Iraqi missile attacks on Israel. The association of mortality with a life-threatening stressor

JAMA. 1995 Apr 19;273(15):1208-10. doi: 10.1001/jama.273.15.1208.


Objective: The imminent deadline for the 1991 Persian Gulf War and, subsequently, the 18 missile attacks by Iraq on Israel represented an unusual, short-term, life-threatening stressor for an entire nation. We studied mortality in Israel in January and February 1991 to determine whether excess deaths were precipitated on days of missile attacks.

Design: A time-series mortality study.

Setting: The state of Israel.

Participants: All Israelis aged 25 years and older.

Main outcome measure: Daily mortality by sex, age, region, underlying cause, and place of death.

Results: On January 18, 1991, the day of the first strike on Israeli cities, a 58% increment in total mortality occurred in the Israeli population (95% confidence interval [CI], 34% to 86%; P < .0001), a 77% excess (95% CI, 40% to 120%) in women and a 41% excess (95% CI, 10% to 79%) in men. This excess mortality occurred largely in the targeted Tel Aviv-central coastal plain and Haifa regions from cardiovascular causes and mainly out of hospital, significantly more so (P < .01) in women than men. Subsequently, on 16 attack days no overall excess was noted, yet a 10% increase in out-of-hospital deaths occurred.

Conclusions: Likely explanations for the initial increase in mortality include acute emotional stress coupled with breathing difficulties induced by gas masks and extended stay in sealed rooms with resultant hypoxia in susceptible individuals. Women were more vulnerable than men. The absence of elevated total mortality in the subsequent attacks suggests a rapid adaptation to the circumstances surrounding the war. The policy of an unventilated sealed room may have been detrimental.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Air Pollution, Indoor
  • Cardiovascular Diseases / mortality
  • Chemical Warfare* / psychology
  • Equipment Failure
  • Female
  • Humans
  • Hypoxia / etiology
  • Hypoxia / mortality
  • Iraq
  • Israel / epidemiology
  • Male
  • Middle Aged
  • Morbidity
  • Mortality* / trends
  • Respiratory Protective Devices / adverse effects
  • Sex Distribution
  • Stress, Psychological* / mortality