Health perspectives among Halabja’s civilian survivors of sulfur mustard exposure with respiratory symptoms—A qualitative study

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Abstract

Background

In 1988, Halabja came under heavy chemical warfare attack using chemicals such as sulfur mustard (SM). Thousands of survivors of SM exposure in the city today live with multiple health complaints, such as severe, long-lasting respiratory symptoms; but their perceptions of health have never been adequately researched. We aimed to explore current major health concern topics in civilian survivors with long-term respiratory symptoms.

Method

Sixteen subjects (f:m10:6, mean age 45.5 years (range 34–67)) were interviewed. Study participants were recruited in 2016 via a purposive sampling strategy among civilian survivors of chemical warfare in the city of Halabja in Kurdistan-Iraq. A qualitative research design was applied including semi-structured, face-to-face interviews. Data was analyzed using systematic text condensation.

Results

The analysis yielded fourteen themes related to: (1) General health: all participants described a deterioration in physical and psychological health, following the SM exposure, foremost involving respiratory symptoms, fatigue, sleeping disorders, ocular problems, depressive symptoms, and anxiety; (2) Quality of life: most notably, they reported a limited family life, limited social relations, lack of work ability, and concern about their financial situation. Moreover, many lived in constant fear of a renewed attack; (3) access to health care services: all participants reported that they had no, or only poor, access to health care services and limited access to specialist care, and all reported lack of financial resources to obtain treatment.

Conclusions

The post-exposure somatic and psychosocial effects such as respiratory symptoms of CWA are plausible contributor to poor general health and quality of life among survivors. We conclude that multidisciplinary interventions are needed to tackle the biopsychosocial complications in survivors of SM exposure to minimize further health damage in the future, as well as to promote their health-related quality of life.

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Most cited references 30

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Comparison of early and late toxic effects of sulfur mustard in Iranian veterans.

Mehrdad Hefazi, Mahdi Balali-Mood (2006)

Sulfur mustard is an alkylating agent that reacts with ocular, respiratory, cutaneous, and bone marrow tissues, resulting in early and late toxic effects. We compare these effects based on the experience in Iranian veterans exposed to the agent during the Iran-Iraq conflict (1983-88). The first clinical manifestations of sulfur mustard poisoning occurred in the eyes with a sensation of grittiness, lacrimation, photophobia, blepharospasm, and corneal ulceration. Respiratory effects appeared as rhinorhea, laryngitis, tracheobronchitis, and dyspnoea. Skin lesions varied from erythema to bullous necrotization. Initial leukocytosis and lymphopenia returned to normal within four weeks in recovered patients, but marked cytopenia with bone marrow failure occurred in fatal cases. Late toxic effects of sulfur mustard were most commonly found in lungs, skin and eyes. Main respiratory complications were chronic obstructive pulmonary disease, bronchiectasis, asthma, large airway narrowing, and pulmonary fibrosis. Late skin lesions were hyperpigmentation, dry skin, atrophy, and hypopigmentation. Fifteen of the severely intoxicated patients were diagnosed with delayed keratitis, having corneal vascularization, thinning, and epithelial defect. Respiratory complications exacerbated over time, while cutaneous and ocular lesions decreased or remained constant. Both the severity and frequency of bronchiectatic lesions increased during long-term follow-up. The only deteriorating cutaneous complication was dry skin. The maximum incidence of delayed kaeratitis was observed 15 to 20 years after initial exposure. Being suggested as the main cause ofassociated with malignancies and recurrent infections, natural killer cells were significantly lower 16 to 20 years after intoxication.

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A qualitative study of quality of life after stroke: the importance of social relationships.

Allen Heinemann, David Cella, Denise B Lynch … (2008)

Stroke is a leading cause of long-term disability in the USA; however, we have an incomplete understanding of how stroke affects long-term quality of life. We report here findings from focus groups with 9 long-term stroke survivors and 6 caregivers addressing patients' post-stroke quality of life. Key themes identified by patients were: social support, coping mechanisms, communication, physical functioning and independence. Role changes in patients were important to caregivers. Much of the discussion with patients and caregivers described specific ways in which the stroke altered social relationships. These findings are consistent with prior research indicating the importance of social factors to quality of life following stroke. Our findings suggest that measures of stroke-related quality of life should include assessment of social function and social support.

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Anxiety, depression, and posttraumatic stress in Iranian survivors of chemical warfare.

Steven Southwick, F Hashemian, Tanay Desai … (2006)

