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War-related stressors are associated with asthma risk among older Kuwaitis following the 1990 Iraqi invasion and occupation
  1. R J Wright1,2,
  2. M E Fay2,
  3. S Franco Suglia2,
  4. C J Clark2,
  5. J S Evans2,
  6. D W Dockery2,3,
  7. J Behbehani4
  1. 1Channing Laboratory, Brigham & Women's Hospital, Department of Medicine, Harvard Medical School; Boston, Massachusetts, USA
  2. 2Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts, USA
  3. 3Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, USA
  4. 4Faculty of Medicine and Health Sciences, Kuwait University, Kuwait
  1. Correspondence to Dr R J Wright, Channing Laboratory 181 Longwood Avenue, Boston, MA 02115, USA; rosalind.wright{at}


Background Contemporary warfare involving civilian populations is a growing public health concern. In addition to the psychological impact, war-related trauma may result in physiological alterations and even broader health effects. Associations were examined between war-related stressors and incident asthma in elderly Kuwaiti civilians following the Iraqi invasion.

Methods A random sample of all Kuwaiti nationals aged 50–69 years on the day prior to the invasion were identified. Among the 7873 meeting eligibility criteria, 5567 (71%) agreed to participate and 5028 completed the questionnaire (91% of those eligible). Of these, 3759 were in Kuwait during the invasion, of whom 2294 were alive at follow-up. After exclusions for prevalent asthma or missingness on covariates, 2066 were available for analysis. War-related experiences were summarised into a continuous score using Rasch modelling. Relative Cox proportional hazard rates (HR) were calculated for asthma adjusting for covariates.

Results Over 13 years of follow-up, physician-diagnosed asthma was reported by 66/996 (6.6%) men and 104/1070 (9.7%) women. In models adjusted for gender, socioeconomic status, smoking, BMI, and air pollution related to burning oil fires, those reporting highest stress exposure were more than twice as likely to report asthma (HR 2.3, 95% CI 1.3, 3.9) compared to civilians reporting no stressors. Experiences were more salient when anchored to fear for loss of life.

Conclusions War-related trauma is associated with increased asthma risk in these elderly civilians. Although prior research has documented the significant and persistent psychological toll of war, these findings implicate even broader health effects.

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  • Dedication We dedicate this paper to the memory of our dear colleague, Professor Jaafar Behbehani of the Kuwait University Faculty of Medicine, who was the inspiration for this work. Jaafar's vision; his personal and professional understanding of the impacts of war on the physical and mental well-being of civilian populations; his untiring dedication and devotion to develop the scientific evidence needed to inform this matter; and his personal elegance and warmth made this work possible. We owe him a great debt and hope that the publication of this paper will in some small way ensure that his contributions to science are appreciated.

  • Funding This study was funded by the Public Authority for Assessment of Compensation for Damage Resulting from the Iraqi Aggression.

  • Competing interests None.

  • Ethics approval Study procedures were approved by the Kuwait University Faculty of Medicine and Harvard School of Public Human Studies Committees.

  • Provenance and Peer review Not commissioned; externally peer reviewed.

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