Current Issues in Longshore and Harbor Workers’ Compensation Act Extension Claims: Unique Illness and Injuries Arising from the Work of U.S. Civilians in Iraq and Afghanistan Gary B. Pitts Gary B. Pitts Pitts & Associates 8866 Gulf Freeway, Suite 117 Houston, Texas 77017 defensebasecomp@aol.com 713-910-0555 713-910-0594 (fax) It is an honor to be involved in any level of the judicial administration of compensation benefits for our civilian contractors working in the Iraq and Afghanistan theaters of war. They are working alongside our military troops, putting their lives on the line for us every day. They are arguably at more risk than our military troops. They work in the midst of a guerrilla war that does not really have safe support areas behind clear front lines, and the majority of our civilian contractors are not allowed to be armed to defend themselves. Their numbers make up an unprecedented high proportion of our war effort. The breakdown of the estimates is as follows (1): 40-50,000 support/logistics contractors These are employees of KBR, the Halliburton subsidiary, which has the military’s logistical support contract. They work as drivers, cooks, carpenters, mechanics, etc. A large percent are American. The rest are from Third World countries. 20,000 non-Iraqi security contractors Of these, 5-6000 are American, British, South African, Russian or European; another 12,000 are from Third World countries such as India, Sri Lanka and Columbia. 15,000 Iraqi security contractors Most were hired by the British security firm Erinys to guard Iraq’s oil infrastructure. 40-70,000 reconstruction contractors Some are Iraqis, but most are from the U.S. and dozens of other countries. They are employed by companies such as KBR, Bechtel, General Electric, Fluor, Parsons and Perini. There is a current combined total of about 140-155,000 American military personnel in Iraq and Afghanistan (2). There are thus about as many civilian contractors as there are soldiers in our war effort. Of the total of 115-155,000 contactors, approximately 25-30,000 are Americans (3). Only those contractors whose employers are working under a contract or subcontract with the U.S. government are covered by the Defense Base Act, but this would be the large majority of contractors. In World War I, World War II, Korea, Vietnam, and the Gulf War, our Army did its own truck driving , cooking and most other basic support functions with soldiers. It is historically new to fill almost all of these functions with civilian contractors. The argument for setting it up this way was to save money and free up trained soldiers for fighting. The idea was that civilian contractors are more expensive per month than soldiers, but we will only need them on a temporary emergency basis. The thought was that we would not have to pay for as many standing military units during peacetime by planning to outsource almost all of the support functions if war comes. It was assumed, as is the usual historical pitfall, that future wars are predictable and would be short. This plan was certainly not based on the vision of a long guerrilla war with no clear front lines. Thus we are making do with a square peg in a round hole. Our military is much smaller than it was during the 1991 Gulf War and the Cold War. We could not carry on the current war without the participation of our civilian contractors, period. The only way to replace them would be to bring back the draft, or make a significantly larger voluntary military, and that mobilization would take a while. In the meantime, in the war against Islamic fascism, the virtual army of American civilian contractors is helping keep the casualties from occurring in the U.S. We should thus take special care in taking care of these people who are taking care of us. The Defense Base Act, which was formed during World War II, provides the compensation for these men and women if they are injured or made ill during their service, and for their families if they die as a result of their service. The coverage of the Defense Base Act is much broader than the usual “in the course and scope of employment” standard that we use in the Longshore and Harbor Workers’ Compensation Act. The Defense Base Act covers everything that comes from the “zone of special danger.” From “wheels up” in the U.S. until “wheels down” back in the U.S. they are covered 24 hours a day, seven days a week, as long as the “obligations or conditions of employment create the zone of special danger from which the injury arose” (4) The only cases that demonstrate the exceptions have been extreme occurrences like the case of the man that hung himself as a weird form of autoerotism and died, or benefits being denied to a woman who plotted her husband’s death overseas (5). The usual industrial accidents that we are all familiar with working with, that occur to longshore and harbor workers in the U.S., can, of course, equally happen in Iraq and Afghanistan. One of my clients said that he was really embarrassed that while he was stationed at Fallujah, during the worst of the fighting there after the bodies of four American civilian contractors had being burned and hung for display from the bridge there (6), he got hurt and was evacuated out of the theater because he slipped and fell and hit himself on the side of an office desk there. In addition to the usual industrial accidents, there are injuries and illnesses coming from the war zones that are different than what you normally see here in the U.S.: 1. Physical injuries from direct enemy action 2. Physical injuries indirectly from enemy action 3. Post-traumatic stress disorder 4. Injuries from the Iraqi and Afghani work environment, not related to enemy action 5. Illnesses endemic to the region 6. Toxic exposures 7. Footnotes 1. PHYSICAL INJURIES FROM DIRECT ENEMY ACTION A. IN GENERAL