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INTRODUCTION

On August 2, 1990, Iraq invaded Kuwait. In response, a coalition of the United States, Canada, the United Kingdom, Australia, and other countries initiated a buildup of military forces called Operation Desert Shield. To liberate Kuwait, Operation Desert Storm was launched on January 16, 1991, with an air offensive; on February 24, the ground war began. By February 28, 1991, the war was over; a ceasefire was signed in April 1991 and all U.S. troops who had participated in the ground war had returned home by June 13, 1991. About 697,000 U.S. military personnel were deployed to the Persian Gulf during the buildup and the war. Most of them were active-duty military personnel, but 261,871 reservists were called to active duty, and 106,047 of them were deployed to the gulf.

In that brief conflict, 148 U.S. personnel died in combat, 145 died outside combat, and 467 were wounded in action. The troops in Iraq experienced uncertainty about possible exposures to chemical and biologic weapons and other contaminants, difficult living conditions, incomplete knowledge of the Iraqi forces they were to engage, and, particularly in the case of reservists, difficulties that accompanied leaving families and jobs. U.S. troops worked and fought in a harsh desert climate far from home and faced an enemy known to have used biologic and chemical weapons. All those factors and others constituted potential physical and psychologic stressors for deployed troops.

The United States is once again engaged in a military conflict in the Middle East. Operation Enduring Freedom (OEF) began on October 7, 2001, in response to the September 11, 2001, terrorist attacks on the United States. Troops are stationed in and around Afghanistan, Southwest Asia, and other locations for military and humanitarian purposes. As of August 8, 2007, in OEF, 419 U.S. military personnel had died (238 as a result of hostile action and 181 as a result of nonhostile action), and 1472 had been wounded in action (DoD 2007).

Operation Iraqi Freedom (OIF) began on March 19, 2003, when U.S.-led coalition forces invaded Iraq. As of August 4, 2007, in OIF, 3672 U.S. military personnel had died (3024 as a result of hostile action and 648 as a result of nonhostile actions) and 27,279 had been wounded in action (DoD 2007). On July 1, 2007, the Department of Defense (DoD) reported that 156,247 U.S. military personnel were deployed in Iraq (Bowman 2007).

OIF can be characterized as a conflict with increasing insurgent attacks. Those attacks include a wide array of tactics, including suicide and car bombs, improvised explosive devices (IEDs), sniper fire, and rocket-propelled grenades. Insurgent attacks are largely unpredictable and often take place in civilian areas, so it is difficult to anticipate and distinguish the enemy. That uncertainty not only increases the risks of being wounded or killed but exacerbates the psychologic stressors experienced by U.S. troops.



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1 INTRODUCTION On August 2, 1990, Iraq invaded Kuwait. In response, a coalition of the United States, Canada, the United Kingdom, Australia, and other countries initiated a buildup of military forces called Operation Desert Shield. To liberate Kuwait, Operation Desert Storm was launched on January 16, 1991, with an air offensive; on February 24, the ground war began. By February 28, 1991, the war was over; a ceasefire was signed in April 1991 and all U.S. troops who had participated in the ground war had returned home by June 13, 1991. About 697,000 U.S. military personnel were deployed to the Persian Gulf during the buildup and the war. Most of them were active-duty military personnel, but 261,871 reservists were called to active duty, and 106,047 of them were deployed to the gulf. In that brief conflict, 148 U.S. personnel died in combat, 145 died outside combat, and 467 were wounded in action. The troops in Iraq experienced uncertainty about possible exposures to chemical and biologic weapons and other contaminants, difficult living conditions, incomplete knowledge of the Iraqi forces they were to engage, and, particularly in the case of reservists, difficulties that accompanied leaving families and jobs. U.S. troops worked and fought in a harsh desert climate far from home and faced an enemy known to have used biologic and chemical weapons. All those factors and others constituted potential physical and psychologic stressors for deployed troops. The United States is once again engaged in a military conflict in the Middle East. Operation Enduring Freedom (OEF) began on October 7, 2001, in response to the September 11, 2001, terrorist attacks on the United States. Troops are stationed in and around Afghanistan, Southwest Asia, and other locations for military and humanitarian purposes. As of August 8, 2007, in OEF, 419 U.S. military personnel had died (238 as a result of hostile action and 181 as a result of nonhostile action), and 1472 had been wounded in action (DoD 2007). Operation Iraqi Freedom (OIF) began on March 19, 2003, when U.S.-led coalition forces invaded Iraq. As of August 4, 2007, in OIF, 3672 U.S. military personnel had died (3024 as a result of hostile action and 648 as a result of nonhostile actions) and 27,279 had been wounded in action (DoD 2007). On July 1, 2007, the Department of Defense (DoD) reported that 156,247 U.S. military personnel were deployed in Iraq (Bowman 2007). OIF can be characterized as a conflict with increasing insurgent attacks. Those attacks include a wide array of tactics, including suicide and car bombs, improvised explosive devices (IEDs), sniper fire, and rocket-propelled grenades. Insurgent attacks are largely unpredictable and often take place in civilian areas, so it is difficult to anticipate and distinguish the enemy. That uncertainty not only increases the risks of being wounded or killed but exacerbates the psychologic stressors experienced by U.S. troops. 11

