smoke from the Kuwait Oil Fires

Expert FExpert EExpert CExpert BExpert A0

200

400

600

800

Death

s


The AnswerThe AnswerDeaths Attributable to Exposure to Smoke from the Kuwait Oil FiresDeaths Attributable to Exposure to Smoke from the Kuwait Oil Fires

Expert Expert **

5%5% 50%50% 95%95% ApproaApproachch

EE 66 1313 2121 TSTS

AA 44 3232 6363 TSTS

CC <1<1 5454 426426 CC

FF 3737 110110 210210 CC

BB 1616 164164 872872 CC

DD 575575 28742874 1149611496 CC

•Experts are listed in order of their median estimate of risk.•Letter identifications are randomly assigned to experts.


CalPUFF ModelCalPUFF Model

Harvard Used CalPUFF Model to Harvard Used CalPUFF Model to Estimate Exposure of Kuwaiti Estimate Exposure of Kuwaiti CitizensCitizens

Computed Plume Rise From Computed Plume Rise From Thermodynamics of Oil FiresThermodynamics of Oil Fires

Used Improved Meteorological Used Improved Meteorological Data and Finer Grid SpacingData and Finer Grid Spacing

Accounted for Coastal Effects and Accounted for Coastal Effects and Considered Plume EnhancementConsidered Plume Enhancement

Values Vary Across Country and Values Vary Across Country and By DayBy Day

Typical Values ~ 40-50 Typical Values ~ 40-50 g/mg/m33 (in (in populated areas of Kuwait)populated areas of Kuwait)

High Days 600 - 800 High Days 600 - 800 g/mg/m33 (in (in populated areas of Kuwait)populated areas of Kuwait)

-120 -100 -80 -60 -40 -20 0 20 40 60 80

-80

-60

-40

-20

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100

. .

..

P eriod A verag e C on tou r P lo t fo r A ll S ou rcesF eb ru ary 10 - O ctob er 1 5 , 1 99 1


The EpidemiologyThe Epidemiology HSPH conducted a cohort study HSPH conducted a cohort study

of 5000 Kuwaitis older than 50 of 5000 Kuwaitis older than 50 on the eve of Iraq’s invasion.on the eve of Iraq’s invasion.

Information was gathered by Information was gathered by questionnaire on health status, questionnaire on health status, smoking, education, income, smoking, education, income, diet, exercise, location during diet, exercise, location during the fires and exposure to the fires and exposure to trauma.trauma.

The survival of those who were The survival of those who were in Kuwait during the occupation in Kuwait during the occupation was 20-30 % lower than the was 20-30 % lower than the survival of those who were survival of those who were outside of Kuwait during this outside of Kuwait during this same period.same period.

This difference was statistically This difference was statistically significant and persisted after significant and persisted after control for age, smoking, control for age, smoking, income and education. income and education.

Survival curves after liberation by location

0.6

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2/27/91 2/26/93 2/27/95 2/26/97 2/27/99 2/26/01 2/27/03

Pro

babi

lity

of S

urvi

val

In Kuwait entire time

In and Out of Kuwait

Out of Kuwait entire time


Post Traumatic Stress Post Traumatic Stress DisorderDisorder

The Al-Riggae Center The Al-Riggae Center conducted a study of ~2000 conducted a study of ~2000 Kuwaitis in 1993 and a follow-Kuwaitis in 1993 and a follow-up study of these same up study of these same individuals in 1998.individuals in 1998.

Information was gathered by Information was gathered by questionnaire on socio-questionnaire on socio-demographics, exposure to demographics, exposure to trauma and symptoms of trauma and symptoms of anxiety, depression and PTSD.anxiety, depression and PTSD.

In 1993 among adults rates of In 1993 among adults rates of PTSD were higher among PTSD were higher among those who had remained in those who had remained in Kuwait during the occupation Kuwait during the occupation than among those who were than among those who were outside of Kuwait.outside of Kuwait.

Prevalence of PTSDPrevalence of PTSD

By Location During By Location During OccupationOccupation

Always Always OutOut

In and In and OutOut

Always Always InIn

14.4%14.4%(28/194)(28/194)

20.5%20.5%(168/819)(168/819)

25.2%25.2%(234/927)(234/927)


The Role of TraumaThe Role of Trauma

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ard R

atio

In Kuwait In Hiding WitnessedViolence

Attacked orArrested

Top figure shows Top figure shows mortality mortality raterate of participants in PHS by of participants in PHS by self-reported exposure to self-reported exposure to trauma.trauma.