It is not known exactly how many American or other civilian contractors have died in the war. The San Diego Union-Tribune reported that at least 136 Titan Corp. employees and subcontractors have been killed (7). KBR reported to PBS that 65 of its employees have been killed (8). By November 2005, the U.S. Dept. of Labor had 428 civilian contractor deaths, and 3,963 other casualties, reported to it, according to the Knight-Ridder News Service (8). Both KBR and L3 Communications reported to PBS that their casualty figures were higher than those so far reported to the Dept. of Labor for their companies (8). It thus appears to be fair to say that about 550 American civilian contractors have been killed in the war to date. American civilian contractors wear body armor (Kevlar vests) the same as our soldiers do. Improved body armor has resulted in much fewer fatal injuries in comparison to previous wars (9). In World War II, the ratio of combat deaths to those wounded in combat was approximately 1 to 2.3. In the Korean War, it was approximately 1 to 3.1. In the Vietnam War, it was approximately 1 to 3.2 (10). As of March 3, 2006, the ratio of combat deaths to those wounded in combat in Iraq is approximately 1 to 9.4 (11). Unprotected areas of the body are where almost all of the injuries are occurring, i.e.: the head , neck, arms, legs , lower torso and sides (12). B. IEDS As of the end of February, 2006, 31.5 % of the combat deaths in Iraq have been from IEDs (improvised Explosive Devices) (13). There is an incomplete list of 136 American civilians killed in Iraq, by name, occupation and date of death (14). It is instructive on how civilian contractors are being killed there. Of these 136 named deceased, 41 died from IEDs, improvised explosive devices, including non-suicide car bombs. This is the most frequent cause of death. Also as evidence of IEDs as the primary casualty producers is that during a 9-month period in 2004, the 31st Combat Support Hospital in Iraq treated 207 severe eye injuries, including 41 eye excisions. Blast fragmentation (shrapnel) caused 82% of those injuries. The most common single cause was IEDs, which caused 51% of all of the injuries. It has been suggested by doctors that polycarbonate ballistic eyewear could prevent many of these injuries, by the way (15). C. GUNSHOTS The second most frequent cause of death for civilian contractors in Iraq is enemy small arms fire, gunshot wounds. Of the 136 named American contractor deaths, 34 died from these (12). I know that the list of 136 is incomplete because I represent the widow of a man that was killed by an enemy gunshot to the abdomen, and he is not on the list. D. MORTAR, ROCKET, MISSILE OR LAND MINE EXPLOSIONS Of the incomplete list of 136 named American contractor deaths, 14 were killed by blast or shrapnel from mortar, rocket, missile or land mine explosions (14). E. SUICIDE BOMBERS Suicide bombers are of two types, walk-in , or driving a vehicle. Of the incomplete list of 136 named American contractor deaths, 8 were from walk-in bombers, and 4 were from bombers driving vehicles (14). F. KIDNAPPING AND EXECUTION From the list of 136 named American contractor deaths, five were executed by the enemy (14). Four of the five were beheaded on videotape, broadcast on some Arab T.V. stations for terrorist effect (16). 2. PHYSICAL INJURIES INDIRECTLY FROM ENEMY ACTION Because of the constant threat of sniper fire and IED roadside bombs, civilian contractors drive very fast when they have to drive anywhere off of a military base in Iraq. This has led to frequent and more severe vehicle accidents as an indirect result of enemy actions. As an example, I am representing a little lady who left her job as a kindergarten teacher in the U.S. to go to Iraq and support our troops by working on their laundry. A few weeks after she got to Baghdad, she was a passenger in a car that was going 100 mph on what would normally be a 50 mph road in peacetime, because they were afraid of being shot or blown up. The driver encountered a package in the road. He swerved to avoid it, as he had been taught to do, because it could be a bomb. Because of the vehicle’s speed , when it suddenly swerved, it flipped several times, and my client is now paralyzed from the chest down. Of the list of 136 named American contractor deaths, 12 were from vehicle accidents (14). As a result of the threat of enemy gunfire or explosive shrapnel, contractors have to constantly wear Kevlar body armor vests, which weigh 30-40 lbs., and also steel or Kevlar helmets when they are outside of a base. Though less catastrophic than vehicle accidents, this additional weight burden has caused or aggravated back injuries in some contractors and contributed to the risks of dehydration and heat stroke in others. 3. POST-TRAUMATIC STRESS DISORDER The psychiatric case definition for post-traumatic stress disorder ( “PTSD”)is attached as an appendix to this paper. U.S. Army research shows that about 16% of troops coming out of Iraq and 11% of those coming out of Afghanistan are having mental health problems, the most prominent being PTSD. The research shows a PTSD rate of 4% among those not exposed to a firefight and 20% for those who endured five or more combat episodes (17). The Army Surgeon General reported last October that among 1000 Army soldiers surveyed three to four months after returning from Iraq, about 30% had developed stress- related mental health problems. PTSD sometimes manifests itself only months, sometimes even years, after the traumatic event. Called “delayed onset” PTSD, this sleeper version of the disorder makes accurate diagnoses when leaving the war zone a serious challenge to mental health providers. It will also be a challenge to the U.S. Dept. of Labor judicial system. The carriers will profit by the fact that people suffering with