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12 GULF WAR AND HEALTH In response to the growing concern about the physical and psychologic health of the returning Gulf War veterans from the 1990-1991 conflict, Congress passed two laws in 1998: PL 105-277, the Persian Gulf War Veterans Act, and PL 105-368, the Veterans Programs Enhancement Act. Those laws directed the secretary of veterans affairs to enter into a contract with the National Academy of Sciences (NAS) to review and evaluate the scientific and medical literature regarding associations between illness and exposure to toxic agents, environmental or wartime hazards, and preventive medicines or vaccines in members of the armed forces. PL 105- 277 also gave NAS permission to identify “other agents, hazards, or medicines or vaccines to which members of the Armed Forces may have been exposed.” In 1996, the Presidential Advisory Committee on Gulf War Veterans’ Illnesses (PAC 1996) found that stress was an important contributor to the Gulf War veterans’ illnesses and encouraged the government to continue its research on stress-related disorders. In response to the above laws, the Institute of Medicine (IOM) has had a program to examine health risks posed by specific agents and hazards to which Gulf War veterans might have been exposed during their deployment. Four reports have examined health effects related to depleted uranium, pyridostigmine bromide, sarin, and vaccines (IOM 2000); insecticides and solvents (IOM 2003); fuels, combustion products, and propellants (IOM 2005); and infectious diseases (IOM 2007). In recent years, the charge to IOM has been expanded to include not only veterans of the 1991 Gulf War but veterans returning from OEF and OIF. Many of the biologic and chemical exposures and their possible health effects have been considered in previous IOM reports, but the health effects associated with deployment-related stress have yet to be considered. A recent IOM report, Gulf War and Health, Volume 4: Health Effects of Serving in the Gulf War (IOM 2006), reviewed the health status of Gulf War-deployed veterans compared with their nondeployed counterparts. That report found that veterans of the Gulf War report higher rates of nearly all symptoms than their nondeployed counterparts; in addition, a higher prevalence not only of individual symptoms but of chronic multisymptom illnesses was found among Gulf War- deployed veterans. Multisymptom-based medical conditions reported to occur more frequently among deployed Gulf War veterans include fibromyalgia, chronic fatigue syndrome, and multiple chemical sensitivity. The literature also demonstrates that deployment places veterans at increased risk for symptoms that meet diagnostic criteria for a number of psychiatric disorders, particularly posttraumatic stress disorder (PTSD), anxiety disorders, depressive disorders, and substance abuse. Furthermore, comorbidities have been reported, for example, symptoms of both PTSD and depression. Finally, the report noted that Gulf War veterans are at increased risk for amyotrophic lateral sclerosis and that there is weak evidence that Gulf War veterans’ offspring might be at risk for some birth defects (IOM 2006). In light of the 1991 Gulf War and the nature of OEF and OIF, the Department of Veterans Affairs (VA) requested that IOM comprehensively review, evaluate, and summarize the peer-reviewed scientific and medical literature regarding the association between deployment- related stress and long-term adverse health effects in Gulf War veterans. In response to VA’s request, IOM appointed the Committee on Gulf War and Health: Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress to conduct the review. DEMOGRAPHICS The 1991 Gulf War, OEF, and OIF reflect many changes from previous wars fought by the United States, particularly in the demographic composition of military personnel and the

