Bull Environ Contam Toxicol (2012) 89:937–944 DU & the Epidemic of Congenital Birth Defects in Iraqi Cities

Source: http://www.springerlink.com/content/u35001451t13g645/fulltext.pdf?MUD=MP

Metal Contamination and the Epidemic of Congenital Birth
Defects in Iraqi Cities
M. Al-Sabbak • S. Sadik Ali • O. Savabi •
G. Savabi • S. Dastgiri • M. Savabieasfahani

M. Al-Sabbak ! S. Sadik Ali
Department of Obstetrics and Gynecology, Al Basrah Maternity
Hospital, Al Basrah Medical School, P.O. Box 1633,
Basrah, Iraq
O. Savabi ! G. Savabi
Department of Prosthodontics, School of Dentistry, Isfahan
University of Medical Sciences, Isfahan, Iran
S. Dastgiri
National Public Health Management Center, School of
Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
M. Savabieasfahani (&)
School of Public Health, University of Michigan, 1415
Washington Heights, EHS Room Number M6016, Ann Arbor,
MI 48109-2029, USA
e-mail: mozhgan@umich.edu

Received: 27 July 2012 / Accepted: 30 August 2012 / Published online: 16 September 2012
Ó The Author(s) 2012. This article is published with open access at Springerlink.com

Abstract Between October 1994 and October 1995, the
number of birth defects per 1,000 live births in Al Basrah
Maternity Hospital was 1.37. In 2003, the number of birth
defects in Al Basrah Maternity Hospital was 23 per 1,000 live
births. Within less than a decade, the occurrence of congenital
birth defects increased by an astonishing 17-fold in
the same hospital. A yearly account of the occurrence and
types of birth defects, between 2003 and 2011, in Al Basrah
Maternity Hospital, was reported. Metal levels in hair, toenail,
and tooth samples of residents of Al Basrah were also
provided. The enamel portion of the deciduous tooth from a
child with birth defects from Al Basrah (4.19 lg/g) had
nearly three times higher lead than the whole teeth of children
living in unimpacted areas. Lead was 1.4 times higher in
the tooth enamel of parents of children with birth defects
(2,497 ± 1,400 lg/g, mean ± SD) compared to parents of
normal children (1,826 ± 1,819 lg/g). Our data suggested
that birth defects in the Iraqi cities of Al Basrah (in the south
of Iraq) and Fallujah (in central Iraq) are mainly folate
This knowledge offers possible treatment options
and remediation plans for at-risk Iraqi populations.
Keywords Iraq ! Metal exposure ! Human birth defects ! Folate-dependent birth defects