PTSD often refuse to disclose the disturbing symptoms common of PTSD, either due to distrust of the mental health establishment or because they are embarrassed to seek help. The largest Army research study was just published at the end of Feb 2006. It reports that mental health screening showed that 21,620 of 222,620, about 1 out of 10, coming out of Iraq are diagnosed with PTSD (18). When they leave the war zone, members of our military are briefed about what PTSD symptoms look like, and they are encouraged to seek help if they have them. The military also checks back up on all soldiers about three or four months after leaving the theater of war, in order to see how they are doing concerning PTSD. This support structure is largely a result of lessons learned from the Vietnam War, and is a military force protection measure. Those with symptoms can be seen in the military health care system, or by the Veterans Administration system, both of which have a lot of experience with PTSD. Civilian contractors coming from the war zone have none of this support structure. They should. They are now being left to their own devices, for the most part. Usually they have to litigate their Defense Base Act claim in order to get any psychological care. For example, there was a Formal Hearing for one of my clients last month, where the man barely survived the suicide bombing in the mess hall in Mosul, Iraq on December 21, 2004 (19). He was burned by the blast fireball, hit by shrapnel in multiple places, and covered by bits of human flesh from the explosion. Friends seated on either side of him died. Since the, he has had the classic symptoms of hypervigilance, startle response, nightmares, flashbacks, avoidance, and social withdrawal, but he is having to wait for a judicial opinion before the carrier will pay for one session of psychotically assistance for a devastating attack that occurred almost a year and a half ago. There is currently not really much of a financial incentive for a carrier not to unreasonably deny benefits. There is currently no effective judicial penalty for a frivolous defense. It is something that could well be reformed, in order to make the system work better for everyone concerned. 4. INJURIES FROM THE IRAQI AND AFGHANI WORK ENVIRONMENT, NOT RELATED TO ENEMY ACTION This category includes dehydration, heat stroke, scorpion and snake bites, and eye and respiratory irritation from sandstorms (20). The average high for July temperature in Kandahar, Afghanistan is 104 degrees; and for Baghdad, Iraq the average in July is 110 degrees (21). The stifling heat is aggravated by the necessity of wearing body armor and a helmet. For the few contractors that get to work in air-conditioning, electricity is usually undependable. Where there is no air-conditioning or electricity to run it, working indoors can be even more sweltering. 5. ILLNESSES ENDEMIC TO THE REGION A. IRAQ The U.S. Department of Defense currently publishes the following Iraqi diseases to be of potential significance (22): Short Incubation _ Diarrheal Diseases _ Sandfly Fever _ Typhoid and Paratyphoid Fevers _ Malaria _ Arboviral Diseases Other than Sandfly Fever Long Incubation _ Enterically Transmitted Viral Hepatitis A and E _ Iraq Bloodborne Viral Hepatitis B, D, and C _ Leishmaniasis [522 cases of confirmed custaneous leishmaniasis were identified in military personnel deployed to Iraq, Afghanistan between Aug. 2002 and Feb. 2004 (23).] _ Schistosomiasis Other Diseases of Potential Military Significance _ Animal-Associated Diseases _ Anthrax _ Brucellosis _ Echinococcosis _ Leptospirosis _ Q Fever _ Rabies _ Sexually Transmitted and/or Bloodborne Diseases _ HIV/AIDS _ Syphilis _ Vector-Borne Diseases _ Plague _ Relapsing Fever _ Typhus _ Other Infectious Diseases _ Acute Hemorrhagic Conjunctivitis _ Cholera _ Intestinal Helminthic Infections _ Tuberculosis Recent medical literature has also identified acute eosinophilic pneumonia and Acinetobacter baumanii as diseases that are appearing among American deployed to Southwest Asia (22). Life expectancy in Iraq has fallen to below 60 and infectious diseases have increased as the public health service has deteriorated since 1990 (25). B. AFGHANISTAN The U.S. Department of Defense currently publishes the following Afghani diseases as being of potential significance(26): Infectious Diseases - Short Incubation Diarrheal Diseases Malaria Typhoid and Paratyphoid Fevers Sandfly Fever Crimean-Congo Hemorrhagic Fever West Nile Fever Meningococcal Meningitis Scrub Typhus Sexually Transmitted Diseases (STDs) Infectious Diseases - Long Incubation Enterically Transmitted Viral Hepatitis A and E Bloodborne Viral Hepatitis B, D, and C Leishmaniasis Other Diseases of Potential Military Significance Animal-Associated Diseases _ Anthrax _ Brucellosis _ Echinococcosis _ Leptospirosis _ Q Fever _ Rabies _ Sexually Transmitted and/or Bloodborne Diseases _ HIV/AIDS _ Syphilis Vector-Borne Diseases _ Plague _ Relapsing Fever, Tick-Borne _ Siberian Tick Typhus _ Typhus, Flea-Borne (Murine) _ Typhus, Louse-Borne Other Infectious Diseases _ Cholera _ Intestinal Helminthic Infections _ Trachoma _ Tuberculosis The difference between the public health environment in the U.S. and Afghanistan is about as sharp a difference as between a camel and a car. Life expectancy at birth in the U.S. is 78 years. In Afghanistan, it is only 43 years. The infant mortality rate in the U.S. is 6.5 deaths per 1,000 live births. In Afghanistan, it is more than 25 times worse. Here are 163.1 deaths per 1,000 live births there. The CIA World Factbook lists the degree of risk of major infectious diseases in Afghanistan as “high” (27). 