Bottom figure shows Bottom figure shows coronary coronary heart disease morbidity ratesheart disease morbidity rates of participants in PHS by self-of participants in PHS by self-reported exposure to trauma.reported exposure to trauma.

The elevations among The elevations among individuals attacked or arrested individuals attacked or arrested are statistically significant and are statistically significant and those among individuals who those among individuals who witnessed violence are on the witnessed violence are on the margin of significance.margin of significance.

Both graphs present results Both graphs present results after control for age, smoking after control for age, smoking and socioeconomic status. and socioeconomic status. 0.0

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Haz

ard R

atio

In Kuwait In Hiding WitnessedViolence

Attacked orArrested


Kuwait’s Public Health Kuwait’s Public Health ClaimClaim

Deaths Attributable to Oil FiresDeaths Attributable to Oil Fires PAAC’s approach was to limit its claims to PAAC’s approach was to limit its claims to

those which were well supported by science those which were well supported by science and to be entirely open in its presentation of and to be entirely open in its presentation of the state of the relevant science.the state of the relevant science.

On the order of 35 deaths among Kuwaitis On the order of 35 deaths among Kuwaitis were due to exposure to smoke from the oil were due to exposure to smoke from the oil fires (based on US DOD model and fires (based on US DOD model and conventional regulatory risk assessment).conventional regulatory risk assessment).

This claim is likely to be quite conservative (i.e., understated) in 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 view of the new air pollution modeling results and the findings of the expert judgment study.expert judgment study.

The social cost to Kuwait of these 35 deaths is ~ 200 million US$ The social cost to Kuwait of these 35 deaths is ~ 200 million US$ (based on a contingent valuation study done in Kuwait and (based on a contingent valuation study done in Kuwait and extrapolation of VSL from the US and Europe).extrapolation of VSL from the US and Europe).


Daily Deaths in Kuwait -- Daily Deaths in Kuwait -- 2 Aug 90 to 6 Nov 912 Aug 90 to 6 Nov 91

Daily Deaths Among Those In Daily Deaths Among Those In Kuwait (data from PACI and MOF Kuwait (data from PACI and MOF files). files).

Oil Fires Started – mid-February Oil Fires Started – mid-February 19911991

Death RateDeath Rate

Before Oil Fires -- 0.28 deaths/dayBefore Oil Fires -- 0.28 deaths/day

During Oil Fires – 0.47 deaths/dayDuring Oil Fires – 0.47 deaths/day

Correlation Between Deaths and Correlation Between Deaths and Smoke Concentration ~ 0.6 Smoke Concentration ~ 0.6 (Weekly Averages)(Weekly Averages)

Not statistically significantNot statistically significant

However, only 200,000 exposed However, only 200,000 exposed people and a relatively short people and a relatively short period of 248 days.period of 248 days.

0

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Dat e

01J UL1990 01SEP1990 01NOV1990 01J AN1991 01MAR1991 01MAY1991 01J UL1991 01SEP1991 01NOV1991 01J AN1992



Current Ambient Air Current Ambient Air Pollution – Pollution –

A Less Obvious, But Perhaps More Severe, A Less Obvious, But Perhaps More Severe, ProblemProblem

Fixed Site MonitoringFixed Site Monitoring

Khaldiyah & Um Al-Haiman Khaldiyah & Um Al-Haiman PM10 ~ 100 PM10 ~ 100 g/mg/m33 annual annual

meanmean

Khaldiyah, Um Al-Haiman & Khaldiyah, Um Al-Haiman & Um Al-AishUm Al-Aish PM2.5 ~ 45 PM2.5 ~ 45 g/mg/m33 annual annual

meanmean 1/3 crustal1/3 crustal

Values Similar to MEXICO Values Similar to MEXICO CITY ! CITY !