It is old knowledge that exposure to chemicals can harm
human reproduction. Ancient Romans were aware that
lead (Pb) poisoning can cause miscarriage and infertility
(Gilfillan 1965; Retief and Cilliers 2006). Today it is well
established that human pregnancy and fetal development
are susceptible to parents’ environmental exposure to
chemical, biological and physical agents (Mattison 2010).
A new concept of the developmental origins of health and
disease has also emerged which is defined as the process
through which the prenatal environment, or the environment
during infancy, shapes the long-term control of tissue
physiology and homeostasis (Barker 2004). We know that
even slight perturbations caused by chemical exposures
during sensitive periods of fetal development can lead to
increased risks of disease throughout the life of an individual
(Sutton et al. 2010).
Pregnant mothers and their growing fetuses are especially
vulnerable to exposure to pollutants. Air and water
pollution, exposure to toxic metals, and exposure to persistent
and volatile organics have been linked to adverse
pregnancy and developmental outcomes (Landrigan et al.
2004; Bocskay et al. 2005). Recently, an unusual number
of birth defects, in many bombarded Iraqi cities, has raised
international concern and a few relevant studies have been
published (Alaani et al. 2011a; 2011b; Al-Ani et al. 2010).
Following bombardment, severe contamination of water,
soil, and air can occur. Metal contamination of the public
after bombardment has been reported (Jergovic et al.
2010). Jergovic et al. (2010) examined the blood serum
metal content of the Croatian population in areas with
‘‘moderate fighting’’ versus ‘‘heavy fighting’’. They found
significantly higher levels of metals in populations from
areas with heavy fighting. Those areas had been targeted
for repeated bombardments by the North Atlantic Treaty
Organization in 1991 and 1995. Various metals are contained
in US small arms ammunition, and are contained in
US bombs (Departments of the Army, the Navy, the Air
Force, Joint Technical Bulletin, 1998; US Department of
the Army Technical Manual, 1990).
Intermittent bombing of populated cities in Iraq has
occurred since 1991. Most significant was the bombardment
of Fallujah, a city in central Iraq, and Al Basrah, a city in
southern Iraq. Fallujah was heavily bombed in 2004. Subsequently,
unusual numbers of birth defects have been surfacing
in that city. Al Basrah was also a target of heavy bombing
(December 1998, March and April 2003). Similar to Fallujah,
after the 2003 invasion and occupation of Iraq, the medical
staff in Al Basrah Maternity Hospital has been witnessing a
pattern of increase in congenital birth defects. Based on these
observations, many suspect that pollution created by the
bombardment of Iraqi cities has caused the current birth
defect crisis in that country (Al-Hadithi et al. 2012).
In the present article, we have reported on 56 Fallujah
families’ hair metal levels and the kinds of birth defects
documented in these families. The Fallujah study was
conducted in 2010. We have also presented a year-to-year
account of the types and numbers of birth defects in Al
Basrah Maternity Hospital from 2003 to 2011. Our aim was
to examine the populations of Fallujah and Al Basrah for
possible metal exposure. In our samples from Al Basrah,
we were looking at three tissues (hair, toenail, and teeth)
and wanted to determine which tissue provides a better
medium for metal analysis.
Materials and Methods
Between May and August 2010, 56 Fallujah families were
recruited into an epidemiological ‘‘case study’’ project.
Cases (n = 46) and controls (n = 10) had come to Fallujah
General Hospital for delivery or treatment. Using a questionnaire,
information on reproductive history of families
and the parents’ siblings, residence history, health and
disease during pregnancy, drug use during pregnancy,
smoking and alcohol use, source of water for the family,
and exposure to potential war contaminants was collected.
Hair samples were collected from all members of the
family (mothers, fathers and the children) and patient
consent was obtained at the same time. Participants had
lived continuously in Fallujah since 1991. Percentages of
birth defects and miscarriages were determined (Fig. 1);
grouping of the years was based on ‘‘before’’ and ‘‘after’’
the 2003 attacks. For the period of 2003 onward, we used
3-year intervals. The remaining single-year data, from
2010, was added to the last group. For each of the groups,
the percentages of birth defects and miscarriages were
determined by totaling live births and multiplying that
figure by 100, then dividing the value by the total number
of birth defects or miscarriages, respectively. The metal
content of hair samples was determined by inductively
coupled plasma mass spectrometry (ICPMS). We collected
hair rather than blood samples, since it is difficult to obtain