6. TOXIC EXPOSURES There has not been a Gulf War Syndrome II. There was fear that there would be (28). Everything in the environment is essentially the same between the two wars, Americans exposed to the same heat, endemic diseases, sand-flies, depleted uranium use, diesel fumes, multiple vaccinations, stressful circumstances, and even oil fire smoke for a while. In what is about as close to a controlled experiment as can be done on a massive scale, there has been only one major difference between the Gulf War and the Iraq War, and it is the consensus reason for Gulf War Syndrome having occurred. Our troops in the Gulf War, and the few contractors that were with them then, were repeatedly exposed to chemical warfare agent fallout, in particular, Sarin nerve gas and mustard gas, from the detonations of Saddam‘s extensive chemical warfare stockpile from aerial bombardment and at Khamisiyah (29). In contrast, our troops and contractors have not been exposed to chemical warfare agents in this war, thank God. The Centers for Disease Control gave Gulf War Syndrome a case definition in 1998 (30). It is a multi-symptom neurological disorder. The 13 categories of symptoms associated with Gulf War Syndrome were established in the Code of Federal Regulations in 2001 (31). Which personnel acquired Gulf War Syndrome has been discovered to be associated with a genetic susceptibility to Sarin nerve gas exposure, such that low-level exposures had devastating effects on the hypocampus neurons in the brains of those most genetically vulnerable (32). This explains why some have been ill and others are not from the same exposures. It was also discovered after the Gulf War that the pyridostigmine bromide (“p.b.”) anti-nerve gas pills that our troops and contractors took during the Gulf War, while protecting them against a kind of nerve gas that they were not exposed to, Soman, made them more susceptible to the low-level fallout exposures to the kind of nerve agent that they were exposed to, Sarin (33). In September 2005, the Veterans Administration Research Advisory Committee on Gulf War Veterans’ Illnesses concluded that Gulf War Syndrome was probably caused by our troops being exposed to chemical agents (34). Gulf War Syndrome was established as an occupational illness with the U.S. Department of Labor through the litigation of six very ill DoD contractors that I have had the honor to represent (35). There have been some known toxic exposures in the current war in Iraq and Afghanistan. I am representing seven contractors, for example, that were repeatedly exposed to large amounts of sodium dichromate at a water treatment plant that had been vandalized in Iraq. This is the same toxic chemical that was the subject of the Erin Brockovich movie in 2001 (36). Our military appears to have absorbed some lessons learned about toxic exposures from the massive chemical casualties of the First Gulf War. We may discover additional toxic mishaps coming from the current war, but so far, thankfully, we have not seen the theater-wide scale of toxic exposures as occurred in the First Gulf War. 7. FOOTNOTES 1. Public Broadcast Service (“PBS”), “Frontline: Private Warriors: Frequently Asked Questions,” p. 2: www.pbs.org/wgbh/pages/frontline/shows/warriors/faqs/ 2. There are currently about 120-135,000 in Iraq and about 20,000 in Afghanistan: http://www.washingtonpost.com/wp-dyn/articles/A33540-2005Jan24.html; and http://www.globalsecurity.org/military/ops/iraq_orbat.htm 3. The Brookings Institute, “Iraq Index: Tracking Variables of Reconstruction & Security in Post-Saddam Iraq,” p. 15: www.brookings. edu/fp/saban/iraq/indexarchive.htm 4. O’Leary v. Brown-Pacific-Mason, Inc., 340 U.S.504, 507, 71 S.Ct. 470 (1951). 5. Gillespie v. General Electric Co., 21 B.R.B.S. 56 (1988); & Kirkland v. Air America, Inc., 23 B.R.B.S. 348 (1990). 6. http://news.bbc.co.uk/1/hi/world/middle_east/3585765.stm 7. Bigelow, Bruce V., “Iraq: 136 Titan Corp. Workers Killed Since Iraq War Began,” The San Diego Union-Tribune, March 25, 2005. 8. PBS, “Frontline,” supra, p.2. See also Brookings Institute, supra, p. 13, which lists 355 non-Iraqi civilain contractors killed in Iraq as of the end of February 2006. 9. Xydakis, M.S., et al., “Analysis of Battlefield Head and Neck Injuries in Iraq and Afghanistan,” Otolaryngol. Head Neck Surg., 133(4): 497-504 (2005). 10. www.cwc.lsu.edu/cwc/other/stats/warcost.htm. See also: Gawande, Atul, M.D., “Casualties of War - Military Care for the Wounded from Iraq and Afghanistan,” The New England Journal of Medicine, 351: Number 24: 2471-2475 (December 9, 2004). 11. U.S. Dept. of Defense statistics: www.defenselink.mil/news/casualty.pdf 12. See, for example: Remalingham, T., “Extremity Injuries Remain a High Surgical Workload in a Conflict Zone: Experiences of a British Field Hospital in Iraq, 2003,” J.R. Army Med. Corps, 150 (3): 187-90 (2004); and Brennan, J., “Experience of First Deployed Otolaryngology Team in Operation Iraqi Freedom: The Changing Face of Combat Injuries,” Otolaryngol Head Neck Surg., 134 (1): 100-5 (2006). 13. The Brookings Institute, “Iraq Index: Tracking Variables of Reconstruction & Security in Post-Saddam Iraq, “ p. 5: www.brookings. edu/fp/saban/iraq/indexarchive.htm An exposition of the mechanics and components of blast injuries can be seen at: www.medscape. com/viewprogram/4714_pnt 14. http://icasualties.org/oif/Civ.aspx 15. Madar, T.H., “Ocular War Injuries of the Iraqi Insurgency, Jan. - Sept. 2004,” Opthalmology, 113(1): 97-104 (2006). 