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We are both doctors: a Palestinian doctor writes to an Israeli colleague

BMJ 2014; 349 doi: (Published 13 August 2014) Cite this as: BMJ 2014;349:g5106

Re: We are both doctors: a Palestinian doctor writes to an Israeli colleague-Starting from rubble: Collateral victims not accounted for? Long term health effects of the last war of Israel on next generation of Gaza people

The letter of Dr. Izzeldin Abuelaish on August 13 points to the issue of collateral damage of Israeli attacks on Gaza, in the past and today.

Here I comment on other, usually unaccounted for, “collateral” damages of war, the "in utero" victims of war.

The last attacks have devastated Gaza, reducing wide areas to rubble, pointing to the use of the largest amount of weaponry ever. We have evidence on the effect of metal weapon remnants in inducing collateral damage on the next generation (s).

We identified as measurable end points the contamination by war remnants on reproductive health, prematurity and structural malformations. Background data for their incidence are available and will allow comparisons over time.

Visualize destruction by heavy weapons, leveling of structures, big craters and imagine the pulverized debris floating in the wind, and think that bombs bring toxicants and teratogens and the cement contains other toxicants and this mixture wanders in the wind and sifts into houses, schools and all over, including in lungs, in food on sale and in the fields. Soon will be clear also which and how many penetration bombs were used in each area, with potential of radioactive contamination from U isotopes. This is Gaza today, in many areas.

The rubble containing war remnants is one of the permanent sources of contamination that persist after war, and toxicants and teratogens stable in the environment, such as metals, are associated with the weaponry (1, 2). These contaminants, once consumed by mothers who were exposed to bombing and white phosphorus (3), are found specifically associated with premature and respectively malformed babies, who were contaminated in utero (4).

The incidence of the malformations in Gaza has increased compared to 1997, steadily since the first usage of military attacks by ground and air on Gaza at the second intifada (5). After Cast lead, when less ammunitions and less heavy bombs were used than since July 7, 2014, and less extensive destruction occurred, the contaminants were in the mothers' bodies and passed to the embryo and fetus, even when conceived 2 years after the attacks (3).

In summary, we know already that military attacks are likely to have set an environmental load on the health of those not yet born, even of those not yet conceived, for a protracted time.

Thus, there are all the reasons to expect damage on reproductive health from the extensive attacks in July and August, more serious even than from previous ones.

We need now to monitor and to measure the consequences of the attacks on the survival and health of the yet unborn or just born children of Gaza to be able to identify war related and unrelated events and count the “victims in utero”.

In Gaza the incidence of prematurity has been increasing in the last 3 years (6); it was around 4.8% of the about 60.000 newborn in 2011 (about 2880 babies/year). Up to before the war in the Neonatal Intensive Care Unit of al Shifa hospital about 30% of premature babies died (about 860 deaths/year). Prematurity is associated with specific contamination in utero of the child by metals that are also weapon components (4).

Already in early August 2014, an increase in premature deliveries to 15-20% was reported in al Shifa. Off course, there are physiologic and psychological reasons why this could happen under the great stress due to the attacks, but it also true that contaminants capable of acting as toxins in the mother upon consumption by breathing can contribute to this increase. The increase in the incidence of prematurity may become a sizeable load in time. We should determine if this component, i.e. war related contamination, has a numeric impact and is qualitatively relevant. This can be done, thus the first action immediately has to be to do the appropriate recording, investigation and analysis. Learning causes of prematurity is important from the point of view of public health and towards strategizing remediation; it will tell us also if we have to start counting the loss of these children as “in utero victims of war”.

Occurrence of major structural malformations, often severely invalidating, and determining serious family and social constrains was shown to be associated to exposure to war (3) and to be specifically associated with in womb contamination by weapon components (4). The incidence of malformations rose, compared to the period 1997 to 2001, steadily since the use of air delivered weaponry by IOF on Gaza and significantly from 2004 (5) reaching in 2011 a value of 2,5% (3, 7), similar to that of high industrialized countries, although in an area where no chemically impacting industry of any size was installed. We expect that there will be a further rise of birth defects lasting a certain time after these recent attacks.

What we do not know is the extent of the expected increases of premature and malformed progeny immediately upon exposure, and in time and how protracted these may be. Resources should be dedicated to investigation these issues.

The cost of perinatal death and chronic impairment of children represents an other “collateral casualty” and these can be considered “in utero victims” which should be accounted for.

In writing “An open letter for the people in Gaza” (8) these, here more in detail, were some of the preoccupations I had in mind and among the responsibilities for long term damage on civilians and forms of collective punishment that we stigmatized.

Last, but not least: the current understanding of negative environmental effects on organisms, although not necessarily implying genetic changes, indicate the possibility that these changes might be inheritable also in second and third generations.

(1) Manduca P, et al. Gaza Strip, soil has been contaminated due to bombings: population in danger., January 2010
(2) Skaik S, et al. Metals detected by ICP/MS in wound tissue of war injuries without fragments in Gaza. BMC Int Health Hum Rights. 2010; 10;
(3) Naim A, et al. Birth defects in Gaza: prevalence, types, familiarity and correlation with environmental factors. Int J Environ Res Public Health. 2012;9:1732-47
(4) Manduca P et al.Specific association of teratogen and toxicant metals in hair of newborns with congenital birth defects or developmentally premature birth in a cohort of couples with documented parental exposure to military attacks: observational study at Al Shifa Hospital, Gaza, Palestine. Int J Environ Res Public Health. 2014 ;11:5208-23
(5)Naim A, et al. Manduca Prevalence of birth defects in the Gaza Strip, occupied Palestinian territory, from 1997 to 2010: Pedigree analysis . Lancet LPHA, 2013
(6) Personal communication, data from al Shifa NICU
(7) Zaqout M, et al. Prevalence of congenital heart disease among Palestinian children born in the Gaza Strip. Cardiol Young. 2013 Sep 19:1-5.
(8) Manduca P, Chalmers I, Summerfield D, Gilbert M, Ang S.An open letter for the people in Gaza. Lancet. 2014;384:397-8

Competing interests: No competing interests

29 August 2014
Paola Manduca
Retired Professor Genetics
Associatio NWRG
vc Neve 8
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