and transport blood samples in a war zone.
In Al Basrah, records of the Department of Obstetrics
and Gynecology at Al Basrah Maternity Hospital were
examined for numbers and types of diagnosed and reported
birth defects during 1994 and then from 2003 to 2011
(Table 1). Birth defects in the newborns were diagnosed by
certified medical doctors. Additionally, between September
2011 and January 2012, twenty-eight families who had
come to Al Basrah Maternity Hospital for treatment or
delivery were recruited into this study by local physicians
and patient consent was obtained. Hair and toenail samples
were collected from two groups: parents who recently had
a child with a birth defect (n = 14); and parents who had a
normal child (n = 14). Only 6 samples of hair and 6
samples of toenails from parents of children with defects
were sufficient in weight to be analyzed for metal levels.
Tooth samples were simultaneously collected at the Al
Basrah Dental School from parents of normal children
(n = 10) and parents of children with cardiac and neural
tube defects (n = 12). Only 5 of each group had sufficient
and suitable tooth tissue for metal analysis. Parents did not
smoke or drink. Two samples of deciduous teeth were
collected from children with birth deformity who had
survived. Deciduous teeth from normal children were
provided by the School of Dentistry at Isfahan University
of Medical Sciences (n = 18, two samples were analyzed).
Patient/parental consent was obtained.
Hair samples’ treatment, digestion and their analysis for
Fallujah samples followed Batista et al. 2009 without
modification. XSERIES 2 ICP-MS (Thermo Fisher Scientific,
Germany) was used in the standard configuration,
with ASX-510 auto-sampler (Cetac, USA). Instrument
optimization was by auto-tune function, when required.
The instrument parameters were: RF Power (W) 1400,
Cool Gas Flow (L/min) 13, Auxiliary Gas Flow (L/min)
0.8, Nebuliser Gas Flow (L/min) 0.85–0.90, Sample
Uptake Rate (mL/min) 0.4 approx., Sample Introduction
System Concentric nebuliser with low-volume impact bead
spray chamber (not cooled) and one-piece torch (1.5 mm
ID injector); Cones Nickel, Xi Design; Detector Simultaneous
pulse/analogue; Uptake Time 25 s at 50 rpm; Stabilization
Delay 10 s at 17 rpm; Wash Time 40 s at
50 rpm, Survey Runs 1—scanning; Main Runs 3—peak
jumping; Number of Points per Peak 1; Dwell Time/Point
5—50 ms; Number of Sweeps/Replicate 25. Internal
Standardization Technique Interpolation, using 6Li, 45Sc,
115In, 159 Tb. Total Time per Sample 2:45 min.
Toenail and hair samples from Al Basrah were prepared
and analyzed as follows: All reagents used were analytical
grade or better. All aqueous solutions were prepared using
deionised water (18.2 MX Millipore, UK). A multi-element
standard and single element standard for the internal
standards (SPEX CertiPrep, UK) were used as calibration
standard and internal standard respectively for ICP-MS
analysis. Concentrated nitric acid (HNO3) and 30% v/v
hydrogen peroxide (H2O2), (BDH Aristar,UK) were used
for the dissolution of samples. Analyses of toenail and hair
samples were conducted at the Inorganic Geochemistry
laboratories of the British Geological Survey (Nottingham,
UK). Toenail and hair samples were washed thoroughly
following a slightly modified version of the protocol
described by Button et al. (2009), which is comparable to
several published methods (Slotnick et al. 2007). Visible
exogenous material was firstly removed using plastic forceps
and a clean quartz fragment. Samples were then
placed in clean glass vials and sonicated for 5 min using
3 mL of acetone, rinsed first with 2 mL of deionised water
then 2 mL of acetone, sonicated for 10 min in 3 mL of
deionised water then twice rinsed with 3 mL of deionised
water, ensuring complete submersion of the sample during
each step. The final rinse solution (3 mL) was retained for
immediate analysis by ICP-MS to ensure removal of
exogenous contamination was complete. The supernatants
from each step of the washing procedure were combined
and reduced to dryness in PFA vials (Savillex, USA) on a
graphite hot block at 80″C. The residue was then reconstituted
in 3 mL of 1% HNO3 for analysis by ICP-MS.
After washing, toenails were left to dry at room temperature
in a clean laminar flow hood. Certified reference
materials GBW 07601 human hair and1 and NCS ZC
81002b human hair (NCS Beijing, China) were used
Both the digestion and analytical method follow the
procedure described in Button et al. (2009). Toenail samples
were acid digested for total elemental determination
using a closed vessel microwave assisted digestion (MARS
5, CEM Corporation, UK). Into each vessel 4 mL of HNO3
and 1 mL of H2O2 was added to accurately weighed toenail
and hair samples and left to stand for 30 min before
sealing the vessels. The microwave heating program was:
