Sleepless in battle | Science Focus Page 1 of 3

The team of crack US Army snipers were close to exhaustion as they trekked across Iraq’s notorious Triangle of Death south of
Baghdad. With daytime temperatures pushing 50°C, they had been forced to march through the night, grabbing fitful sleep
whenever they could. Then one morning in May 2007, what they had dreaded finally happened. Two Iraqi civilians blundered across
the hide in which they were trying to get some sleep.

What happened next became the focus of a court martial – and a conviction for murder. The jury heard that Sergeant Evan Vela had
been ordered to kill one of the Iraqi civilians – and did so without a second thought. Yet Sgt Vela told the court that he couldn’t
recall pulling the trigger or even hearing the shot. He was, he insisted, suffering the effects of extreme sleep deprivation – the
result of having less than five hours’ sleep in the previous 72 hours.

Medical experts testified that such extreme lack of sleep could have led him to act like an automaton, unable to exercise any moral
judgement. And the court appeared to agree. Vela was found guilty of murder, but received a sentence of ten years, rather than
the maximum of life imprisonment without parole.

The Vela case is hardly unique. For as long as wars have been fought, soldiers have had to battle with sleep deprivation and have
sometimes lost, with terrible consequences. Nor are those in the armed forces alone in their struggle against fatigue: millions of
ordinary people suffer from its effects as well, struggling to stay effective at work, or awake while driving. Research suggests that
up to 20 per cent of all accidents on motorways are fatigue-related.

Now there’s growing excitement about a new generation of compounds that seem able to keep drowsiness at bay for days on end,
with minimal side effects. Known as eugeroics – from the Greek for ‘beneficial arousers’ – they seem to offer the prospect of a
whole new way of living, ridding ourselves of the need to spend around 20 to 30 per cent of every day asleep.

But there’s also growing concern about whether there may be a price to pay for interfering with a process every known organism
appears to undergo naturally. “Saying we sleep just to stop feeling tired is like saying we need to eat just to stop feeling hungry,”
says Professor Jim Horne, director of the Sleep Research Centre at Loughborough University.

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For anyone needing to keep awake for just a few hours longer than normal, there’s a natural stimulant that according to some
anthropologists may even have been used by Stone Age humans: caffeine. Found in dozens of plants and first isolated by chemists
around 200 years ago, caffeine boosts brain activity and improves mental and physical performance. Research has shown it’s
especially effective when taken just before a brief nap of around 15 minutes (see ‘Beat your body clock’, on p69). But it also
produces a host of side effects, from ‘the shakes’ to the heart palpitations that put former PM Tony Blair in hospital in 2003.

Around 70 years ago, scientists synthesised what appeared to be a better remedy, known as dextroamphetamine, or dexedrine.
First used during World War II, it appeared to have fewer side effects. Yet by the 1960s, a darker side was seen. Regular users
needed ever-higher doses to achieve the same effects, while those who tried to give up the drug ran into a host of problems, from
disturbed sleep to violent outbursts.

Banned from non-prescription use in 1970, dexedrine still found uses in special circumstances – the crew of the abortive Apollo 13
lunar landing mission of 1970 were ordered to take the drug by NASA officials after one of the sleep-deprived astronauts made a
near-fatal error programming the onboard computer. It is still used by some military personnel.

Yet concern about the potentially deadly side effects of dexedrine remain. In April 2002 an American F-16 pilot accidentally
bombed Canadian troops in Afghanistan, killing four. At the subsequent inquiry, defence lawyers claimed the pilot’s judgement had
been impaired by taking dexedrine.

The 21st-century battleground has pushed the search for safe but effective solutions to sleep deprivation up the research agenda.
“Typical operational scenarios might include lack of sleep for 24 to 36 hours, or short sleep – four hours a night – for several days,”
says Jan Walker of the US Defense Advanced Research Projects Agency (DARPA), Virginia. “Sleep deprivation interferes with the
ability to do higher-order mental processing, such as complex problem solving.”

In the late 1970s, French scientists appeared to have discovered the perfect solution: modafinil. Originally developed to treat
medical conditions in which patients suddenly fall asleep, modafinil boosts performance for hours on end, while not interfering
with the ability to sleep. Tests revealed that troops given modafinil could perform effectively for 40 hours at a stretch – and then
get a normal night’s sleep without the sleeping pills often needed after taking dexedrine, before taking more modafinil to keep
going for another 40 hours.

Such results have impressed military commanders. Soldiers in the French Foreign Legion were given modafinil during the first Gulf
War in 1991, while the US Air Force approved modafinil for use among some of its pilots in 2003. Britain’s Ministry of Defence has
confirmed that it has been studying the drug’s effects since the late 1990s – though it has yet to approve its use.

The MoD’s more cautious attitude towards modafinil may prove well-placed. Quite how modafinil staves off the need for sleep is
far from clear, and side effects ranging from nausea to anxiety and over-confidence have emerged in studies. Such findings cast a
shadow over the vision of a sleep-free society, in which we all take drugs like modafinil to add years of productive activity to our
lives. The long-term health effects of such drugs aren’t clear, and some people may be at high risk from side effects. Researchers at
Vanderbilt University, Nashville, have found that modafinil raises heart rate and blood pressure, prompting them to warn about the
potential risk to patients with cardiovascular disease.

Researchers are studying alternatives to modafinil, such as orexin and ampakines. While both appear to reduce the need for sleep
in animals, studies in humans have so far proved disappointing – and their long-term effects are also unknown.

But there is another, more fundamental concern about attempts to create drugs for a sleep-free society. Even if the drugs
themselves prove harmless, doing without sleep seems to be anything but.

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While scientists admit they still don’t know the real purpose of sleep, they point to evidence linking disrupted and inadequate
sleep to life-threatening conditions. Last December, the International Agency for Research on Cancer warned that women involved
in shift working face a significantly higher risk of breast cancer. “Sleep loss – even just an hour a day – is associated with metabolic
effects such as impaired glucose tolerance,” says Dr Adrian Williams, director of the Sleep Disorders Centre at St Thomas’ Hospital,
London. “We shouldn’t think about reducing the sleep we get until we better understand these issues.”

His concerns are underscored by a recent major study of the impact of sleep loss on heart disease. Published in September 2007 by
a team of researchers from the University of Warwick and University College London, the study examined the effects of changes in
the sleeping patterns of over 10,000 civil servants.

The results showed that those who had cut their sleep from seven hours per night to five hours or less faced as much as a 70 per
cent increased risk of premature death – and a doubling in the risk of dying from cardiovascular disease. Researchers suspect the
explanation for the dramatic increase lies in the effect of the lack of sleep on risk factors for heart disease such as high blood
pressure. But precisely what happens during sleep to keep the body healthy remains a mystery.

According to the study, a regular routine of sleeping for around seven hours a night is necessary to stay in peak condition. “Sleep
represents the daily process of physiological restitution and recovery, and lack of sleep has far-reaching effects,” says Professor
Francesco Cappuccio of the University of Warwick.

It seems that, however much we may want to get more out of our lives by cutting back on sleep, most experts agree that doing so
may come at far too high a price. “The idea of the sleep-free society is pretty foolish,” says Prof Horne. “If sleeping each day is the
only chance we get to unwind, then we should take more sleep, not less.”

http://www.sciencefocus.com/feature/health/sleepless-battle 2017. 08. 23.