"Economy-class syndrome" a major health threat

Airlines fail to warn of the dangers of DVT

Last November Emma Christoffersen, aged 28, from Newport, South Wales, collapsed in the arrival hall of Heathrow airport after flying to England from Australia. She later died. A post mortem revealed the cause of death to be pulmonary embolism. “We were told she died from sitting in the cramped seat of a jumbo jet for such a long time,” her mother told the media. “I'd never heard of the condition ... I don't want other parents to go through what we have endured and that is why I want to give this warning about the danger of flying.”

Since Emma's death, several other cases of DVT (Deep Vein Thrombosis) have been reported. On December 10, an Australian law firm, Slater and Gordon, announced it was preparing compensation claims for victims of DVT against a number of major airlines including Qantas, Ansett, British Airways and Air France claiming they had failed to warn passengers of the risks. Within four weeks, 1,000 people joined the action, including relatives of 40 people who had died. A Perth firm followed, broadening the frame of reference of the case to include patients who contracted the condition while travelling by train across the continent from Australia's east coast to Western Australia.

The cases include:

* Helen-Marie Ghannage, 69, who began having breathing difficulties at Sydney Airport after leaving a Qantas flight from Paris last October. She collapsed at the exit gate and was unable to be revived. Medical staff blamed a blood clot that had formed in her leg and travelled to her lungs. A coroner later confirmed their diagnosis. Ghannage's death will form the cornerstone of the legal action.

* Thomas Lamb, who flew Singapore Airlines from Heathrow to Melbourne just one month later. Lamb complained of breathing difficulties after disembarking. He then lapsed into a coma and died on November 10 from a clot in his lungs.

* Rebecca Brown, who says she spent most of her European holiday three years ago in a London hospital after severe leg cramps on her flight from Australia to Heathrow turned out to be caused by blood clots. “The X-rays at hospital showed seven clots in my lungs which could have easily gone to my brain and killed me. I am totally amazed more people don't know how dangerous long distances can be,” said Brown, who will be suing British Airways.

* Stuart March, 30, who claims he suffered a clot in his left arm after a Qantas flight from Melbourne to Brisbane that lasted less than two hours. Marsh said, “I had a slightly tingly arm when I left the plane but I didn't think much of it. Over the next few days it swelled up like a big black balloon.” March eventually collapsed and was taken to hospital where he was treated with blood-thinning drugs that he continues to take. “Straight away they asked me if I had been on a plane,” he said.

* Alan McCarthy, 49, who collapsed in Australia after returning from Ireland. McCarthy told reporters, “I'd never even heard of this condition before and it annoys me to think I could have been warned about it before flying.”

DVT has been dubbed the "economy class syndrome" because it is thought that the reduced legroom for passengers in cheaper seats places them at greater risk of developing blood clots in the deep veins of the legs. Sitting motionless in cramped conditions for long periods of time can cause blood clots to form. When the passenger disembarks and becomes active again these clots can be swept into other parts of the body. If they lodge in vital organs, such as the lung (pulmonary embolus), they can be fatal.

Evidence is now coming to light that the airline industry has known about the dangers of DVT for more than 30 years. Recent reports in the British press reveal that doctors warned of the risks more than 30 years ago, but the airlines failed to institute precautionary measures.

According to the Observer, a scientific study was written on the condition in 1968. In 1985 a group of doctors working near Heathrow wrote to the medical journal Lancet reporting that they had treated large numbers of airline passengers suffering blood clots. “We see a steady stream of illnesses which have developed in flight. The major manifestation of the illness may not occur until after disembarkation. We have seen several patients with thromboembolism presenting in this way, with a near fatal outcome in one case.”

Slater and Gordon have released a letter of complaint sent to Qantas by a solicitor who developed DVT in 1989. After almost dying, he wrote the letter when his doctor told him that the blood clot was aviation-induced. Some eight weeks later, a Qantas corporate solicitor replied: “Qantas has not adopted any procedures to advise passengers of the alleged risks inherent in long periods of inactivity. To adopt procedures to cover a situation that is extremely unusual would not appear to be warranted at this time.”

According to Andrew Grech, manager of Slater and Gordon, a similar letter was written to an airline 10 years ago by a woman whose doctor had advised her that her clot could have been caused by a long-haul flight. “Obviously we have to verify the authenticity of those stories, but these people in particular have no motivation to lie about their experiences,” said Grech. “Time has long since passed the point where the woman could claim compensation.”