16. http://www.foxnews.com/story/0,2933,132880,00.html; http://www.cnn.com/2004/WORLD/meast/09/21/iraq.beheading/; http://www.foxnews.com/story/0, 2933,119615,00.html; & http://mypetjawa.mu.nu/archives/042688.php 17. Hoge, C.W., et al, “Combat Duty in Iraq and Afghanistan, Mental Health Problems and Barriers to Care,” New England J. Med., 351(1): 13-22 (2004). See also “Meeting the Mental Health Needs of Veterans of the Wars in Iraq and Afghanistan: An Expert Interview With Col. Elspeth C. Ritchie, M.D., M.P.H.,” Medscape Psychiatry & Mental Health, 10 (2) (2005); and http://www.military.com/opinion/0,15202,79791,00.html 18.http://newsyahoocom/s/nm/20060228/hl_nm/iraq_health_dc&printer=1;_ylt=AmPNYY1FRB8.fO1EJdG28e4R.3QA; _ylu=X3oDMTA3MXN1bHE0BHNlYwN0bWE- ( A full copy of this article appears in the Appendix below); http://www.military.com/opinion/0,15202,79791,00. html; and http://www.military.com/NewsContent/0,13319,FL_stress_072705,00.html  19. http://www.usatoday.com/news/world/iraq/2004-12-22-us-iraq_x.htm 20. “Combat Medicine in Iraq, Part I: An Expert Interview - Col. Cliff Coonan,” www.medscape.com/viewarticle/451483?src=search 21. http://www.weatherbase.com/weather/weather.php3?s=005604&refer; and http://www.weatherbase.com/weather/weather.php3? s=009904&refer=&units=us 22. http://www.pdhealth.mil/deployments/iraqi_freedom/endemic.asp 23. “Returning Home & Illness and Americans in Southwest Asia,” www.medscape.com/viewprogram/4450-pnt, p. 5. See also Centers for Disease Control, “Cutaneous Leishmaniasis in U.S. Military Personnel - Southwest/ Central Asia,” MMWR 53(12): 264-5 (2004). 24. Ibid, pp.1-4; Shorr, A.F., et al., “Acute Eosinophilic Pneumonia Among U.S. Military Personnel Deployed In or Near Iraq, “ Journal of the American Medical Assn. (“JAMA”), 292 (24): 2997-3005 (2004); and Davis, Kepler, et al., “Multidrug-Resistant Acinetobacter Extremity Infections in Soldiers,” Emerg. Infect. Dis., 11 (8) (2005). 25. Dyer, Owen, “Infectious Diseases Increase in Iraq as Public Health Service Deteriorates,” British Medical Journal (“BMJ“), 329: 940 ( October 23, 2004). 26. http://www.pdhealth.mil/deployments/enduring_freedom/concerns.asp. See also Wallace, M.R., et al, “Endemic Infectious Disease of Afghanistan,” Clin. Infect. Dis., 34 (Suppl.5): S171-207 (2002). 27. CIA - The World Fact Book - Afghanistan: www.cia.gov/cia/publications/factbook/geos/af.html 28. Enserinck, M., “War in Iraq. Bracing for Gulf War Syndrome II,” Science, 299 (5615): 1966-7 (2003). 29. During the Gulf War air campaign, coalition aircraft flew 990 sorties against 23 Iraqi chemical and biological weapons research, production and storage facilities. U.S. Department of Defense, Gulf News, 4(2): at p. 1 (March, 2000). Three months before the air war began, Livermore National Laboratory predicted that chemical warfare agent fallout would cover the positions of U.S. troops in Saudi Arabia. USA Today, p. 1 (August 14, 1997). Though this classified research was performed for the U.S. Air Force, the study never reached General Schwarzkopf during the Gulf War. USA Today, p. 1 (August 15-17, 1997). From the beginning of the air war until its end, each of the nearly 14,000 M8A1 chemical alarms deployed in the war went off an average of two or three times a day. U.S. Congress, Committee on Government Reform and Oversight, Gulf War Veterans’ Illnesses: VA, DoD Continue to Resist Strong Evidence Linking Toxic Causes to Chronic Health Effects, at p. 18 (November 17, 1998). The most sophisticated chemical detection equipment in the Gulf War was with the Czech Republic chemical detection forces. They detected the nerve agent Sarin on January 19, 1991, near Hafir al Batin where hundreds of thousands of U.S. troops were massed. Ibid, at pp. 15 & 17. The U.S. Department of Defense has admitted that the Czech detections were valid. Ibid, p. 15. French forces also detected nerve gas during the air bombing campaign. Ibid, p. 17. The U.S. Department of Defense has admitted that approximately 100,000 U.S. troops were exposed to low-level Sarin nerve gas from the destruction of just one Iraqi ammunition dump in March, 1991, at Khamisiyah. Ibid. On 6/1/04, the General Accounting Office (the U.S. Congress research arm) strongly criticized the Pentagon’s previous plume models of chemical fallout that occurred during and in the weeks after the Gulf War. The DoD underestimated the exposure of chemical warfare agents, such as nerve gas and mustard gas. DoD models of the effects of toxic plumes of chemical agents did not realistically simulate actual bombings or demolitions, the GAO report said. The DoD’s models underestimated the plume heights and the extent of the hazard areas. A copy of the GAO report can be seen at: http://www.gao.gov/docdblite/details.php?rptno=GAO-04-821T 30. Fukuda, K., “Chronic Multisymptom Illness Affecting Air Force Veterans of the Gulf War,” Journal of the American Medical Assn., 28:981-988, at 983 (9/16/98). 31. There are 13 categories of symptoms correlated with Gulf War Illness. These categories track the medical research regarding Gulf War Illness. They are set out at 38 Code of Federal Regulations, Section 3.317 (effective July 1, 2001), and are as follows:The undiagnosed illness compensation program for Gulf War veterans now include those who have suffered six months or more of disabilities, who are disabled 10% or more, and suffer from signs or symptoms including: 1.) Fatigue 2.) Signs or symptoms involving skin 3.) Headache 4.) Muscle pain5.) Joint pain 6.) Neurological signs or symptoms7.) Neuropsychological signs or symptoms 8.) Signs or symptoms involving the respiratory system (upper or lower)9.) Sleep disturbances10.) Gastrointestinal signs or symptoms11.) Cardiovascular signs or symptoms12.) Abnormal weight loss13.) Menstrual disorders 32. Mackness, B., et al., “Low Paraoxonase in Persian Gulf War Veterans Self-Reporting Gulf War Syndrome,” Biochemical and Biophysical Research Communications, 276:729-733 (2000); and Haley, R.W., Billecke, S., & La Du, B.N., “Association of Low PON1 Type Q (Type A) Arylesterase Activity with Neurologic Symptom Complexes in Gulf War Veterans,” Toxicol. Appl. Pharmacol., 157:227-233 (1999). 