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INTRODUCTION 13 uncertainty of conditions for many reservists. The 1991 Gulf War and, in particular, OEF and OIF have occasioned the increased activation of reserve and National Guard units to supplement the all-volunteer military. Those units and the military in general also have more women serving and have women serving in more occupations than ever before. In the Vietnam War, 3,143,645 men and 7166 women served in the Vietnam theater. The military during the Vietnam era was about 87% white, 11% black, and 5% Hispanic (Kulka et al. 1990). About 75% of those who served in the Vietnam theater were volunteers and 25% were draftees; in World War II, 66% were draftees (MRFA 2007). The average age of a U.S. enlisted soldier was 26 years in World War II and about 21 years in Vietnam (25-27 years for all military personnel serving in Vietnam) (Schlenger 2007). Only very small percentages of the soldiers in World War II and the Vietnam War were in the reserves or National Guard. Of the nearly 700,000 U.S. troops who fought in Operation Desert Shield and Operation Desert Storm in 1990-1991, almost 7% were women and about 17% were in activated National Guard and reserve units. Military personnel, with a mean age of 28 years, were, overall, older than those who had participated in previous wars. Some 70% of the troops were white, 23% were black, and 6% were Hispanic or other (DoD 1994). As of 2005, 14% of the almost half-million active-duty Army personnel were women, as were 23.2% of Army reserves and 12.8% of Army National Guard. The proportion of Hispanics in the Army increased from about 4% in 1985 to 11% in 2005, and the proportion of blacks decreased in the same period from 27% to 22% (U.S. Army 2007). COMMITTEE’S INTERPRETATION OF ITS CHARGE Given the committee’s charge from the VA—to assess the long-term health effects of deployment-related stress—the committee began by defining deployment-related stress as deployment to a war zone. Combat is one of the most potent stressors that a person can experience, but as military conflicts have evolved to include more guerilla warfare and insurgent activities, restricting the definition of deployment-related stressors to combat may fail to acknowledge other potent stressors experienced by military personnel in a war zone or in the aftermath of combat (King et al. 2006). Such stressors encompass an enormous array of physical and psychologic events, including constant vigilance against unexpected attack, the absence of a defined front line, the difficulty of distinguishing enemy combatants from civilians, the ubiquity of IEDs, caring for the badly injured or dying, duty on the graves registration service, and being responsible for the treatment of prisoners of war. The deployment stressors associated with any armed conflict also include noncombat stressors. Non-combat-related stressors that might be experienced by deployed personnel are separation from family, friends, and colleagues; loss of or reduction in income; and concern over employment status when deployment ends (O’Toole et al. 1999). Therefore, the committee considered that military personnel deployed to a war zone, even if direct combat was not experienced, have the potential for exposure to deployment-related stressors that might elicit a stress response and that the emotional and physical reactions of military personnel to those stressors can vary widely. The committee recognized that factors other than deployment-related stressors can affect the outcome of exposure to potential stressors, including the stress response itself and individual risk and protective factors. The stress response is a coordinated set of interactions among multiple organ systems in the body, including the brain, gut, heart, liver, immune system, thyroid, adrenals, pituitary, gonads, bone, and skin. Acute stress responses are usually adaptive, preparing the organism for

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14 GULF WAR AND HEALTH “fight or flight.” When exposure to the stressor has ended, the acute stress response subsides, and the body returns to its normal state. However, if the body’s reactions persist after the stressor has ended, a chronic stress response can develop, which can be maladaptive and result in feelings of anxiety and lack of control and chronic health effects. Stressors can also lead to adverse psychosocial effects, such as marital conflicts and homelessness, concurrently with or after the development of health effects. Whether the stress response leads to adverse health effects in either the short term (hours to days) or the long term (months to years) is determined by a number of factors, including the intensity of the stressful experience, the effects of previous stressors, innate and acquired vulnerabilities, and various protective influences. Risk factors, such as genetic susceptibility and prior exposure to stressors, can increase the likelihood of having adverse effects during and after deployment; protective factors, such as military training and a supportive family and social environment, can reduce the likelihood of having adverse effects. Because of the various deployment-related stressors, the complex nature of the stress response, and risk and protective factors that can potentially modify a person’s response to stress, the committee has provided a schematic (Figure 1-1) to indicate how it interpreted its task. COMMITTEE’S APPROACH TO ITS CHARGE The committee’s charge was to comprehensively review, evaluate, and summarize the peer-reviewed scientific and medical literature regarding the association between deployment- related stress and long-term adverse health effects in Gulf War veterans. Specifically, the committee was to study the physiologic, psychologic, and psychosocial effects of stress. VA requested that the study’s findings not be limited to veterans of the 1991 Gulf War but be applicable to veterans of OEF and OIF. Thus, to evaluate associations between deployment-related stress and adverse effects, the committee considered all studies that identified health effects found in military personnel deployed to a war zone. Potential health effects considered included not only physiologic effects but also psychiatric effects, such as depression and PTSD, and psychosocial effects, such as marital conflict and incarceration. In addition, the committee considered studies of deployed veterans with combat-related PTSD and associated health effects, because PTSD can result only after exposure to a traumatic stressor and a war zone is rife with potentially traumatic events. In conducting its deliberations, the committee considered studies of veterans of World War II, the Korean War, the Vietnam War, the 1991 Gulf War, OEF, and OIF. Although most of the literature focused on U.S. military veterans, studies of veterans from other countries were included. The possible health effects identified in Gulf War and Health, Volume 4: Health Effects of Serving in the Gulf War (IOM 2006) were also considered for this report. The committee’s task was not to judge individual cases of particular diseases or conditions nor did it examine treatment approaches for any health effects. The committee also did not address policy issues, such as decisions regarding compensation, potential costs of compensation, or any broader policy implications of its findings.

