Long-term Psycho-social Impact of a Chemical Weapons Attack on the Population of Sardasht, Iran

S. Khateri, M.Ghanei, C.Palmer

Shahriar Khateri M.D
Janbazan Medical and Engineering Research Center (JMERC)
Chemical warfare victims research unit,
Janbazan Organization (Veterans’ affairs)
19615/616, Tehran – Iran
Tel: +9821 2412114
Fax: +9821 2412502
E-mail: khateri@jmerc.ac.ir

Abstract:
         Exposure to chemical warfare (CW) agents may result in substantial short and/or long lasting effects including behavior and psychological disorders of exposed individuals.
         In recent years the CW agents have been employed against unprotected civilians in military conflicts and terrorist attacks.
         During the 1980s, UN fact-finding teams confirmed the use of chemical weapons on massive scale by Iraqi forces against Iranians. It is verified that the main type of chemical agent used was mustard gas and it was frequently used against the civilian targets as well.
         The most tragic use of mustard gas was the chemical bombardment of the city of Sardasht in Northwestern Iran in June 1987. (1)
         An estimated 4,500 people - more than a third of city's population – were exposed to the toxic chemical. (2-9)
         Now, sixteen years following the Iran-Iraq war, Iran has the world’s largest population of chemical attack survivors, a significant proportion of whom are chronically ill.(10)
         Until recently, there has been little attempt to conduct an in-depth analysis of factors such as acute versus long-term psycho-social effects among CW-exposed civilians. The population of Sardasht provides an excellent test case for such an analysis.
         This study illustrates patterns of psycho-social effects among the mustard gas exposed civilian population of Sardasht. This study may be of use in designing of both civil defense and medical management strategies in case of future chemical attacks on unprotected civilian populations (such as psychological intervention for victims and survivors). It may also assist in the prevention and mitigation of the psycho-social impact of these agents.
         Results of this study reveal that long-term psychological and social effects of a chemical weapon military or terrorist attack may be worse than the acute effects of such an attack.

Introduction:
         Individuals who have sustained wartime injuries and survived the experience may nevertheless develop serious long-term health problems as a result.(11) Previous studies of this phenomenon, which focused primarily on the effects of trauma due to conventional armament, have documented various clinically defined categories of chronic disorders in battle-injured personnel. However, a similar body of medical literature has not been as extensively developed for persons affected by nuclear, biological or chemical (NBC) weapons. In particular, there have been few in-depth analyses of long-term psycho-social effects among these populations. Nevertheless, the increasing probability of military or terrorist use of such agents, and the employment of chemical weapons against Iran by the regime of Saddam Hussein during the Iran-Iraq war of the 1980s, makes it imperative that both short- and long-term physical and psychological consequences be evaluated and used as the basis for therapy.
         No nation since the end of the Great War has been subjected to chemical attack as intensively as Iran. Chemical agents, primarily “mustards” that destroy tissue through alkylation reactions, were employed intensively against both Iranian troops and civilians (confirmed in both cases by UN fact-finding teams).
         A particular horrifying example occurred on 28 June of 1987 in Sardasht, a town of approximately 12,000 in the Kurdish area of Northwestern Iran.
         On that date, Iraqi aircraft made two separate bombing runs against four residential areas, during which four 250 kg bombs containing sulfur mustard warheads exploded in the city center.
         This action exposed approximately 4,500 persons to mustard, causing numerous deaths and long-term chronic illness among survivors.
         The population of this town therefore represents a model for longitudinal evaluation of mustard effects. These people suffer from a high rate of chronic illness, as do other sectors of the Iranian population who have sustained mustard exposure. Accordingly, our group (JMERC), which has responsibility for oversight of the health status of our country’s chemical warfare victims, has conducted evaluations to characterize chronic disease and (in this investigation) psycho-social profiles of the people of Sardasht.

Methods:
         Archival data on living victims of the attack was obtained from both the Iranian Health Ministry and the Janbazan Organization, which are the agencies primarily responsible for the maintenance of records concerning health and other biodata for persons present at the sites of chemical bombardment in 1987.
         Verification of mustard exposure for each case used in this study was accomplished by cross-referencing information provided by MO with medical records maintained by Janbazan.
         A representative cross-section of 400 individuals, 69% male, 31% female was selected from among residents of Sardasht, confirmed to have been exposed to mustard agent as a result of the chemical attack of June 1987. Each participant was administered a standardized questionnaire that addressed individual experiences at the time of exposure to the agent; and life experiences following the attack. Responses to the questionnaire were broadly grouped into the following categories:

i. Perceptions of events occurring during and after the attack and willingness to remember;
ii. Impact on self-image, family and interpersonal relationships;
iii. Civil preparedness for enemy use of chemical weapons;
iv. General observations.