100% power (1,200 W), 5 min ramp to 100″C, held for
2 min, ramped for 5 min to 200″C then held for 30 min.
The pressure in the system was approximately 200 psi
under these conditions. This method resulted in complete
sample dissolution. The solutions were transferred with
MQ water to PFA vials and evaporated to dryness on a
hotplate at 110″C. Samples were reconstituted with 1 mL
of 3% v/v HNO3, heated at 50″C for 10 min and then made
up to 3 mL with deionised water to give a final solution of
1% HNO3 for direct determination via ICP-MS.
The enamel and coronal dentine components of teeth were
density separated using a heavy liquid method. This was
achieved by lightly crushing the decoronated tooth material
and adding the powder to the heavy liquid bromoform
(CHBr3) in a separating funnel. The bromoform was then
slowly diluted with acetone to achieve the optimal density for
enamel and dentine separation (2.7 g/mL). The enamel
formed sediment at the base of the funnel and was removed.
The two components were washedwith acetone and dried in a
laminar flowhood prior to dissolution. The teeth samples were
accurately weighed into acid washed polypropylene autosampler
tubes (Sarstedt), to which 0.2 mL of 2:1 HNO3:HCl
was added, allowed to dissolve over 5 min, then 0.8 mL of
deionised water added, left to stand for 10 min and then made
up to a final volume of 10 mL with deionised water. The
sample solutions were diluted approximately 94,000 prior
to analysis to ensure a final calcium concentration of
100–200 mg L-1, to avoid matrix interference and clogging
of the ICP cones and torch. The final matrix prior to analysis
contained 1 HNO3 and 0.5% HCl. Multielement analysis of
toenail, hair and teeth digests was performed by inductively
coupled plasma mass spectrometry (ICP-MS, Agilent 7500,
Agilent Technologies, UK). The instrument was fitted with a
micro flow concentric nebuliser and quartz Scott-type spray
chamber. The instrument response was optimised daily using
a commercially available Tune solution (SpexCertiprep).
Multielement analysis was performed in collision cell mode
using He (4 L/min) to minimise potential interferences such
as that of the polyatomic ion 40Ar ? 35Cl on 75As. An internal
standard comprising of Sc, Ge, Rh, In, Te, and Ir was added to
the sample line via a T-piece to monitor instrument signal
stability. The limit of detection (LOD) for the method
expressed as themean blank signal ? 3SDwas as follows:Al
and Fe\2 mg/kg; V, As, Se,Mo,Cd.01 mg/kg;Mnand
Zn.2 mg/kg; Co, Th and U.005 mg/kg; Cr, Ni, Cu,
W, and Pb were.07,.02,.1,.08,.03 mg/kg
respectively. Recoveries for both reference materials were
generally better than 100 ± 15% for when compared to
available reference values. SPSS version 19 was used for all
statistical analyses; an independent sample T Test was used to
compare metals between two groups. A paired sample two
tailed T Test was used to compare birth defects in Al Basrah
data. Significance level was set at a = 0.05.
Results and Discussion
It is well-known that exposure to stressors alters the in
utero development of a human fetus and has adverse health
consequences for the offspring, including a short gestation
period, reduced birth weight, increased risk of metabolic,
cardiac and psychiatric disease, and overall reduced lifespan
(Seckl 1998; Landrigan et al. 2004; Perera et al. 2004;
Llop et al. 2010). Populations caught in war-zones or
forced to live with severe nutritional restrictions (such as
those imposed on the Iraqi population by U.N. sanctions
from 1991 to 2003) suffer immediate and chronic stress
that leads to long-lasting physical and mental damage. In
addition to the harsh effects of sanctions, many Iraqi cities
have experienced large-scale bombardment. An accurate
tally of the types and volume of ammunition dropped on
the Iraqi population is not available. However, reports have
indicated that large numbers of bullets have been expended
into the Iraqi environment (Buncombe 2011). Thus the
environmental contamination of Iraqi cities with materials
contained in bullets and bombs may be expected. Toxic
metals such as mercury (Hg) and Pb are an integral part of
war ammunition and are extensively used in the making of
bullets and bombs (Departments of the Army, the Navy,
the Air Force, Joint Technical Bulletin 1998; US Department
of the Army Technical Manual 1990).
The case study of 56 Fallujah families and the metal
analysis of hair samples from this population indicated
public contamination with two well-known neurotoxic
metals, Pb and Hg. Hair metal data from Fallujah showed Pb
to be five times higher in the hair samples of children with
birth defects (n = 44; mean ± SD 56,434 ± 217,705 lg/
kg) than in the hair of normal children (n = 11; 11,277 ±
27,781 lg/kg). Mercury was six times higher (n = 44;
8,282 ± 25,844 lg/kg Vs n = 11; 1,414 ± 3,853 lg/kg)
(Fig. 3). Fallujah mothers who participated in this study did