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INTRODUCTION 15 Deployment to a War Zone Deployment-Related Stressors Perception of Stress Protective Risk Factors Factors Acute and/or Chronic Stress Response Increased Chronic Stress Burden Adverse Health and Psychosocial Effects FIGURE 1-1 Schematic depiction of the relationship between deployment to a war zone and adverse health and psychosocial effects. Deployment to a war zone results in exposure to numerous stressors that can lead to acute and chronic stress responses that in turn can have potential long-term consequences, including adverse health and psychosocial effects. The nature of the stress response and the adverse health and psychosocial effects can be modified by a number of risk and protective factors. ORGANIZATION OF THE REPORT Chapter 2 presents the types of evidence the committee reviewed, how the committee assessed the strength of the evidence, and the categories of evidence the committee used to summarize its findings. Chapter 3 discusses the many types of stressors to which veterans might be exposed in a war zone. Chapter 4 discusses the biology of the stress response and Chapter 5 the diagnosis, course, prevalence, risk factors, and neurobiology of PTSD. Chapter 6 compiles and summarizes the available data on health effects that might be associated with deployment- related stressors. Psychosocial effects associated with deployment-related stress are discussed in Chapter 7. Finally, Chapter 8 summarizes the committee’s conclusions and recommendations.

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16 GULF WAR AND HEALTH REFERENCES Bowman S. 2007. CRS Report for Congress. Iraq: U.S. Military Operations. Washington, DC: Congressional Research Service. Order Code RL31701. Updated July 15, 2007. DoD (Department of Defense). 1994. Report of the Defense Science Board Task Force on Persian Gulf War Health Effects. Washington, DC: Office of the Under Secretary of Defense for Acquisition and Technology. DoD. 2007. OEF/OIF Casualty Update. [Online]. Available: www.defenselink.mil/news/casualty.pdf [accessed August 4, 2007]. IOM (Institute of Medicine). 2000. Gulf War and Health, Volume 1: Depleted Uranium, Pyridostigmine Bromide, Sarin, Vaccines. Washington, DC: National Academy Press. IOM. 2003. Gulf War and Health, Volume 2: Insecticides and Solvents. Washington, DC: The National Academies Press. IOM. 2005. Gulf War and Health, Volume 3: Fuels, Combustion Products, and Propellants. Washington, DC: The National Academies Press. IOM. 2006. Gulf War and Health, Volume 4: Health Effects of Serving in the Gulf War. Washington, DC: The National Academies Press. IOM. 2007. Gulf War and Health, Volume 5: Infectious Diseases. Washington, DC: The National Academies Press. King LA, King DW, Vogt DS, Knight J, Samper RE. 2006. Deployment risk and resilience inventory: A collection of measures for studying deployment-related experiences of military personnel and veterans. Military Psychology 18(2):89-120. Kulka RA, Schlenger WE, Fairbank JA, Hough RL, Jordan BK, Marmar CR, Weiss DS. 1990. Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel Publishers. MRFA (Mobile Riverine Force Association). 2007. Vietnam War Statistics. [Online]. Available: http://www.mrfa.org/vnstats.htm [accessed July 2, 2007]. O’Toole BI, Marshall RP, Schureck RJ, Dobson M. 1999. Combat, dissociation, and posttraumatic stress disorder in Australian Vietnam veterans. Journal of Traumatic Stress 12(4):625-640. PAC (Presidential Advisory Committee). 1996. Presidential Advisory Committee on Gulf War Veterans’ Illnesses: Final Report. Washington, DC: U.S. Government Printing Office. Schlenger WE. 2007. Abt Associates, Inc. Personal Communication. U.S. Army. 2007. Demographics. [Online]. Available: http://www.armyg1.army.mil/hr/demographics.asp [accessed July 2, 2007].