““Back of the Envelope” Risk Back of the Envelope” Risk AssessmentAssessment

Elements of Risk Elements of Risk AssessmentAssessment

Adult Population ~ 300,000Adult Population ~ 300,000

Baseline Mortality Rate ~ Baseline Mortality Rate ~ 9/1000 p-yr9/1000 p-yr

PM2.5 Level ~ 30 PM2.5 Level ~ 30 g/mg/m33

Risk Coefficient ~ 0.4 % per Risk Coefficient ~ 0.4 % per g/mg/m33

ResultsResults ~ 300 deaths per year~ 300 deaths per year


The Public Health StudyThe Public Health StudyPhase I – Medical Monitoring & ScreeningPhase I – Medical Monitoring & Screening

HSPH conducted medical HSPH conducted medical monitoring and screening of monitoring and screening of about 5% of the participants about 5% of the participants in Phase I.in Phase I.

In addition to the In addition to the questionnaire information, questionnaire information, the participants’ height, the participants’ height, weight and resting blood weight and resting blood pressure were determined. pressure were determined. Venous blood samples were Venous blood samples were collected and analyzed for collected and analyzed for cholesterol & blood sugar cholesterol & blood sugar and for the metals lead and and for the metals lead and mercury.mercury.

The results indicate high The results indicate high levels of both hypertension levels of both hypertension and total cholesterol in this and total cholesterol in this sample of elderly Kuwaitis. sample of elderly Kuwaitis.

Hypertension

34.7% 35.5%

19.6%

10.2%

0%

10%

20%

30%

40%

50%

Resting Blood Pressure (mm/Hg)

< 120/80 120-139 / 80-89 140-159 / 90-99 ≥ 160/100

Cholesterol

38.8% 36.3%24.9%

0%

20%

40%

60%

Cholesterol

Cholesterol Level (mg/dl)

< 200 ≥ 200 & < 240 ≥ 240


Blood Mercury LevelsBlood Mercury LevelsTentative Results from Phase I Medical Tentative Results from Phase I Medical

ScreeningScreening

0.1

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10.0

100.0

1000.0

-3.00 -2.00 -1.00 0.00 1.00 2.00 3.00

Normal Z-Score

Bloo

d M

ercu

ry (u

g/L)

Lognormal distributionLognormal distribution 15% <= LOD (1 15% <= LOD (1 g/dL)g/dL) Median ~ 5 Median ~ 5 g/dL g/dL GSD ~ 2.5GSD ~ 2.5

WHO and US EPA criteria:WHO and US EPA criteria: WHO PTWI = 0.5 WHO PTWI = 0.5 g/kg-d or ~ 25 g/kg-d or ~ 25

g/dLg/dL EPA RfD = 0.1 EPA RfD = 0.1 g/kg-d or ~ 5 g/kg-d or ~ 5 g/dLg/dL

Values regressed on fish Values regressed on fish consumption, gender and age:consumption, gender and age:

Women’s levels 3 Women’s levels 3 g/dL lower than g/dL lower than men’s.men’s.

Local fish consumption important.Local fish consumption important. All participants notified of results All participants notified of results

and provided with Arabic version of and provided with Arabic version of EPA/RfD guidance on mercury. EPA/RfD guidance on mercury. Those with values above WHO Those with values above WHO criterion were notified in person by criterion were notified in person by Dr. Behbehani and offered free re-Dr. Behbehani and offered free re-testing of their blood. testing of their blood.


Exposure Epidemiology

PHS I & II

Kuwait Longitudinal Health Study

PM & VOCsMercury in Fish

Chemical Body Burden

Integration & Interpretation

Kuwait Burden of Disease Study

Environmental Risk & Decision Analysis

Kuwait National Center for Environment and Kuwait National Center for Environment and HealthHealth

MOHVital Statistics

KUFaculty of Medicine

PAAC

KISR

KUScience &

Engineering

EPA

MOH EPA Citizens NGOs Industry

Descriptive Descriptive Epidemiology:Epidemiology:

Infant Mortality 1950-2005 – “No Obvious Infant Mortality 1950-2005 – “No Obvious Reversal”Reversal”

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Descriptive EpidemiologyDescriptive EpidemiologyAdult Survival: 1950 to 2005 – “A Different Adult Survival: 1950 to 2005 – “A Different

Picture”Picture”

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Males 45q15

Females 45q15

Descriptive EpidemiologyDescriptive EpidemiologyComparing Male & Female Mortality: 2001 to Comparing Male & Female Mortality: 2001 to

20052005

“Excess Mortality of Young Men”“Excess Mortality of Young Men”