not take any medication and described their diet as ‘‘good’’
during pregnancy. Only one couple was first cousins.
Mothers did not drink or smoke during pregnancy. All
families consumed water from local aqueducts or locally
bottled waters. Siblings of the parents had no history of
children with congenital defects. Figure 1 shows a chronological
increase in the percentages of birth defects and miscarriages
in these Fallujah families. Six photographs of
Fallujah children and their conditions are provided in Fig. 2.
Mercury and Pb, two toxic metals readily used in the manufacture
of present-day bullets and other ammunition, were 6
and 5 times higher in hair samples from Fallujah children
with birth defects compared to Fallujah children who
appeared normal (Fig. 3). Uranium, Hg and Pb, (lg/kg,
mean ± SD) in the hair samples of parents from Italy, Iran,
and Fallujah (Iraq), are shown in Fig. 4. Though statistically
not significant, the hair of parents of children with birth
defects had more uranium, Pb and Hg than the hair of parents
of normal children.
The most common abnormalities in Fallujah children
were congenital heart defects (n = 24 out of 46), neural
tube defects (n = 18 out of 46), and cleft lip/palate (n = 4
out of 46). Cardiac defects, neural tube defects, and facial
clefting are known as folate-dependent birth defects since
folate intake reduces their occurrence (MRC Vitamin
Study Research Group 1991; Wilson et al. 2003; Obican
et al. 2010). The Fallujah study has highlighted the role of
metals in the manifestation of the current birth defect
epidemic in that city. Recent data has linked metal exposure
to oxidative stress and folate deficiency in humans
(Wang et al. 2012). We also know that in utero metal
exposure can culminate in birth deformities by increasing
oxidative stress in the womb as the fetus grows (Apostoli
and Catalani 2011).
In general, reports of health problems in the Iraqi population
and in the surrounding countries have continued to
surface (Rajab et al. 2000). News of increases in childhood
cancers, of perinatal and infant morbidity and mortality,
and of unusual increases in congenital birth defects, have
continued to emerge from across Iraq. Data from a central
Iraqi city, Al-Ramadi, have corroborated the Fallujah
findings (Al-Ani et al. 2010).
Another Iraqi city where birth defects and cancers
continue to climb is Al Basrah.
The earliest data on the occurrence of congenital birth
defects in Al Basrah came from an article entitled ‘‘Incidence
of Congenital Fetal Anomaly in Al Basrah Maternity
Hospital’’ (Alsabbak et al. 1997). This research reported on
the total number of live births (10,015) in Al Basrah
Maternity Hospital between October 1994 and October
1995. The number of birth defects per 1,000 live births
during this period was 1.37. Table 1 contains the yearly
account of the number of birth defects per 1,000 live births
in Al Basrah Maternity Hospital from 2003 to 2011. Central
nervous system related defects occurred most frequently.
Statistical analysis of this data has shown no
significant difference between the number of children born
with anencephaly and the number born with Spina Bifida
(p = 0.28). There were significantly more cases of anencephaly
than of hydrocephalus, limb deformity, omphalocele,
or short extremities (p = 0.009, p = 0.005,
p = 0.000, p = 0.000). In addition, the number of Spina
Bifida cases was significantly higher than the number of
hydrocephalus, limb deformity, omphalocele, or short
extremity cases (p = 0.05, p = 0.005, p = 0.000,
p = 0.001). Within 8 years, the occurrence of congenital
birth defects in Al Basrah Maternity Hospital increased by
an astonishing 17-fold.
The prevalence of congenital hydrocephalus in California
(US) has been reported as 0.6 per 1,000 (Jeng et al.
2011). Worldwide hydrocephalus affects about one in
every 1,000 live births. The reported numbers of hydrocephalus
from Al Basrah Maternity Hospital were 3.5 times
higher than the world average and six times higher than in
the United States. Defects of the abdominal wall, like
omphalocele and gastroschisis, were also frequently
reported in Al Basrah. Omphalocele generally occurs in
0.25/1,000 live births and is associated with a high rate of
mortality and severe malformation, such as cardiac
anomalies and neural tube defects. The average number of
omphalocele observed in Al Basrah Maternity Hospital
between 2003 and 2011 was 3.3/1,000 live births.
Neural tube defects (NTDs) occur very early in human
development. The prevalence of NTDs in the mainland
United States is 1/1,000 live births (CDC; Williams et al.
2002). Some of the highest numbers of NTDs have been
reported from coal mining regions in China (10/1,000) (Li
et al. 2006). The occurrence of NTDs in Al Basrah (12/
1,000) is the highest ever reported and it is increasing. Our
data has shown that in Al Basrah, the total number of birth