33. Koplovitz, I., et al, “Reduction By Pyridostigmine Pretreatment of the Efficacy of Atropine and 2-PAM Treatment of Sarin and VX Poisoning in Rodents,” Fundamental and Applied Toxicology, 18:102-106 (1992); and U.S. Senate Committee on Veterans’ Affairs Staff Report, Is Military Research Hazardous To Veterans? Heath? Lessons Spanning Half a Century, at p.26 (12/8/94). The U.S. military has been ordered to stop the use of p.b. pills. El Paso Times (8/24/99). 34. Scientific Progress in Understanding Gulf War Veteran's Illnesses: Report and Recommendations. The full text of the report can be found at: http://www1. va.gov/rac-gwvi. Findings 1, 3 & 4 of the V.A. Research Committee are the most relevant ones. They state the following: "Finding 1 - A substantial proportion of Gulf War veterans are ill with multisymptom conditions not explained by wartime stress or psychiatric illness. "Finding 3 - A growing body of research indicates that an important component of Gulf War veterans illnesses is neurological in character. "Finding 4 - Evidence supports a probable link between exposure to neurotoxins and the development of Gulf War veteran's illnesses. (Emphasis added) [Note: The neurotoxin exposures consisted of: nerve gas, the p.b. pills, and pesticides.] Pages 47-53 and 59-66 of the report discusses exposure to chemical weapons during the Gulf War, the correlation between low-level exposure to chemical agents and chronic illness, research showing the synergistic effects of combinations of exposures, and the enhanced genetic vulnerability of some individuals to chemical agent exposure. 35. Herman Piceynski v. Dyncorp, BRB No. 97-1451 (7/17/98), 1994- LHC-2387 (10/18/99); Karl Lane v. Bell Helicopter Co., 1998 - LHC-1012 (6/4/99), BRB Nos. 99-1007 & 99-1007A (6/23/00); Donald Frans v. General Dynamics, 2000-LHC-00593 (1/22/01); James Keenan v. General Dynamics, 2000-LHC-00349 (2/22/01); John Knebel v. General Dynamics, 2000-LHC-1290 (3/22/01); and Larry Pascaretti v. General Dynamics, 2002-LHC-792, OWCP No. 2-116652 (4/18/01). 36. http://en.wikipedia.org/wiki/Chromium APPENDIX “1-in-10 US Iraq Veterans Have Stress Disorder: Study” Feb 28, 2006(Reuters News Service) Nearly one in 10 American soldiers who served in Iraq were diagnosed with post-traumatic stress disorder, most after witnessing death or participating in combat, a study said on Tuesday. Mental health screening of veterans showed 21,620 out of 222,620 returning from Iraq and assessed over the year ending April 30, 2004, suffered from post- traumatic stress -- a disorder that can lead to nightmares, flashbacks and delusional thinking. Overall, 19.1 percent of soldiers and Marines who returned from Iraq met the military's "risk criteria for a mental health concern" such as post-traumatic stress or depression, compared to 11.3 percent among veterans who served in Afghanistan and 8.5 percent from deployments elsewhere, the report published in the Journal of the American Medical Association said. The survey covered 222,620 returning veterans from Iraq, 16,318 from Afghanistan and 64,967 from other deployments. "A higher percentage of those soldiers (returning from Iraq) report mental health concerns and use mental health services when they get home ... compared to soldiers who are returning from deployment to Afghanistan or other locations," said study author Col. Charles Hoge of Walter Reed Army Institute of Research in Silver Spring, Maryland. Of those diagnosed with post-traumatic stress, 80 percent said they had witnessed people being killed or wounded or had participated in combat and fired their weapon, the report said. Of those not diagnosed, half had experienced violence or combat. Post-traumatic stress disorder and other combat-related mental problems can lead to family strife, divorce, alcohol and substance abuse, and unemployment, Hoge said. While one in five veterans returning from Iraq reported concerns about their mental health, about one-third ultimately went for at least one session to be evaluated or counseled, the study said. "The majority of service members who were referred for mental health treatment, got that treatment," Hoge said. "We're trying to encourage soldiers to come in early because we know that earlier treatment of mental health problems is the best way to prevent the long-term consequences that we've seen from past wars. "The findings have important implications for estimating the level of mental health services that may be needed," Hoge added. Copyright © 2006 Reuters Limited. Post-traumatic Stress Disorder DSM-IVÔ Diagnosis & Criteria 309.81 Posttraumatic Stress Disorder Diagnostic Features The essential feature of Posttraumatic Stress Disorder is the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criterion A1). The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior) (Criterion A2). The characteristic symptoms resulting from the exposure to the extreme trauma include persistent reexperiencing of the traumatic event (Criterion B), persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (Criterion C), and persistent symptoms of increased arousal (Criterion D). The full symptom picture must be present for more than 1 month (Criterion E), and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F). document.write('');  Traumatic events that are experienced directly include, but are not limited to, military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness. For children, sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence or injury. Witnessed events include, but are not limited to, observing the serious injury or unnatural death of another person due to violent assault, accident, war, or disaster or unexpectedly witnessing a dead body or body parts. Events experienced by others that are learned about include, but are not limited to, violent personal assault, serious accident, or serious injury experienced by a family member or a close friend; learning about the sudden, unexpected death of a family