Sir--Belgium has been at the centre of attention in recent weeks, first with the dioxin contamination of chicken and then with the Coca-Cola crisis. On June 8, 26 children from one school developed nausea, headache, fatigue, palpitations, abdominal discomfort, and malaise after having drunk bottled Coca-Cola. They were taken by ambulance to a hospital where 18 remained for observation. Over the next 2 days, several other children from the same school were also taken to hospital. On the evening news of June 9 it was announced that Coca-Cola was recalling the incriminated product. From then on, similar episodes linked to the drinking of various types of Coca-Cola beverages occurred in other schools and individuals; most complaints consisted of vague constitutional symptoms and were transient. Neither physical findings nor laboratory results revealed any significant abnormality. However, one case of intravascular haemolysis was tentatively attributed to Coca-Cola. All this was the subject of intense media coverage. The national health authorities took measures to forbid the sale of all Coca-Cola products. Hundreds of people contacted the National Poison Centre to report complaints after having drunk Coca-Cola beverages. Cases of "poisoning" were also reported from northern France. Careful review of laboratory reports in alleged cases of haemolysis indicated that these claims were unsubstantiated. The diagnosis of intravascular haemolysis was based on the finding of a slightly raised plasma haemoglobin (possibly artefactual), but there were no other indications of intravascular or extravascular haemolysis.
On June 15, the Coca-Cola company announced that they had identified two causes for this outbreak. In the bottles from one Belgian plant, "bad carbon dioxide" was to blame and a "fungicide" applied on transport pallets had contaminated the outside of some cans from another plant. Coca-Cola submitted the results of independent chemical analyses to one of us (DL) for toxicological advice. The analyses revealed the presence in some bottles of very low, but odorous amounts of hydrogen sulphide (about 5-15 ppb), possibly originating from the hydrolysis of carbonyl sulphide. Small amounts of 4-chloro-3-methylphenol were found on the outside of some cans (about 0·4 µg/can). In both cases, it is unlikely that such concentrations caused any toxicity beyond an abnormal odour. No other notable chemicals had been found.
Many features of this outbreak point to mass sociogenic illness (MSI), described as "a constellation of symptoms of an organic illness, but without identifiable cause, which occurs among two or more persons who share beliefs related to those symptoms".1 MSI has occurred in schools, workplaces, and in communities under intense political pressure.2-4 MSI outbreaks are characterised1-4 by the preponderance of illness among female preadolescents, transmission by the media, health professionals, social and family networks, and the telephone; absence of illness among other groups in the same environment (eg, one or two classes out of many), presence of unusual physical or mental stress among those reporting illness, benign morbidity including hyperventilation, rapid spread and resolution, with possible relapses in the setting of the original outbreak. The outbreak is triggered by exposure to non-toxic amounts of aversive chemicals and occurs on a background of stress in a population. These criteria are not all necessary, but are typical attributes of MSI.1 Conversely, their sole presence is not proof of MSI.5 In the present context, the most significant features appear to be the initial occurrence among school children, the intense media coverage, the lack of epidemiological and toxicological plausibility, and the background of high awareness and even anxiety about the safety of modern foods caused by the dioxin crisis. It is probably significant that a company with such a high visibility and symbolic image was involved in this episode. Besides the important role of the media, the scale of the outbreak may have been amplified by the radical measures taken by the health authorities, who had been previously accused of mismanagement of the dioxin crisis, as well as by the deficient communication by the Coca-Cola company.
We propose that the outbreak of Coca-Cola-related health complaints in Belgium can be attributed to acute somatisation. The remarkable consistency of the reported complaints, as well as the context of anxiety and upheaval about the safety of modern foods, points to a diagnosis of MSI. We are strong proponents of the precautionary principle that must govern public-health policies in matters of food and environment. However, in the present instance there is reason to believe that most health complaints are due to acute somatisation. The value of proposing this diagnosis is to recognise that victims (in this case the community) need social healing and not medical cure. Previous episodes of MSI have shown that an essential determinant in the resolution of such outbreaks is rapid and appropriate reassurance by the medical profession that there is no imminent danger to the community. This must be complemented by further thorough and transparent investigation.
The authors are members or have been advisors to the Health Council ("Hoge Gezondheidsraad--Conseil Supérieur de l'Hygiène") of the Federal Ministry of Health and Social Affairs, but the above opinions are their own. There are no conflicts of interest that have influenced these opinions.
*Benoit Nemery, Benjamin Fischler, Marc Boogaerts, Dominique Lison
Departments of *Occupational Medicine and Pneumology, Psychiatry,and Haematology, Katholieke Universiteit Leuven, B-3000 Leuven, Belgium; and Industrial Toxicology and Occupational Medicine, Université Catholique de Louvain, Brussels (e-mail: ben.nemery@med.kuleuven .ac.be)
1 Philen RM, Kilbourne EM, McKinley TW, Parrish RG. Mass sociogenic illness by proxy: parentally reported epidemic in an elementary school. Lancet 1989, ii: 1372-76.
2 Modan B, Swartz TA, Weissenberg E, Landrigan P, Miller B, et al. The Arjenyattah epidemic. Lancet 1983; ii: 1472-76.
3 Barron RA, Leaning J, Rumack BH. The catastrophe reaction syndrome: trauma in Tbilissi. Int J Law Psychiatry 1993; 16: 403-26.
4 Hay A, Foran J. Yugoslavia: poisoning or epidemic hysteria in Kosovo? Lancet 1991; 338: 1196.
5 Aldous JC, Ellam GA, Murray V, Pike G. An outbreak of illness among schoolchildren in London: Toxic poisoning not mass hysteria. J Epidemiol Community Health 1994; 48: 41-45.
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