TCS Daily

Baghdad Boil to Return?

By Roger Bate - May 13, 2004 12:00 AM

It's heating up in the Southern Iraqi desert and sand flies are returning. They bring with them "Baghdad Boil," a nasty disease, more properly known as cutaneous leishmaniasis. They go about their ghastly business of extracting a blood meal and laying its eggs in human skin. In the previous 12 months there have been over 650 cases of the disease. Poor planning, imprudent regulations and military incompetence mean the Boil will be worse this summer than it otherwise should. It is unfortunate that young men, fighting for their country and being shot at on a daily basis, are contracting a largely preventable disease.

Arcane rules about drug protocols and lack of Food and Drug Administration approval for the best drugs means all cases have to be hospitalised back in US where treatment can last a month. As such, the cost is exorbitant and unnecessarily adds to a burgeoning war bill. Each case costs the US taxpayer over $20,000 in terms of flights, medical testing and other interventions, medical staff time, drugs and opportunity cost of soldiers incapacitated. As one Iraq-based medical entomologist put it: "We were better off during the Second World War since doctors in the field had experience of the disease and could use drugs and insecticides in situ as required."

The vast majority of US soldiers sent to Iraq were not issued with proper bed nets and mosquito repellent. This is an odd oversight: In Operation Desert Storm in 1991 there were 34 cases of the disease and so the military was fully aware of what to expect this time around.

"It is understandable that these items are not top of any soldier's equipment list, but [the current] failure rate is ridiculously high," says a senior US military medic. One reason for the lack of supply is that the military units have to buy these items from small internal budgets that were unable to cover supplies -- a false economy given the costs of treatment. Furthermore, not all the bed nets deployed by US and other allied forces are adequate. Bed nets must have a very fine mesh, at least 18 holes per sq inch, otherwise the tiny sand fly can penetrate them.

Failure of management and command has also led to inappropriate requisitioning. Deltamethrin is the insecticide that has been most widely used by soldiers, even though it is known to break down in sunlight and sand storms. The choice was made partly to appease contentious environmental concerns about impacts on wildlife (not sand flies, presumably). The military should impregnate all equipment with the best insecticides, including DDT, which is better and cheaper than deltamethrin. Indeed, the Iraq-based entomologist I spoke with would love to use DDT but he cannot since it's not available due to the US Government ban. Taxpayers could save several million dollars if DDT was used instead of Deltamethrin (and the soldiers would benefit too from fewer sand flies).

Although the inability to use DDT is annoying, the entomologists' largest frustration is that in some instances requests for insecticides last summer went unanswered for many months. The results were immediate. "We started seeing soldiers basically eaten alive, 1,000 bites a night in a handful of cases," said one military medic. It is incredibly hot in the desert in the summer and most soldiers sleep in shorts and nothing else, with their tent flaps wide open to keep the air flowing.

One solution is mobile air-conditioning units, which keep the troops cool enough so they can shut the flaps on the tents and sleep in more than just shorts. Where these tents have been used, biting rates and infections fell massively. A-C tents should be deployed immediately in some locations, such as Nasiriya, because 10-15% of troops in some units are coming down with the infection -- compromising their military potency.

More broadly a massive spray program using the best insecticides should be undertaken of the areas where the sand flies are most likely to carry the Leishmaniasis parasite. The US military has done some of this and looks set to expand on the current program before the summer really starts. This would lower the incidence of bites, and hence disease, not just of the military but of the children of Iraq, who are most likely to die from the nastier form of the disease (visceral leishmaniasis).

For the soldiers returning home, carrying visceral leishmaniasis - which the CDC describes as when "leishmanial parasites replicate in the reticuloendothelial system (e.g., spleen, liver, and bone marrow)" -- remains a possibility. In Desert Storm over a third of the 34 cases were visceral, with organ damage occurring in a few cases. So far none of the 650 cases in Operation Iraqi Freedom has been visceral; this might be because in Desert Storm (in 1991) most of the troops were stationed in Saudi Arabia, where visceral leishmaniasis is more common, but it may also be that the soldier's immune systems are fighting off the disease at the moment. But immunity may not last long; some soldiers may have the disease and currently be asymptomatic. Recently two visceral cases were reported in Afghanistan; we may yet see cases in Iraq.

Since the parasite can survive in the body for years, it could start damaging the organs of soldiers years from now. Vigilance is required for returning troops, they deserve better than waiting and hoping they do not develop a potentially fatal disease.


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