Synchronic and Diachronic Investigation of the Long-Term Effects on

Reproductive Health of Heavy Metals, Environmentally Stable

Military Remnants in Gaza, Palestine: A Summary

Paola Manduca

Newweapons Research Group, Genoa, Italy

Keywords: Heavy Metals, Weaponry, Chronic Human Contamination, Reproductive Health Outcomes.

Abstract: Here is reported research “on the other side of weapons”, that of the victims, aiming to diffuse knowledge of

the long-term damages to health by heavy metals in weaponry, invisible and stable war remnants in the XXI

century wars. The work reported is exemplary in identifying at each time point (synchronic approach) and

along 13 years (diachronic approach) the source of heavy metal contaminants in weaponry, their chronic

uptake by humans and proving association of exposure to attacks and metal contamination with reproductive

damage in the war setting of Gaza Palestine. Many heavy metals found in weaponry are toxicants, fetotoxic

and carcinogens, are spread indiscriminately by ammunitions, are stable in the environment, suggesting that

their use in attacks on civilian areas falls under more than one prohibition by international law. To date, we

are not aware of other studies of surveillance of reproductive health in any war area on a wide random cohort,

nor of this being accompanied by systematic parallel investigation of human contamination by heavy metals

delivered by weapons, white phosphorus shells, and in wounds by not-fragmenting ammunitions. The data

altogether, allow comparison among time points (diachronic view); this view allowed to understand the entity

of the long-term effects of metal contamination of mothers on birth outcomes, the persistence of these effects

vis a vis the environmental contamination, to single out and confirm which of the many metal elements found

at high levels in post-war area is affecting negatively the outcomes at birth, and to describe long-term impact

of recent war events on health, before and after displacement of war remnants. It documents that one of the

tolls by war-remnant heavy metals contamination is increase of deaths in the perinatal age, “invisible war

victims”.

1 INTRODUCTION

These investigations focused on the role of heavy

metals, fetotoxic and carcinogenic or toxic for

mammals, and “invisible stable weapons remnants”

of war, and on their role as effectors of negative

reproductive health outcomes.

Heavy metals, components of many weapons

systems of this century, which Israel used on Gaza,

do not disappear from the environment, and have the

potential to cause, by various mechanisms, long-term

health damages upon acute and chronic exposure and

via accumulation in organs (Domingo, 1994; AIRC,

2020; ATSD, 2011;

Rice, 2014; Amadi, 2017;

Wai,2018; Rahman, 2016; Cheng, 2012; Grandjean,

2105; Bommarito, 2017).

Military aggressions and wars draw an almost

continuous line of fire along the last 23 years, from

Yugoslavia through Southwestern, Western and

Central Asia, Middle East, and north Africa.

Although the impact of stable war remnants is a

concern in each of these places of war, there are only

sporadic scientific reports about these stable

chemicals, heavy metals delivered by weaponry, in

association with negative outcomes of reproductive

health of populations.

To investigate the changes in reproductive health

associated to contamination of a population by stable

effectors as heavy metals delivered by weaponry,

poses many challenges of various nature.

Daunting ones are the lack of specific biomarkers

of their biological effects, the scarce knowledge about

the mechanism of action of heavy metals, and the

complexity due to the compresence of several heavy

metals in the war-remains. Much more work is

necessary to tackle these aspects.

Manduca, P.

Synchronic and Diachronic Investigation of the Long-Term Effects on Reproductive Health of Heavy Metals, Environmentally Stable Military Remnants in Gaza, Palestine: A Summary.

DOI: 10.5220/0012007300003536

In Proceedings of the 3rd International Symposium on Water, Ecology and Environment (ISWEE 2022), pages 243-255

ISBN: 978-989-758-639-2; ISSN: 2975-9439

 2023 by SCITEPRESS – Science and Technology Publications, Lda. Under CC license (CC BY-NC-ND 4.0)

243

Some wars are ongoing, posing difficulties in

access. Others have been very long, and even after the

wars, there have been “intrinsic” factors hindering

adequate design for systematic studies, e.g., the

displacement of populations and/or the concomitance

of other crisis also potentially impacting health, lack

of previous birth registry to use as reference.

There was also decisive hindrance by “extrinsic”

factors, local governments, or external occupiers,

opposing to the documentation of long-term effects

on reproductive health potentially due to the

weaponry used and to their remnants, because this

documentation could imply responsibilities for

having used these weapons in wars waged extensively

on the civilian populations. Thus, local, and

occupying authorities took unhelpful, or at time

threatening, postures against the research, even when

collaboration was sought by local professionals;

international health bodies, when intervened, often

did not publish the results in scientific journals with

review.

In Gaza, aside minor events, the research work

was accepted and facilitated by the local authorities,

the UN bodies in the field, and by highly

collaborative professionals. What is presented here is

the result of a collective effort.

In Gaza the “intrinsic” conditions allowed to

adopt a satisfactory scientific design; paradoxically,

the inhuman siege contributed to make easier some of

the aspects of the research, since it forced people to

residential stability, thus defining the length of post-

war chronic exposures to war remains and allowed to

trace the chronology of the removal of ruins and war

remnants.