member or a close friend; or learning that one's child has a life- threatening disease. The disorder may be especially severe or long lasting when the stressor is of human design (e.g., torture, rape). The likelihood of developing this disorder may increase as the intensity of and physical proximity to the stressor increase. The traumatic event can be reexperienced in various ways. Commonly the person has recurrent and intrusive recollections of the event (Criterion B1) or recurrent distressing dreams during which the event is replayed (Criterion B2). In rare instances, the person experiences dissociative states that last from a few seconds to several hours, or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment (Criterion B3). Intense psychological distress (Criterion B4) or physiological reactivity (Criterion B5) often occurs when the person is exposed to triggering events that resemble or symbolize an aspect of the traumatic event (e.g. anniversaries of the traumatic event; cold, snowy weather or uniformed guards for survivors of death camps in cold climates; hot, humid weather for combat veterans of the South Pacific; entering any elevator for a woman who was raped in an elevator). Stimuli associated with the trauma are persistently avoided. The person commonly makes deliberate efforts to avoid thoughts, feelings, or conversations about the traumatic event (Criterion C1) and to avoid activities, situation, or people who arouse recollections of it (Criterion C2). This avoidance of reminders may include amnesia for an important aspect of the traumatic event (Criterion C3). Diminished responsiveness to the external world, referred to as "psychic numbing" or "emotional anesthesia," usually begins soon after the traumatic event. The individual may complain of having markedly diminished interest or participation in previously enjoyed activities (Criterion C4), of feeling detached or estranged from other people (Criterion C5), or of having markedly reduced ability to feel emotions (especially those associated with intimacy, tenderness, and sexuality) (Criterion C6). The individual may have a sense of a foreshortened future (e.g., not expecting to have a career, marriage, children, or a normal life span) (Criterion C7). The individual has persistent symptoms of anxiety or increased arousal that were not present before the trauma. These symptoms may include difficulty falling or staying asleep that may be due to recurrent nightmares during which the traumatic event is relived (Criterion D1), hypervigilance (Criterion D4), and exaggerated startle response (Criterion D5). Some individuals report irritability or outbursts of anger (Criterion D2) or difficulty concentrating or completing tasks (Criterion D3). Specifiers The following specifiers may be used to specify onset and duration of the symptoms of Posttraumatic Stress Disorder: Acute. This specifier should be used when the duration of symptoms is less than 3 months.Chronic. This specifier should be used when the symptoms last 3 months or longer.With Delayed Onset. This specifier indicates that at least 6 months have passed between the traumatic event and the onset of the symptoms. Associated Features and Disorders Associated descriptive features and mental disorders. Individuals with Posttraumatic Stress Disorder may describe painful guilt feelings about surviving when others did not survive or about the things they had to do to survive. Phobic avoidance of situations or activities that resemble or symbolize the original trauma may interfere with interpersonal relationships and lead to marital conflict, divorce, or loss of job. The following associated constellation of symptoms may occur and are more commonly seen in association with an interpersonal stressor (e.g., childhood sexual or physical abuse, domestic battering, being taken hostage, incarceration as a prisoner of war or in a concentration camp, torture): impaired complaints; feelings of ineffectiveness, shame, despair, or hopelessness; feeling permanently damaged; a loss of previously sustained beliefs, hostility; social withdrawal; feeling constantly threatened; impaired relationships with others; or a change from the individual's previous personality characteristics. There may be increased risk of Panic Disorder, Agoraphobia, Obsessive-Compulsive Disorder, Social Phobia, Specific Phobia, Major Depressive Disorder, Somatization Disorder, and Substance-Related Disorders. It is not known to what extent these disorders precede or follow the onset of Posttraumatic Stress Disorder. Associated laboratory findings. Increased arousal may be measured through studies of autonomic functioning (e.g., heart rate, electromyography, sweat gland activity). Associated physical examination findings and general medical conditions. General medical conditions may occur as a consequence of the trauma (e.g., head injury, burns). Specific Culture and Age Features Individuals who have recently emigrated from areas of considerable social unrest and civil conflict may have elevated rates of Posttraumatic Stress Disorder. Such individuals may be especially reluctant to divulge experiences of torture and trauma due to their vulnerable political immigrant status. Specific assessments of traumatic experiences and concomitant symptoms are needed for such individuals. In younger children, distressing dreams of the event may, within several weeks, change into generalized nightmares of monsters, of rescuing others, or of threats to self or others. Young children usually do not have the sense that they are reliving the past; rather, the reliving of the trauma may occur through repetitive play (e.g., a child who was involved in a serious automobile accident repeatedly reenacts car crashes with toy cars). Because it may be difficult for children to report diminished interest in significant