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The wages of war
By Ruth SoRelle, MPH

It is ironic that as the United States stands poised on the brink of a controversial war with Iraq that the Institute of Medicine has arrived at a conclusion about one that was taking place 40 years ago.

In the late 1970s and early 1980s, much heat was generated over the effects of the defoliant Agent Orange and one of its contaminants - dioxin. Many of those who fought in Vietnam and many of those who lived there have, over the years, attributed a host of health effects to exposure to this chemical that was sprayed over the jungle landscape during that divisive conflict.

Previously, Hodgkin's and non-Hodgkin's lymphoma had been associated with exposure to the herbicide and now the Institute of Medicine has reassessed studies of the effects of the chemicals and decided that a form of blood malignancy called chronic lymphocytic leukemia, which shares many traits with the lymphomas, can also be associated with exposure to the herbicide.

Nothing has changed in the studies of cancer rates, but the understanding of how cancer itself occurs has changed dramatically in the time that studies have taken place. Both this type of leukemia and the lymphomas originate from part of the immune system called the B-cells. When these cells mutate and become malignant, they can become cancers. Chronic lymphocytic leukemia can also transform into an aggressive non-Hodgkin's lymphomas known as Richter's Syndrome.

As Irva Hertz-Picciotto, PhD, MPH, professor of epidemiology at the University of North Carolina at Chapel Hill and University of California at Davis as well as chairman of the IOM committee, noted: "The similarities between CLL (chronic lymphocytic leukemia) and lymphomas -- which we have long known to be associated with exposure to the types of chemicals used in Agent Orange and other defoliants -- began to raise questions about whether CLL should be considered separately from other forms of leukemia."

In its new assessment, the IOM committee evaluated six studies that looked at a variety of cancer rates, including those of specific leukemias, among agricultural workers exposed to herbicides and among people who live in areas where such herbicides were commonly used. The leukemia risk was found in those whose worked in fields and were exposed as well as those who handled these chemicals that stripped the vegetation from the landscape?

How many Vietnam-era soldiers suffered chronic lymphocytic leukemia because of their exposure to herbicides? No one can tell. Maps of when, where and how much herbicide was used in particular locations are inaccurate, incomplete and difficult to interpret. Pinpointing the risk of a particular G.I. from that period of time would be almost impossible. Scientists must extrapolate information from exposed civilians to the situations of soldiers -inexact science at the best. Who, however, is to say that it will not become more exact in the future.

With 7,000 new cases diagnosed annually in the United States, chronic lymphocytic leukemia is the most common form of the rare diseases lumped under the term of leukemia. It joins the two types of lymphomas, soft-tissue sarcomas (forms of tumors) and chloracne (a skin condition) as diseases for which there is evidence of a link to Agent Orange. There are other diseases in which the evidence is considered "suggestive" but not proven.

Forty years after a war, scientists are still determining its effects on those who were involved. As the nation considers another, it is important to recognize that the consequences of conflict are not always apparent and that the cost of war is often paid tens of years into the future.

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