Positive “extrinsic and intrinsic” conditions in

Gaza allowed to persevere in the investigations for 13

years, for what is an unprecedented span of time in

any war area, although with interruptions due to the 3

wars waged on Gaza meanwhile (2009, 2012, 2014).

Nonetheless, the recurring attacks with varied set of

weaponry posed and extra challenge to the

interpretation of data.

Anyhow, it was possible to acquire reiterate

extensive synchronic information through surveys at

birth and parallel analytical data of metal load in

women and newborns, and to include verified recall

of exposures to potential environmental sources of

heavy metals; repeat of the surveys and assessments

in time, having developed and used the same standard

methodology for acquiring data along the years,

allowed to compare diachronically the sets of yearly

data.

The investigation in Gaza covered the span of the

years 2006- 2019. It started documenting the delivery

by weaponry of heavy metals, and its assumption by

the population. It involved studies of human

contamination by heavy metals in random cohorts.

One of them was of 95 children; 5 were cohorts of

women delivering a baby, for a total of 14.000

women, including some exposed at different and

multiple times to major military assaults by the Israeli

army. The survey of the outcomes of birth involved

about 13.500 women, in 4 cohorts.

The studies also collected, through collaboration

with UN and local environmental and agricultural

authorities, analytical and historic details of the

environment and of usage of chemical in civil life,

obtaining a body of circumstantial information,

including that about the localization of military

attacks which confirmed women’s recall of exposure

to these attacks. Together, this extended consultancy

surrogated the interpretation of association of heavy

metals in weapons remnants as effectors of

reproductive health and helped to understand the

timing and circumstances that caused the diffusion of

these effectors in the environment.

The research developed stepwise; each step

motivated by the results of the previous one and

incorporated the novel questions that these posed; it

resulted in obtaining eventually a picture of the

environmental contaminants delivered by weapons,

of the pattern of their assumption by civilians under

acute and under chronic exposures and of the

correlation of the assumption of heavy metals by

women with their reproductive outcome.

Rare sporadic reports, and our own unpublished

data from other war areas suggested decrease in

reproductive and whole health in people residing in

locations militarily attacked, and, in some cases,

reported human and environmental contamination by

heavy metals.

A word will be spent on the potential use for the

information presented here.

2 METHODOLOGIES

Multiple sources of information were used, various

scientific tools and different methodologies

appropriate to cover each sector of the investigations

and these were published (Skaik, 2010; Abed, 2014;

Naim, 2012; Manduca, 2011, 2013, 2014, 2019;

Baraquoni, 2020; Vänskä, 2019).

The research involved field work, environmental

assessments, and hospital-based work with local

professionals as partners and consultants and

analytical measures were done abroad certified labs,

the same since 2011.

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Protocols were prepared for each step of the

work: adequate collection for the analysis of inert and

biological samples, clinical and environmental data

recording and preservation of biological samples for

analytical studies.

Inert samples from bombed sites or ammunitions,

were used to investigate the presence of heavy metals

in weapons used in Gaza. Hair was collected of 4cm

length at the nape for adults. The appropriacy for

analytical studies on formalin preserved biological

samples was also tested.

The amount of 23 heavy metals in inert materials,

hair and in biopsies of the wounds was determined by

Inductively Coupled Plasma Mass Spectroscopy

(ICP-MS) in 2 certified laboratories in Italy and in

Canada. All hair samples of women and babies were

analyzed in the same laboratory which legitimizes

comparisons. In all the analysis appropriate controls

were utilized. E.g. for inert samples, the soil from

outside the crater zone; for biopsies, layers of the

tissue at a distance from the wound from the same

individual; for hair, adult controls were from

individuals from countries outside the war area and

for newborns the hair of normal Gaza’s babies.

Detailed protocols for collection of participants

consensus and hair samples, questionaries for

registration of data at birth from mothers included

questions on mother’s historical health records,

parity, prenatal prevention care and provider,

nutrition, medication and habits, marriage with first-

and second-degree relatives, but also health records

for the other children of the couple, and for the

parents’ extended family, data on child sex, living

parameters, clinical diagnosis, singlet or twin, type of

delivery. The questions on exposures to possible

toxicants/teratogens in civil life (8), on military

events exposure (15 or more), about the state of the

dwelling and rubble reuse after wars (4) were updated

after each new war to account for the changes in the

environment.

3 RESULTS

3.1 Chronology of Military Attacks

The temporal context of the major attacks in Gaza is

shown in Table I with the extent of damages since

2008.

Table 1: Chronology of the major military attacks on Gaza

before 2021, number of victims/damages.

The attacks reported here followed a shorter but

intense one in 2006, when were used for the first time

weapons that caused wounds without fragments

strikingly like those reported at the same time in the

contemporary war to Lebanon. Call for help to

understand the strange wounds that were presented

with in these attacks, issued by doctors in these two

countries to professionals abroad, and their reports of

unexpected prognosis after care for these previously

unseen wounds, together with the published

information of the development by US firms of metal-

augmented weaponry, and the acknowledgement by

Israel of “field testing” novel weaponry, triggered our

research “on the other side” of weapons.