Qantas has so far not responded to these claims, other than to repeat that the company has increased the amount of information made available to passengers about in-flight health and that it carries exercise information on its web site and in-flight audio program. A spokesman declared that Qantas was about to substantially upgrade its warnings about DVT to include wearing loose clothing, eating less and reducing alcohol intake.

Australian Federal Labor MP Neil O'Keefe told the Sydney Morning Herald that an unnamed airline had made an out-of-court settlement with a passenger who had nearly died from a blood clot after a flight from Asia to Australia. “I also believe there have been a number of out-of-court settlements in the last decade,” O'Keefe declared, adding that this proved the airlines knew about the syndrome but had failed to act.

In the midst of this avalanche of publicity, doctors at England's Ashford Hospital, the closest hospital to Heathrow airport, have released the results of a study showing that flight-related DVT is costing as many as 2,000 lives a year. They say that at least one long-haul passenger dies every month at their hospital from blood clots and at least a third of these will have travelled from Australia. The passengers in their study were aged between 28 and the late 70s and all had flown economy class. According to John Belstead of Ashford Hospital, “They are all people who collapsed after getting off a flight, or after getting up at the end of an overnight flight. Most of them come from baggage claim, they seem to walk about a half-mile, then go down.”

A study conducted at Tokyo's Narita airport clinic documented 25 deaths in eight years from aviation induced DVT. Reports in the Australian press have revealed that 12 “economy-class syndrome” patients a month are being admitted to the St George Hospital at Kogarah, close to Sydney's international airport.

Senior surgeon Professor Reginald Lord said that Sydney's St Vincent's Hospital saw almost one person every week with the potentially fatal condition. “We're an inner-city hospital and I estimate that perhaps we see one-tenth of the affected individuals. So that might come down to about 400 cases coming through Sydney airport each year.” A study initiated by Lord in 1993 demonstrated that of 45 patients with DVT, 37 had recently taken a long flight. Lord said that research at St Vincent's suggested that sleeping pills commonly taken on international flights could also be a contributing factor.

While certain conditions can heighten vulnerability to DVT—such as blood disorders including previous clotting, age, obesity, pregnancy, cancer—even young people in peak physical condition can fall victim. Vascular surgeon David Grosser reported that he treated three British Olympic athletes suffering blood clots in the leg after they flew to Australia to compete in the Sydney Games: “The message about the Olympians is it can happen in young people who are really fit and aren't sick. If it can happen to these people, it can happen to virtually anyone who flies if the right sort of conditions pertain,” Grosser said.

Professor Brian Trudinger, an obstetrician at Sydney's Westmead Hospital explained that he was in good health when he developed a blood clot after a flight from London in 1995. He was subsequently hospitalised and given emergency treatment for a pulmonary embolus. Castigating the airline industry's inaction over blood clotting risks, he remarked that the surge in reported cases was “only the tip of the iceberg”.

The Flight Attendants Association of Australia has confirmed that a male Qantas flight attendant was admitted to hospital last week with a pulmonary embolus following a Sydney-to-Lost Angeles flight—the first time a member of the association, which represents 4,000 Qantas and Lauda air flight attendants, has suffered from a clot after a long-haul flight.

Doctors internationally are calling for health officials to conduct a full-scale study to establish just how many people are affected. In most countries, hospitals are not even required to record whether blood clot patients have recently travelled on an aircraft. While Qantas began a study of the causes of blood clots in collaboration with Queensland's Griffith University early last year, many accuse the airlines of failing to make an adequate effort.

“We have no idea how many passengers could have these [DVTs],” said Trudinger. “One way to measure it would be to go out to Mascot [airport] at the peak arrival time for overseas flights and use ultrasound on disembarking passengers to see the extent of the problem ... and then the airlines could develop strategies accordingly.”

Vascular specialist Professor Colin Chesterman has supported Trudinger, attacking the paucity of research on the condition.

Commenting on the airline industry's response to the crisis, Peter Harbison, managing director of the Centre for Asia Pacific Aviation in Sydney declared: “The only thing that has happened in the past few weeks is that airlines have made sure warning notices are included with tickets. That will help airlines in terms of contributory negligence.”

While certain medical options exist to help prevent clotting, such as blood thinning medication, the most obvious and long term solution involves the reorganisation of airline seating arrangements, as well as the provision of space and facilities for in-flight movement and exercise.

But under conditions of cut-throat competition in long distance flights, the airlines are desperate to squeeze in every possible passenger, making the reduction of seats an unattractive—and unprofitable—proposition.