Results:
         Perceptions of events occurring during and after the attack and willingness to remember:
         94% recall that those who died as a result of the attack did so in a horrifying manner that they perceived as being worse in nature to death by conventional weapons. Another 5% reported that they personally repressed recollection of the attack since it resulted in depression; and 2% who found the experience too painful to think about at all. Other responses reflected religious beliefs and/or rationalizations used by participants in this study to reconcile their experience.Representative comments included: 7.8%, who believed the attack was divinely ordained; 5.2 % who claimed that they had expected the event as a consequence of the nature of the war.
         Impact on self-image, family and interpersonal relationships: 56% of respondents reported strong feelings of personal depression as a long-term effect, while 76% reported improved family cohesion and strengthened friendships for a short time period following the attack; however 82.5 % reported that over the 16 years following the attack, relationships with family and friends deteriorated significantly (while personal depression remained high).

Civil preparedness for enemy use of chemical weapons.
         Most respondents undertook no advance preparation for the kind of attack that occurred: 93% had no information and received no training on protection against chemical weapons prior to the attack. Nevertheless 76% of the survivors with chronic illness, believed that that if protective measures and training had been available for use by the general public at the time of the attack, their health problems would be considerably less severe. By contrast, 16.6% of the study population believed that no amount of protection or civil preparedness training would have done any good.

General observations:
- Women appear more vulnerable than men to both short- and long-term psycho-social effects of the attack.
- Survivors who were under 19 years of age at the time of attack suffer from more significant long-term psychological effects
- Using the standard PTSD assessment instruments (GHQ-D/CAPS) according to the DSM IV Criteria: 68.5% of male subjects and 89% of female subjects are suffering from PTSD.

         This is significantly higher than the population of those cities that had been under conventional weapons attacks and much higher than normal population.

Conclusions:
         The pattern of psychosocial response that emerges in this study of an attack with mustard agent on an unprotected civil population is consistent with effects of catastrophic events (natural or man-made) that have been reported in other populations. These include a progressive sense of alienation and depression among a significant portion of the affected population; loss of family unity and hostility toward friends and neighbors. However, the effects are anecdotally more severe in the populations exposed to chemical weapons, even if damage and/or deaths caused by the munitions is less than that incurred as a result of an attack by conventional munitions.
         Contributing factors to this effect may be related to the horrendous deaths experienced by victims heavily exposed to mustards. However at a deeper, intrinsic level, the psychological impact of chemical weapons probably is a result of their ability to kill horribly in an unpredictable manner and by invisible means. Thus the element of uncertainty that accompanies a chemical attack acts as a significant combat multiplier, particularly in an unprotected target population.
         The attack on Sardasht, as horrible as it was, provided a valuable opportunity to analyze the effects of sulfur mustard on an unprotected population. In Sardasht, a civil infrastructure existed which responded to the damage, and better documentation of the incident was conducted than, for instance, the massacre at Halabja in Iraq. In the latter case – and other incidents where the Iraqis used weapons of mass destruction against their own people – re-creation of the actual event was difficult due to the deliberate isolation of the stricken communities by Iraqi security forces, and the lack of structured rescue operations.
          This study may be of use in designing both civil defense and medical management strategies in the event of future chemical attacks on unprotected civilian populations, such as psychological intervention for victims and survivors. It may also assist in the prevention and mitigation of the psychosocial impact of these agents.

Key Words
Psychosocial, Chemical Warfare, Iran-Iraq War, Sardasht, Mustard agent

References:

1. Reports of specialists appointed by the Secretary General to investigate allegations by the Islamic Republic of Iran concerning the use of chemical weapons. New York: Security Council of the United Nations Document S/16433, 1986.
2. UN document S/18953 Jun.29.1987
3. UN document S/18956 Jun.30.1987
4. UN document S/18966 Jul.6.1987
5. UN document S/18967 Jul.7.1987
6. UN document S/18953 Jun.29.1987
7. Conference of Disarmament CD/827 Apr.12 .1988
8. UN document S/19006 Jul.30.1987
9. Society for medical care of chemical war victims Crime Against Humanity Nov.1987 Tehran-Iran
10. Khateri, S. Victims of chemical weapons in Iran . Society for chemical weapons victims Support – April 2003, ISBN:964-93602-5-5
11. Wessely .S. et al, Psychological implications of chemical and biological weapons. Long term social and psychological effects may be worse than acute ones BMJ 2001;323:878-879 ( 20 October )

Tables:
Table 1: Age distribution of subjects (current age in years)

Table 2: Gender Distribution of Subjects:

Editor’s Note: All of us thank Dr. Shahriar Khateri for the work he and the Janbazan Veteran’s Organization have done in compiling and documenting these data for the exceptionally important reports and papers on the short, -mid and long term aspects of chemical weapons poisoning and the subsequent long term treatment requirements. These data were first brought to the attention of the international community via the ASA Newsletter and the CBMTS series of meetings. This report was presented to CBMTS V at the Spiez Laboratory Switzerland in April.