3.2 Heavy Metal Remnants Delivered

by Weapons in the Environment

and in Wounds

Craters and WP ammunition were tested for the kind

and load of heavy metals and were shown to delivery

fetotoxic and carcinogen metals (Table II).

Table 2: Qualitative summary of content in heavy metals,

among the 23 tested, which were found in fivefold or more

amounts compared to controls. Al - aluminum, Hg -

mercury, W - tungsten, Mo - molybdenum. WP = white

phosphorus. Yes >5 fold than control.

The craters tested were produced in 2006 and

2009 by heavy bombs that made wide and deep holes

in land. In 2009, 3500 WP shells, each spreading its

content for a radium of 300m, were used on Gaza,

potentially covering with their content 1/9 of the

surface of the Gaza strip.

Biopsies at the site of wounds caused by weapons

without fragments, including White phosphorus

burns, were collected, and tested for their metal

Synchronic and Diachronic Investigation of the Long-Term Effects on Reproductive Health of Heavy Metals, Environmentally Stable

Military Remnants in Gaza, Palestine: A Summary

245

content, as proof of fact that the weapons that had

produced them delivered heavy metals.

Tissue from 15 victims was analyzed. Each

wound was clinically classified by surgeons. Wounds

within the same group of clinical classification had

similar content and quantity of metals, while wounds

in clinically different groups had a different specific

metal signature.

Figure 1: Wounds from victims in 2006 and 2009 from

which biopsies were analyzed by ICP/MS.

In Fig 1 is shown the kind of damage inflicted to

the victims and the clinical classification of wounds,

and in Table III the comparison of the load of heavy

metals detected in the tissue from each clinically

different kind of wounds.

Table 3: Qualitative summary of metal load in clinically

different wounds and date of the wounding. Cd-cadmium;

U- uranium; V-vanadium; Sr-strontium; Cu-copper; Ba-

barium; Sn-tin. Yes highlighted in green > 5fold than

control; yes highlighted in blue >2 fold than control.

The data are proof of fact that weaponry without

fragments each delivered heavy metals, and that the

metal signature was specific for the different clinical

damages inflicted.

3.3 Human Intake of Heavy Metals

Delivered by Weapons

Testing the hair of 95 children for the load in 23

metals 8-9 months after the attacks in 2009, showed

that 60% of them had higher load in the hair grown in

the last 3-5 months for all the toxic metals reported in

Tables II and III than control children living in 2

towns in Italy and 1 town in Israel, and of the

standards load form other not war areas (not shown).

This finding implied that was ongoing human

contamination by metals delivered by weaponry and

signaled chronic intake by a wide segment of the

population, alerting to the possibility that high level

of contamination of humans might affect their health

for a long time, and might negatively interfere with

pregnancy, embryo, and fetal development.

3.4 Changes in the Prevalence of Major

Structural Birth Defects Bridging

War- Retrospective Approaches

Aware of the potential risks of heavy metal

contamination for reproductive health, two

retrospective approaches were used to assess if there

had been changes in prevalence of major structural

birth defects (BD) in the time bridging the 2009 war:

analysis of data retrieved from registers of all

pediatric hospitals in Gaza (Table IV), and

reconstruction of BD incidence in the history of more

than 40 families with a normal child born in 2011

(Fig.2).

From the records of the pediatric hospitals in

Gaza was calculated the prevalence of major birth

defects occurring at two time points, in 2006 and

2010, spanning the military attacks in 2009 (Table

IV).

Table 4: Prevalence of BD among 0-2 years old children

registered in all Pediatric hospitals of the Gaza strip in the

first six months of 2006 and 2010.

Increase (p<0,001) in 0-2 years old patients with

BD occurred spanning the attacks in 2009.

Collecting from parents the self-reported events

of BD in their progeny and the date of birth of all their

children, is possible to reconstruct the frequency of

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BD in the progeny as they occurred in time (Figure

2).

Figure 2: Increase in time (1997-2010) of the frequency (%)

of major malformations in families with a normal newborn

in 2011 and with a previous child with birth defect.

Sp=sporadic, Fam=documented familiar. Cochran-

Armitrage trend test for Sporadic malformations p<0.001,

for familiar malformations p=0.59.

The prevalence of BD increased in time between

1997 and 2010; those BD for which there was not

documented familiarity contributed disproportionally

to the overall rise, supporting the hypothesis that

environmental effectors affected the incidence of BD

and that these effectors were introduced between

2006 and 2010.

The two independent retrospective approaches

showed the increase in prevalence of BD bridging the

2009 war. The two approaches concur to signal

increase in BD after the major war in 2009.

The reconstruction approach sets the starting time

of the increase to the first campaigns of airstrikes on

Gaza; these started in late 2005 as soon as colonial

settlers left the Gaza Strip;

3.5 Association between Mother’s

Exposure to Attacks, Progeny

Outcome, and Metal

Contamination in Newborn Hair

A survey at birth was conducted to establish if there

was a correlation between the exposure of women to

attacks and their probability to have a baby with BD,

and if the BD babies had a higher load in heavy metals

than normal babies. Survey at birth was implemented

in Gaza in 2011. Data of a random cohort of almost

3000 delivering women were collected in sequence in

one Maternity. In the registration questionnaire

included questions about exposure of the mother to

potential negative effectors of health (habit to smoke

tobacco or shisha, use of drugs, use of chemicals,

nearness to/work in industrial and agricultural areas

and exposure to previous military attacks) and

historic residence of the couple.