In the 1980-1988 Iran-Iraq War, extensive use of chemical weapons resulted in high rates of morbidity and mortality. While much is known about the physical consequences of chemical warfare, there is a paucity of information about the long-term effects of chemical attacks on mental health. To assess the long-term psychological impact of chemical warfare on a civilian population. Cross-sectional randomized survey conducted in July 2004 of 153 civilians in 3 towns exposed to warfare in northwestern Iran: Oshnaviyeh (low-intensity conventional warfare), Rabat (high-intensity conventional warfare), and Sardasht (both high-intensity conventional warfare and chemical weapons). Full or partial posttraumatic stress disorder (PTSD) diagnosis, anxiety symptoms, and depressive symptoms were assessed using Farsi versions of the Clinician-Administered PTSD Scale, Hamilton Scale for Anxiety, and Beck Depression Inventory, respectively. Overall participation rate was 93%. Respondents had a mean age of 45 years and were all of Kurdish ethnicity. Among individuals exposed to both high-intensity warfare and chemical weapons, prevalence rates for lifetime PTSD, current PTSD, major anxiety symptoms, and severe depressive symptoms were 59%, 33%, 65%, and 41%, respectively. Among the low-intensity warfare group, the corresponding rates were 8%, 2%, 18%, and 6%, respectively, while intermediate rates were found among those exposed to high-intensity warfare but not to chemical weapons (31%, 8%, 26%, and 12%, respectively). Compared with individuals exposed to low-intensity warfare, those exposed to both high-intensity warfare and chemical weapons were at higher risk for lifetime PTSD (odds ratio [OR], 18.6; 95% confidence interval [CI], 5.8-59.4), current PTSD (OR, 27.4; 95% CI, 3.4-218.2), increased anxiety symptoms (OR, 14.6; 95% CI, 6.0-35.6), and increased depressive symptoms (OR, 7.2; 95% CI, 3.3-15.9). Exposure to high-intensity warfare but not to chemical weapons was also significantly associated with lifetime PTSD (OR, 5.4; 95% CI, 1.7-17.6), compared with those in the low-intensity warfare group. Further, compared with individuals exposed to high-intensity warfare alone, those exposed to both high-intensity warfare and chemical weapons were at higher risk for lifetime PTSD (OR, 3.4; 95% CI, 1.5-7.4), current PTSD (OR, 6.2; 95% CI, 2.0-20.1), increased anxiety symptoms (OR, 5.6; 95% CI, 2.5-12.6), and increased depressive symptoms (OR, 3.7; 95% CI, 1.8-7.2). Exposure to chemical warfare is an extreme traumatic event that has long-lasting adverse consequences on mental health.

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Author and article information

Contributors

Faraidoun Moradi: Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: ValidationRole: Writing – original draftRole: Writing – review & editing

Mia Söderberg:

ORCID: http://orcid.org/0000-0003-0662-6541

Role: Formal analysisRole: MethodologyRole: SupervisionRole: Writing – review & editing

Fazil Moradi: Role: MethodologyRole: ValidationRole: Writing – review & editing

Bledar Daka: Role: Formal analysisRole: Writing – review & editing

Anna-Carin Olin: Role: Formal analysisRole: Funding acquisitionRole: SupervisionRole: Writing – review & editing

Mona Lärstad: Role: Formal analysisRole: MethodologyRole: SupervisionRole: Writing – review & editing

Huso Yi: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 21 June 2019

Publication date Collection: 2019

Volume: 14

Issue: 6

Electronic Location Identifier: e0218648

Affiliations

[1 ] Section of Occupational and Environmental Medicine, Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

[2 ] Region Västra Götaland, Närhälsan Research and Development, Primary Health Care, Gothenburg, Sweden

[3 ] Department of Anthropology and Philosophy, Martin Luther University Halle-Wittenberg, Halle, Germany

[4 ] Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

[5 ] Department of Respiratory Medicine and Allergology, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

National University of Singapore, SINGAPORE

Author notes

Competing Interests: The authors have declared that no competing interests exist.

* E-mail: moradi.faraidoun@ 123456gu.se

Author information

Mia Söderberg http://orcid.org/0000-0003-0662-6541

Article

Publisher ID: PONE-D-18-15723

DOI: 10.1371/journal.pone.0218648

PMC ID: 6588230

PubMed ID: 31226143

SO-VID: 0f9476e6-3530-4479-8a17-21b2ef9b0582

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 17 June 2018

Date accepted : 6 June 2019

Page count

Figures: 0, Tables: 5, Pages: 16

Funding

Funded by: Section of Occupational and Environmental Medicine, Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy,

Award Recipient : Faraidoun Moradi

Funded by: Region Västra Götaland, Närhälsan Research and Development Primary Health Care, Gothenburg,

Award Recipient : Faraidoun Moradi

The study funded as part of a PhD thesis doctoral study grant (DOS) awarded to Faraidoun M. by Region Västra Götaland, Närhälsan Research and Development Primary Health Care, Gothenburg and supported by Section of Occupational and Environmental Medicine, Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Data Availability The sharing of the data used in this study has been restricted because they contain sensitive, identifying information which is not possible to suitably anonymize for public sharing. Further, the participants have not consented to the sharing of their data publicly. Data can be made available upon request after any details that may risk the confidentiality of the participants have been removed. The authors confirm that the data made available would not differ in their scientific content. To request access to these data, please contact the Ministry of Martyrs and Anfal Affairs Bureau of Sulaymaniyah: shahidanwanfal@ 123456gmail.com .

Health perspectives among Halabja’s civilian survivors of sulfur mustard exposure with respiratory symptoms—A qualitative study

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Most cited references 30

Comparison of early and late toxic effects of sulfur mustard in Iranian veterans.

A qualitative study of quality of life after stroke: the importance of social relationships.

Anxiety, depression, and posttraumatic stress in Iranian survivors of chemical warfare.

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