defects more than doubled between 2003 and 2009.
A comparison between the metal levels in the hair
(n = 6) and toenail (n = 7) of parents of children with
birth defects from Al Basrah, and the associated p values,
has been presented in Table 2. For most metals (Al, Mn,
Co, Cu, Zn, Mo, Pb, Th, and U), hair contained significantly
higher amounts of the metal than did toenail, suggesting
that hair is a better biomarker of exposure.
Examining the Pb hair levels of parents from Al Basrah and
Fallujah revealed that the hair of parents of children with
birth defects in Al Basrah had 6,500 ± 8,589 (lg/kg); in
Fallujah this value was 3,950 ± 3,133 lg/kg; both values
being considerably higher than Pb found in the hair samples
of parents of normal children from Fallujah
(2,012 ± 2,052 lg/kg). The 1.6-fold higher Pb in the Al
Basrah parents’ hair compared to Fallujah parents’ hair
may be explained by the fact that Al Basrah is an oilindustry
dominated area whereas Fallujah is not. Overall,
parents of children with birth defects from Al Basrah and
Fallujah had twofold, and one-fold, higher Pb in their hair
than did parents of normal children respectively. Al Basrah
parents who had children with birth defects also had 1.4
times higher enamel Pb (n = 5, 2,497 ± 1,400) than did
parents of normal children (n = 5, 1,826 ± 1,619). Additional
samples of teeth from the parents of children with and
without birth defects from Al Basrah are necessary to help
draw reliable statistical conclusions for this population.
Table 3 contains a literature review of the metal levels
in whole deciduous teeth of children from different geographical
locations. Enamel is a hard and dense material
which is formed during fetal life and it receives small
amounts of systemic blood flow thereafter. For this reason
it is considered to primarily reflect prenatal exposure to
metals. Whole-tooth metal analysis would include enamel,
dentin, cementum, and dental pulp. The impact of living in
a large city with dangerous levels of air pollution is evident
in the high levels of Pb in teeth from Mexico City and
Karachi. Similarly, the level of Pb in teeth from Canadian
mining areas is indicative of an exposed or impacted
population. Mean whole tooth Pb reported from other
locations was 1.5 lg/g. Hence, the tooth Pb level of an
unimpacted population is more accurately estimated by this
1.5 lg/g value. The enamel portion of the deciduous tooth
from a child with birth defects from Al Basrah (4.19 lg/g)
had nearly three times higher Pb than the calculated value
for a whole tooth from an unimpacted population. Additional
samples of deciduous teeth from Al Basrah children
with birth defects are necessary to help draw reliable statistical
conclusions for this population. Samples of deciduous
teeth are currently being collected from impacted (Al
Basrah, Iraq) and unimpacted (Isfahan, Iran) areas to
enable us to draw meaningful conclusions in this regard.
Interestingly, mining, smelting, and living near industry or
hazardous waste sites have all been associated with an
increased risk of birth defects (Ahern et al. 2011; Zheng
et al. 2012; Suarez et al. 2007).
Present knowledge on the effects of prenatal exposure to
metals, combined with our results, suggests that the bombardment
of Al Basrah and Fallujah may have exacerbated
public exposure to metals, possibly culminating in the
current epidemic of birth defects. Large-scale epidemiological
studies are necessary to identify at-risk populations
in Iraq. The recognition that birth defects reported from
Iraq are mainly folate-dependent offers possible treatment
options to protect at-risk populations.
Acknowledgments We thank Drs. Hossein Malekafzali, Howard
Hu, and Timothy Johnson for their interest in this research. We thank
Drs. Vasantha Padmanabhan, Marjorie Treadwell, Kataneh Salari, for
their critical reading of this manuscript, and we thank Blaine Coleman
for technical assistance. Funding for this research was provided by the
University of Michigan Department of Obstetrics and Gynecology.
Open Access This article is distributed under the terms of the
Creative Commons Attribution License which permits any use, distribution,
and reproduction in any medium, provided the original
author(s) and the source are credited.
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End quote.

Tables and charts omitted. See original link

The fact that the authors do not have Swedish/Euro/Anglo names does not detract from the scientific integrity of the work, despite claims in some stuck up regions of the nuclear industry that it does.

One Response to “Bull Environ Contam Toxicol (2012) 89:937–944 DU & the Epidemic of Congenital Birth Defects in Iraqi Cities”

  1. CaptD Says:

    Yet more reasons to end ☢ assisted wars, the aftermath claims yet more innocents, and this problem will not go away anytime soon!

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