In this cohort of women those that recalled being

under bomb and/or WP attacks in 2009 had with

significant higher frequency newborns with BD,

compared with women not exposed to attacks

(p<0.001) (Table V).

Table 5: Correlation of the mother exposure in 2009 to

attacks, by kind of weaponry, with the prevalence (%) BD

in their progeny born in 2011.

Recall by mothers of their exposure to military

attacks was verified, crossing the address of their

residence with the place and kind of ammunition used

in attacks, on the maps recording military attack,

accessed by courtesy of the UN Mine Action Team.

The hair of newborns in the cohort was collected

within 5minutes from delivery, metal load was

measured, and the results indicated passage of heavy

metals in utero.

Comparison of the load of heavy metals in BD

versus normal babies, showed significant higher

amount of mercury (p<0,003), tin (p<0,002), and

selenium (p<0,004) in BD newborns than in normal

babies. Preterm babies, also tested, showed a different

pattern of contamination than BD and normal

newborns, having higher load in barium (p<0,03) and

tin (p<0,002).

There was correlation between mother exposure

to weapons, negative outcome of pregnancy, and

higher load of heavy metals in BD or preterm

newborns hair than in normal babies. The

contaminants in highest load were specific: mercury

and selenium for BD and barium for preterm.

The association of these specific metals in high

load respectively in BD and preterm, is consistent

with what is known respectively about the teratogenic

effect of mercury, and the synergism in teratogenicity

of high loads of selenium with mercury, and about the

toxicant effect during pregnancy of barium.

The association: mother exposure to attacks-

negative birth outcome-high load in specific heavy

metals was found almost 2 years after the women

were exposed to the attacks in 2009, implying long-

1997-1998 1999-2000 2001-2002 2003-2004 2005-2006 2007-2008 2009-2010

%Sp/TOT %Fam/Tot %BD/tot

Synchronic and Diachronic Investigation of the Long-Term Effects on Reproductive Health of Heavy Metals, Environmentally Stable

Military Remnants in Gaza, Palestine: A Summary

247

term effects of an event of acute contamination and/or

effects due to long resilience in the environment

where heavy metals war-remnants remained, and

ongoing chronic contamination. It is compatible with

the second possibility the fact that these women, in

the large majority of cases (90%) continued to reside

in the place where the attacks had occurred, and

remains of weaponry remained in or near their

housing.

3.6 Recent Exposure to Military

Attacks Increased the Load of

Heavy Metals Above a High

Background in a Cohort of Women

and Their Newborns

In early 2015, was assessed the extent of women

contamination in relationship with recent exposure to

weaponry of a cohort of 502 women, who were 1-3

months pregnant during the attacks in 2014. 70% of

the women recalled exposure to the recent attacks on

their housing; their recall was verified in 108 random

cases, and damages to their housing was confirmed in

99% of the cases by photos.

Hair from the mothers and their newborns was

tested for metal load, reflecting the last 4 months of

accumulation in mother and the whole fetal life in the

newborns. It was found positive correlation between

proximity of the mothers to military attacks and a

higher load of toxicants (Ba, Al, V, Sr, Cd and Cr),

teratogen (Hg, W) and a carcinogen (As) compared to

women not exposed to attacks (30% of the cohort).

There was no difference for the concentration of

microelements (Cu, Se, and Mo).

Trans-placental passage occurred for heavy

metals from mothers to their newborns, the median

metal load of the babies being much lower than the

mothers' load.

Of relevance, the samples of hair from these 502

Gaza women had higher 95 percentile values of

concentration compared with a standard control of

hair from individuals the outside war area (Table VI)

for heavy metals of relevance for health and identified

as weapon remnants also from previous attacks, in

2009.

Table 6: 95percecntile of the load (ppb) of 23 metals in the

cohort of 502 mothers that delivered in 2015, compared to

standard controls (in red). Highlighted in blue are the metals

with values higher for women in Gaza than for the controls,

column on the right indicate the p value for the comparison.

Molybdenum, selenium, tin and titanium showed no

significant difference from controls.

These data point to a high background of already

existing contamination by weapon remnants and to

chronical assumption, to which the recent attacks

added quantitatively.

3.7 Birth Registry and Prevalence of

Negative Outcomes at Birth, from

2011 to 2019

Comparison of birth surveys taken in different years

was possible because the same methods, procedures,

and randomness of the cohorts, was used. It showed

that further increase in the incidence of birth defects

and preterm babies occurred from 2011. The increase,

between 2011 and 2016, bridging 2 wars in 2012 and

2014, was very significant; prevalence values did not

change significantly after 2016.

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Table 7: Comparison of the incidence of negative birth

outcomes (%) in surveys in 2011, 2016 and 2028-2019. In

each of these years respectively 2940, 6104, 4707 deliveries

were registered in sequence. Preterm, born before 37 weeks

of gestation age; BD, birth defect. N is the number of cases.