0.0001

0.001

0.01

0.1

1

0 1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85

Age groups

Lo

g n

Mx

Males

Females

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 ParadigmMind-Body ParadigmWebster, 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: Major Salient Conditions: PHS I and PHS IIPHS I and PHS II

MaleMale FemaleFemale

Number of Men and Women Number of Men and Women Reporting Reporting WitnessingWitnessing Specific Specific

War-related EventsWar-related Events

Number of Men and Women Number of Men and Women ReportingReporting

Being Victim ofBeing Victim of Specific War- Specific War-related Eventsrelated Events

Summary Measure of War-Related Summary Measure of War-Related Trauma 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 War-Related Stressor Score and Asthma Score and Asthma

Incidence: Adjusted Incidence: Adjusted ModelModel

Hazards Ratio (95% Confidence Interval)

War-related Stressors

None Reference Group

Low 1.0 (0.6, 1.8)

Intermediate 1.4 (0.8, 2.4)

High 2.3 (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 Infarction 1.21 (1.05 1.40) §

186 (15021)

Angina Pectoris 1.59 (1.13 2.22)§

33 (15875)

Coronary Heart Disease * 1.25 (1.09 1.44)§

194 (14975)Adjusted for: age, sex, education, literacy, smoking, BMI, oil fire pollution* Includes MI and angina pectoris

§P<0.01

PHS Phase II PHS Phase II

Father Mother

Child Child Child

N~1800 N~1800

N~1200 N~1200 N~1200

8-11 yrs 4-7 yrs 0-3 yrs

Public Health Impacts of Kuwait Oil Fires – 28 May 2008 55

PHS Phase II -- PHS Phase II -- QuestionnaireQuestionnaire

Individual Individual CharacteristicsCharacteristics

Age, sexAge, sex Height and weight Height and weight Smoking Smoking Diet and exerciseDiet and exercise

Medical historyMedical history Date of deathDate of death

(Deceased only)(Deceased only) LocationLocation

During invasion, During invasion, occupation and oil occupation and oil firesfires

Social/PsychologicalSocial/Psychological Current functioningCurrent functioning Depression and Depression and

anxiety Checklistanxiety Checklist Gulf War Syndrome Gulf War Syndrome Social network and Social network and

supportsupport Coping strategiesCoping strategies

Traumatic eventsTraumatic events Before and After Before and After

occupationoccupation During occupationDuring occupation


PHS Phase II -- Biologic PHS Phase II -- Biologic Markers Markers

AnthropometryAnthropometry Height, Weight, and Blood pressure Height, Weight, and Blood pressure

Clinical MeasuresClinical Measures (fingerstick, 89% participation) (fingerstick, 89% participation) Immediate readingImmediate reading

Total cholesterol, HDL, LDL, triglyceridesTotal cholesterol, HDL, LDL, triglycerides Blood glucose (Blood glucose (randomrandom) )

HgbA1C (HgbA1C (blood sugar control)blood sugar control) C-reactive proteinC-reactive protein ( (systemic inflammationsystemic inflammation))

Future genetic testingFuture genetic testing Blood drops stored on specially treated filter paperBlood drops stored on specially treated filter paper

Hair sampleHair sample ( (60% of possible60% of possible)) Environmental metals (Environmental metals (mercurymercury))

Salivary cortisolSalivary cortisol ( (““ChildrenChildren”” only, 37% participation only, 37% participation)) Measure of stress responseMeasure of stress response


Ado

lesc

ence

Pr

enat

al

Early

Adu

lthoo

d

Old

er A

dulth

ood

Mid

dle

- Age

Chi

ldho

od

Infa

ncy

Pren

atal

Accelerated Lifecourse Research Design

PHS III

PHS II

PHS II

PHS ILongitudinalFollow-up

The childhood The childhood shows the man, shows the man, as the morning as the morning shows the day.shows the day.John Milton, John Milton, Paradise LostParadise Lost

(1667)(1667)

PHS Phase II PHS Phase II & Possible Extensions & Possible Extensions

Father Mother

Child Child Child

N~1800 N~1800

N~1200 N~1200 N~1200

Interview Age

24-27 yrs20-23 yrs16-19 yrs

Interview Age

GrandChild

GrandChild

GrandChild

GrandChild

GrandChild

Child Child<16 yrs 28+ yrs

Recruit Siblings

Recruit Children ofSecond Generation



Documents

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