activities and constriction of affect, these symptoms should be carefully evaluated with reports from parents, teachers, and other observers. In children, the sense of a foreshortened future may be evidenced by the belief that life will be too short to include becoming an adult. There may also be "omen formation" - that is, belief in an ability to foresee future untoward events. Children may also exhibit various physical symptoms such as stomachaches and headaches. Prevalence Community-based studies reveal a lifetime prevalence for Posttraumatic Stress Disorder ranging from 1% to 14%, with the variability related to methods of ascertainment and the population sampled. Studies of at-risk individuals (e.g., combat veterans, victims of volcanic eruptions or criminal violence) have yielded prevalence rates ranging from 3% to 58%. Course Posttraumatic Stress Disorder can occur at any age, including childhood. Symptoms usually begin within the first 3 months after the trauma, although there may be a delay of months, or even years, before symptoms appear. Frequently, the disturbance initially meets criteria for Acute Stress Disorder (see p. 429) in the immediate aftermath of the trauma. The symptoms of the disorder and the relative predominance of reexperiencing, avoidance, and hyperarousal symptoms may vary over time. Duration of the symptoms varies, with complete recovery occurring within 3 months in approximately half of cases, with many others having persisting symptoms for longer than 12 months after the trauma. The severity, duration, and proximity of an individual's exposure to the traumatic event are the most important factors affecting the likelihood of developing this disorder. There is some evidence that social supports, family history, childhood experiences, personality variables, and preexisting mental disorders may influence the development of Posttraumatic Stress Disorder. This disorder can develop in individuals without any predisposing conditions, particularly if the stressor is especially extreme. Differential Diagnosis In Posttraumatic Stress Disorder, the stressor must be of an extreme (i.e., life-threatening) nature. In contrast, in Adjustment Disorder, the stressor can be of any severity. The diagnosis of Adjustment Disorder is appropriate both for situations in which the response to an extreme stressor does not meet the criteria for Posttraumatic Stress Disorder (or another specific mental disorder) and for situations in which the symptom pattern of Posttraumatic Stress Disorder occurs in response to a stressor that is not extreme (e.g., spouse leaving, being fired). Not all psychopathology that occurs in individuals exposed to an extreme stressor should necessarily be attributed to Posttraumatic Stress Disorder. Symptoms of avoidance, numbing, and increased arousal that are present before exposure to the stressor do not meet criteria for the diagnosis of Posttraumatic Stress Disorder and require consideration of other diagnoses (e.g., Brief Psychotic Disorder, Conversion Disorder, Major Depressive Disorder), these diagnoses should be given instead of, or in addition to, Posttraumatic Stress Disorder. Acute Stress Disorder is distinguished from Posttraumatic Stress Disorder because the symptom pattern in Acute Stress Disorder must occur within 4 weeks of the traumatic event and resolve within that 4-week period. If the symptoms persist for more than 1 month and meet criteria for Posttraumatic Stress Disorder, the diagnosis is changed from Acute Stress Disorder to Posttraumatic Stress Disorder In Obsessive-Compulsive Disorder, there are recurrent intrusive thoughts, but these are experienced as inappropriate and are not related to an experienced traumatic event. Flashbacks in Posttraumatic Stress Disorder must be distinguished from illusions, hallucinations, and other perceptual disturbances that may occur in Schizophrenia, other Psychotic Disorders, Mood Disorder With Psychotic Features, a delirium, Substance-Induced Disorders, and Psychotic Disorders Due to a General Medical Condition. Malingering should be ruled out in those situations in which financial remuneration, benefit eligibility, and forensic determinations play a role. 309.81 DSM-IV Criteria for Posttraumatic Stress Disorder A. The person has been exposed to a traumatic event in which both of the following have been present: (1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others (2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior. B. The traumatic event is persistently reexperienced in one (or more) of the following ways: (1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed. (2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur. (4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. (5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: (1) efforts to avoid thoughts, feelings, or conversations associated with the trauma (2) efforts to avoid activities, places, or people that arouse recollections of the trauma (3) inability to recall an important aspect of the trauma (4) markedly diminished interest or participation in significant activities (5) feeling of detachment or estrangement from others (6) restricted range of affect (e.g., unable to have loving feelings) (7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span) D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: (1) difficulty falling or staying asleep (2) irritability or outbursts of anger (3) difficulty concentrating (4) hypervigilance (5) exaggerated startle response E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month. F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: Acute: if duration of symptoms is less than 3 months Chronic: if duration of symptoms is 3 months or more Delayed Onset: If onset of symptoms is at least 6 months after the stressor. |
AMERICAN CONTRACTORS IN IRAQ