Highlighted in blue, the p values of significant differences

in incidence between years.

For BD the change in prevalence was not

associated to increase in intermarriages, which

instead decreased since 2011. The increase in BD

between 2011 and 2016 was substantial in such short

time, and so was the contribution of sporadic novel

cases, deduced in the basis of the family history, also

collected in the survey. The change of the prevalence

in preterm is extremely relevant and compatible with

being induced by chronic exposure to metal

contaminants in the environment which likely

accumulated during the two wars in 2012 and 2014).

3.8 Assessment of Exposures, Metal

Load in Mothers in Relation with

Outcome of Pregnancy, Years

2011-2019

In the 6-9 months after the attacks in 2014 the load of

metals in mothers exposed to them was higher than in

not exposed. Between 2015 and 2019 there were no

major new military attacks on Gaza.

The two major military attacks in 2012 and 2014

were accompanied by extensive destruction of

housing and infrastructures and, following these

attacks, clearing of the debris and reconstruction had

to wait years to be done, due to lack of machinery and

cement imposed by the blockade by Israel and, since

2013, also by Egypt.

Cleaning up started in middle 2016, involved

removal of the rubble of destroyed buildings and

infrastructures and its reuse through pulverization of

the debris in open air and disposing of the biggest

chunks by or into the sea.

Before this time, the rubble remained largely in

the proximity of hit buildings and infrastructures, in

the roads and fields, available to be washed out and

dispersed by flood rains and enter the (still) open

sewage. In 2016, 34% of the cohort of mothers in the

survey resided near open sewage or garbage mounds

also containing remnants of the destructed structures.

The significant increase in BD and preterm births

in 2016 compared to 2011, had no correlation with

previous exposure of the mother to attacks in 2014

(43%). Rather, having babies with BD was

significantly associated with nearness of the

residence to places where garbage was burned in open

air, and having BD and preterm babies were

associated to residence near to open sewage, as shown

in Table VIII.

Table 8: Percentage of mothers residing near risky locations

and recalling exposure to attacks in 2014, in relationship

with the outcome of their pregnancy.

The cohort of mothers which resided in proximity

to military remnants had also significantly higher load

of toxicants in their hair (Ba, V), teratogen (Hg) and

carcinogen (Co), compared to those leaving far from

these sources of contaminants (Table IX).

Table 9: The heavy metals whose load in mothers’ hair was

higher for residents near sewage and open burning of

garbage that in the hair of those not near.

Thus, in 2016 there was correlation between

woman residence near risky deposit of war remnants,

higher probability of having a BD or preterm baby

and their higher load of contamination by specific

heavy metals.

In the survey of births in 2018-19, no correlation

was found between mother’s exposures to previous

military attacks with the metal load in their hair or

with the outcome of pregnancy. In 2018-19 only 12%

of the mothers still lived near war remnants.

Nonetheless, the prevalence of negative outcome

at births did not decline from 2016 and the

95percentile values of concentration of the heavy

metals, concerning for their toxicity or impact on

health, were consistently higher than those of

references, and, for most, similar as in the previous

years (Table X).

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Military Remnants in Gaza, Palestine: A Summary

249

Table 10: The 95 percentile values of the metal load of 12

toxic metals in the hair of the women in the cohorts

registered in the years 2015-2019 compared to reference

samples (in red). Highlighted in blue are the values

significantly higher in the cohorts tested than in the

reference control. For titanium and arsenic the 95percentile

values become higher than control only since 2016.

Comparison of the median values of the load of

these metals in women in time (Table XI) is more

reflective of the diffusion in the population than the

95percentile values. Median values showed

significant increase from 2015 to 2018-19 for some

of them As, Cd, Co, Cr, Sr, Ti, U and V (highlighted

in pink); decrease, only in 2018-19 for Hg and Mo,

and decrease since 2016 for Se (highlighted in green);

the level was unchanged for Ba.

Table 11: Comparison of the median metal concentration in

hair of cohorts of mothers in the years 2015-2019.

This data confirms the patterns seen in comparing

95percentiles values, the resilience of these metals in

the environment and the continuing assumption by

the population in the post-war context up to 5 years

from the last military attacks. They also confirm the

increase above the control values of titanium and

arsenic only from 2016.

The lack of correlation between mother exposure

with birth outcomes in 2018-19 is compatible with the

wider spread of heavy metals in the environment

during the disposal of war remains that made them

equally available to all. Chronic and diffuse exposure

to the environmental toxicants flattened the

differences in metal loads due to previous recent or

locally confined sources of exposure. The wider

spread of contaminants in the environment

"equalized" and stabilized at a high level the

stochastic chances of negative events occurring

during pregnancy

Analysis of the subgroup of newborn with birth

defect in 2016 showed the presence of a higher load

of titanium in their hair than in those of normal or

preterm babies. Titanium, and Arsenic 95 percentile

values were not different that control in the cohort

tested only 6-9 months after the attacks of 2014, but

their 95percentile values increased since 2016; the

median values for Ti increased in 2016 and median

values for As in 2018, as shown above in Tables X

and XI.

In 2016, there was association of BD newborn

with higher load in titanium than in the group of

preterm babies, and with a slightly higher load in

mercury, as previously found in 2011; preterm babies

had higher loads than normal babies for a number of

metals, noticeably including barium.

Table 12: Metal load in newborn hair in the year 2016 total

sample is 60. Amounts in ppb are shown, for BD and

preterm newborns and these are compared to each other and

highlighted, in yellow= more than 2 fold, in grey more than

1,5 folds.

In 2011 the value in ppb amounts of mercury (0.93

ppb) was higher than in 2016, but in both years was

higher than in normal and preterm babies. The value

of barium amounts in preterm babies in 2011 and

2016 were similar (1,07 and 1,09 ppb). Tin was much

lower in 2016 in BD babies and for preterm babies,

compared to newborns in 2011.

Cadmium amounts did not change in time, while

chrome levels were 1,5 folds higher in 2016 than in

2011 only in preterm babies. Other metals tested 2011

did not differ in preterm or BD in their loads from

normal babies.

These data suggest that, while there is consistent

high load for some metals associated with BD or

preterm outcomes, there may also be a difference in

kind or/and amount of each metal in the weapons

remnants from each successive war, that can also

affect the negative outcomes at birth.

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4 DISCUSSION

To date, no study has been produced of surveillance

of reproductive health in any war area on a random

cohort of relevant size accompanied by systematic

parallel investigation of human contamination by

heavy metals delivered by weapons and by objective

verification of individual's exposures to war-related

events, or of newborn contamination by heavy metals

related to the kind of negative outcome at birth.

Also, there was no previous proof of fact and

characterization of heavy metals delivered in the

wounds by white phosphorus ammunitions and by

not-fragmenting ammunitions, both weapons used in

Gaza.

The main points of force and the novelty of the

study are the consistent methodological approach of

its design and data collection, its time frame allowing

diachronic vision of the data, the multidisciplinary

sources of information from which it draws.

Lack of these elements in previous reports, may

be due to the limitations posed, by intrinsic and

extrinsic factors, to investigations in a war or afterwar

area.

4.1 Methodology in Data Collection

and Multidisciplinarity

Methodologically, epidemiological studies on

random cohorts of size adequate to the questions

investigated, are the best if not the only way to

eliminate biases. The elaboration of an appropriate

questionnaire for birth survey, inclusive of

environmental questions focused to the contemporary

local context, in addition to the Eurocrat or WHO

format, allows to ascertain synchronically the

contribution of diverse environmental factors to

reproductive health, and measure of metal

contamination on the same random subset of

population in which the epidemiologic outcomes are

registered allows correlations between the two sets of

information.

Methodologic consistence made possible to

compare, diachronically, different sets of birth

surveys and epidemiologic data, including the

objectively verified recall of exposures by the

individuals, and of measures of contamination by

heavy metals.

The knowledge of the environmental situation and

of its changes in time has been most valuable.

Consultation with experts in other fields allowed to

acquire knowledge often neglected or unavailable in

this type of investigations, which proved very

valuable for integration of the questionaries of survey

in the course of the work, for validation of subjective

recalls, and for interpretation purposes.

The knowledge of the precise chronology of the

attacks and documentation of their places, and often

also of the weaponry used, allowed the validation of

recall of exposures by the women; that of the

modalities of disposal of debris and of the length of

time till they were unremoved, the modalities of

recycling and places where it occurred, and the

damages in the infrastructures, the lag in

reconstruction, have been important factors for

interpretation of the data in this study. The

multispecialty collaborations also made possible to

prove the delivery by weaponry to the ground in Gaza

of defined heavy metals, and to give proof of fact of

which of these metals are delivered in wounds.

The possibility we had to use a diachronic lens

proved important for interpretation of data. It was

very exceptional to have the privilege to pursue these

studies along many years and with many colleagues

in Gaza.

4.2 Summarizing and Concluding

The heavy metals delivered by various weaponry

were identified and, in the limited types of

ammunitions tested, were detected carcinogen,

fetotoxic and toxic metals. In the case of metals

embedded in the flesh at the site of the wound, they

imprinted a molecular signature different for each

type of clinically classified wound. Also white

phosphorus ammunition delivered heavy metals in

the wounds.

Nine months from the attacks in 2009, heavy

metals were found in the hair of 60% of children in a

random cohort covering all the Gaza strip.

At least since the first time they were tested for, in

2010, heavy metals delivered by weapons in the

environment were assumed by the population, and

since then there has been chronic exposure to war-

remnants of the civilians. The level of heavy metals

contamination in the population was shown to

increased immediately in the individuals exposed to

the 2014 military attack.

The measure of metal load in random cohorts of

women in Gaza showed all the time that were tested

since 2011, a higher 95 percentile value for metals

associated to weaponry, by comparison with the

reference, controls from outside the war area.

Molybdenum instead was always lower than controls

and titanium concentration increased over the control

only in 2016. A similar pattern was found comparing

in time of the median values of metal loads, thus

ruling out the eventual relevance of spike values,

Synchronic and Diachronic Investigation of the Long-Term Effects on Reproductive Health of Heavy Metals, Environmentally Stable

Military Remnants in Gaza, Palestine: A Summary

251

which confirmed a high background for weapon

related heavy metals since 2011.

Still, above the high background, differences were

found in the load of heavy. metals according to

exposures of the individuals to war related events and

their residence. Association with these exposures

persisted till 2016, when still 78% of the women

resided near the rubble generated by attacks but was

lost once the ruins were removed and pulverized in

open air by 2018, and when only 12% of women

resided near rubble. At this time the overall

background contamination did not decrease, but the

association between previous exposure and amount of

individual contamination was lost.

The unchanged high load in metals in the

population before and after removal of the war-

remnants showed that environmental “remediation

with reuse" of the war-remains, which was the only

way accessible under siege and space confinement,

may have contributed to the spread of contamination,

but hardly to its decrease.

The role of exposure to attacks and war remnants

on reproductive health was shown using more than

one approach.

First, in general, the increase in prevalence in

negative birth outcomes bridged wars. Spanning both

the war in 2009 and the couple of wars 2012 and 2014

significant increase in BD was registered; also,

prevalence in preterm births spiraled by 2016.

More in detail, the women with objectively

documented exposures to military attacks or/and war

remnants were those with higher probability to have

a BD baby or preterm delivery and had the higher load

in many heavy metals than their unexposed

concitizens. This was associated to chronic

assumption of metals, given that in all cases the

women had kept residence for about 2 years in the

same place of the attacks and of war remains thereof.

The cohort of 502 women tested for their metal

load in the immediacy of the attacks in 2014 was not

large enough to draw conclusions on the immediate

effect of birth outcome of acute exposure to these.

The prevalence of negative birth outcomes

remained in 2018-19 at the same level as in 2016,

suggesting that by then a threshold level of

"environmental factors", capable to sustain an

unabated stochastic chance of negative birth outcome,

was reached. At this time no association was found

between recall of previous exposure to attacks or

dwelling near rubble with birth outcome.

Chronic contamination of the mothers was

accompanied, to differing extent for each metal, to

passage in utero. Excess load of some metals was

found specifically associated in the hair of newborns

either with BD or preterm outcomes.

Some contaminants associated specifically with

BD or preterm were the same metals in comparable

amounts in 2011 and 2016; these were respectively

mercury and barium. and both times of testing were 2

years after a previous severe military attack.

Mercury was confirmed as inducer/co-inducer of

BD, based on its high load specifically in hair of BD

newborns, on the high load in the hair of mothers

exposed to military attacks and war remnants in

association with the higher incidence of BD progeny

in this subgroup. Mercury remained significantly high

compared to references controls throughout the years

in the population, in parallel with high frequency of

BD.

Barium was confirmed as inducer/co-inducer of

preterm births, based on its high load specifically in

hair of newborns of mothers exposed to weapons and

military remains in 2011 and 2016. Barium remained

significantly high in the population compared to

references controls throughout the years, in parallel

with higher frequency of preterm newborns.

In addition to high load of mercury for BD and of

barium for preterm in 2011 and 2016, other

contaminants were found in 2016 in newborns hair;

specifically associated with BD, was titanium which

was found in higher amounts than before in 2016;

specifically associated with preterm were arsenic and

chrome, also toxicants. Cadmium was not higher in

the hair of BD or preterm babies in 2011, while was

higher than normal in that of preterm babies in 2016.

No comparison was possible between 2011 and 2016,

for uranium and vanadium also higher in preterm in

2016, since these were not measured in 2011. Both

these last metals do not trespass quantitatively the

placenta but may have a role on the physiology of the

mother, as does barium, and influence women

capability to carry to term the pregnancy.

Recently Huang, 2021, examined in a cohort of

Bangladeshi women the load for 56 metals and

reported barium, titanium, and arsenic to be

associated with preterm birth, but did not distinguish

BD babies.

The relevance as direct effectors on BD and

preterm outcomes of the heavy metals can be

understood based on the known characteristic of their

action and the epigenetic regulation of prenatal

development by environmental factors [Perera, 2020;

Toraño, 2016

; Dabre, 2006; Granijean , 2015; Cui,

2004)].

It is not known if other heavy metals, also

chronically present in high amounts in the whole

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population in Gaza, may act in synergy with the ones

above in inducing effects on developmental health.

Thus, the use of diachronic lenses allowed to

confirm which if the various metals detected as

weapon-remnants may have a decisive role in

determining the negative reproductive outcomes,

even in compresence with other heavy metals

contaminants, but also to visualize the possible "novel

"relevance of metal effectors introduced, in kind or in

relative amounts, through weapons modernization, as

Gaza has been a "work in progress" as to the use of

weaponry for the Israeli army.

Higher prevalence of BD and preterm babies since

after 2011 translated in increase in newborn and

infant death (Maartje, 2015), with costs for families

and health care, and misery for parents and the

affected child, even more pronounced when, as in

Gaza, the possible interventions are themselves

limited by the circumstances of the siege, imposing

scarcity in economy, in medical and welfare supplies,

and limitations in professional training. These

limitations continue to endanger the chances of care

for the BD and babies born preterm that survive.

From these data, the level of increase in Gaza of

major BD and preterm babies since 2011 translated in

increase of about 1700/year additional newborn and

infant deaths.

In addition, has been reported that the further

development of children can be affected at various

stages and levels (Vänskä, 2019) by Gaza's

contaminated environment, as it happens in other

places (Alvarado-Cruz, 2018); this is an issue that

requires further studies and follow up.

Today, after another war in 2021 and the

"preventive" attacks in 2022, the contamination by

weapon remains will have increase, and the

probability of heavy metals inducing negative birth

outcomes may also have increased.

Finally, and the high load of heavy metals in the

population may be also an effector of the reported

increase in prevalence in Gaza of various non-

communicable disease, infertility, cancers, and

infective multiple antibiotic-resistant pathogens,

affecting people of all ages and sex.

The population in the world whose health might

be affected by negative long-term effects of the metal

war-remnants amounts to some hundred million of

people, and apparently war lords never take a break,

while our common environment and bases of health

continue to be devastated.

In a better world, where science could follow-up

its work smoothly, and medicine could support the

necessary development of safe care, the information

provided here would be translated in actions.

Although main molecular mechanisms were

already identified in vitro for the action of heavy

metals, which include the accumulation of excessive

reactive oxygen species, DNA damage, and over-

activation of signaling pathways, shortening of

telomeres, estrogen like action, binding to

macromolecules and interference with key structural

and enzymatic proteins, further investigations are

needed on the role of the metals “candidate” here as

inducers of BD, by testing their ability to affect cell

differentiation, communication and growth and in

model mammal's systems should be studied, in

particular eventual key stages of the development

during embryo an fetal development, the interference

of heavy metals and the effects of exposure on the

physiology of the placenta and on the proceeding of

the pregnancy; it is needed to search for molecular

biomarkers that result from exposure in vivo and

which could be used to alert of the risks before/during

human pregnancy. This work is costly and requires

structured labs and, first of all, attention to the issue.

But, in general, is possible at the state of the global

art.

Meanwhile, it is necessary that clinicians identify

substances potential “candidates for remediation” at

first among the available pharmacopeia, e.g. among

substance already widely used in pediatric age, tested

for long time of usage, for lack of side effects on

women, pregnancies, infants, and children; these

should be molecules off-patent, and widely produced

or product-able, so potentially affordable for

prevention on population scale also in countries that

have been already afflicted by wars.

At the same time, and in the better world that is

surely coming, the documented testimony of long-

term health damages by war-remnants presented here

could catch the attention of the human right advocates

and lawmakers and be considered as proof of fact of

illegitimate use of weaponry with indiscriminate ray

of action and documented consequences affecting

civilians at large and used for whatever legal and

international law implications there can be.

ACKNOWLEDGMENTS

First thanks go to the women that participated giving

their time and attention and permission to elaborate

their answers to a questionnaire and to take samples

of hair.

The list of colleagues that contributed to the

acquisition of data and their elaboration in this report

is very long; in alphabetic order: Abdallah, H., Abu

Abadi, D., Dr. Abed Y., Abu Hamad,G., Abu Mosa,

Synchronic and Diachronic Investigation of the Long-Term Effects on Reproductive Health of Heavy Metals, Environmentally Stable

Military Remnants in Gaza, Palestine: A Summary

253

T., Dr. Abu-Shaban, N., Dr. Abu-Shaban. N., Dr. Al

Baraquoni, L., Dr. Albarqouni, N.M.A., Al Dalies,

H., Al Meziny, K., Al Shawwa, R., Balousha, S., Dr.

Barbieri, M., Dr. Barbieri,M.,Dr. Diab,S.Y., El

Balawi, M., El Shawwa, R., Dr. Giani, U., Dr.

Minutolo, R., Miqdad,H., Mohammed, W.,

Myöhänen,, A., Eng.Naim, A., Dr. Parodi,

Dr.S.Perko, K., Dr. Punamäki, R.L, Dr. Qouta, S.R.,

Salah, M., Salem, E., Dr. Signoriello, S. Dr. Skaik, S.,

Dr. Vänskä, M.

Thanks for permissions and the support to 3

successive Ministers of Health in Gaza, Dr Naim B.,

Dr. Dr M.Mokallathi, peace be upon him, who

allowed to start the research when Dean of the

Medical Faculty of the Islamic University of Gaza,

Dr. Raysh Y., and gratitude to the UN Mine Action

team, to the EQA, Agency of the Environment in

Gaza, for sharing insights and information, to

UNRWA for valuable consulting, and to a number of

colleagues in Europe that supported with scientific,

pragmatical and moral advice the research all along.

The research was according to the Ethical

principles of the Helsinki convention, was approved

by the Ethical committee of the Islamic University of

Gaza and was done under permission of the Gaza

Ministry of Health.

Funds were: Italian Cooperation to P.M-, Interpal

UK to P.M, Jacobs foundation #5585within a

collaborative project with Tampere university, and all

along through the donations of benevolent individuals

or associations that support health and welfare for

Palestinians to the association NWRG, to whom goes

our gratitude.

I declare no conflict of interest of any kind.

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