Investigations of the health effects of past wars have often focused on narrowly defined hazards or health outcomes, such as infectious diseases (for example, typhoid and malaria) during the Civil War, specific chemical hazards (for example, mustard gas in World War I and Agent Orange and other herbicides in Vietnam), and combat injuries. A discussion of the possible health effects of Gulf War service, however, involves many complex issues, some of which are explored below. They include exposure to multiple biologic and chemical agents as described above, limitations of exposure information collected during or modeled after deployment, individual variability factors, and illnesses that are often nonspecific and lack defined medical diagnoses or treatment protocols. The committee was not tasked with addressing those issues, but it presents them in this introductory chapter to acknowledge the difficulties faced by veterans, researchers, policymakers, and others in reaching an understanding about the veterans’ ill health.

Multiple Exposures and Chemical Interactions

Although Operation Desert Shield and Operation Desert Storm were relatively brief, military personnel were potentially exposed to numerous harmful agents simultaneously. These include agents administered as preventive measures (such as PB, vaccines, pesticides, and insecticides), hazards of the natural environment (such as sand and endemic diseases), job-specific agents (such as paints, solvents, and diesel fumes), war-related agents (such as smoke from oil-well fires and DU), and hazards from cleanup operations (such as sarin and cyclosarin). Thus, military personnel might have been exposed to various agents at various doses for various periods. Many of the exposures are not specific to the Gulf War, but the number and combination of agents to which the veterans might have been exposed make it difficult to determine whether any agent or combination of agents is the cause of many Gulf War veterans’ illnesses. The veterans also experienced numerous psychological stressors such as uncertainty about the presence of chemical and biological agents, seeing dead or wounded combatants and civilians, and anxiety about their families and jobs at home. The impacts of these psychologic stressors are discussed in more depth in Gulf War and Health, Volume 6.

Limitations of Exposure Information

Determining whether Gulf War veterans face an increased risk of illness because of their exposures during the war requires extensive information about each exposure, such as the actual agents, the duration of exposure, the route of entry, the internal dose, and documentation of adverse reactions. But very little is known about most Gulf War exposures. After the ground war, an environmental-monitoring effort was initiated primarily because of concerns related to smoke from oil-well fires and exposure to sarin and cyclosarin rather than for the other agents to which the troops might have been exposed. Consequently, exposure data on other agents are lacking or are severely limited. At the request of the DoD, the RAND Corporation conducted a postwar survey to assess possible exposures to pesticides (RAND, 2000).

Various exposure assessment tools have been used in research to fill gaps in exposure information, but there are problems in reconstruction of past exposure events. For example, veterans have been surveyed to obtain recollections about agents to which they might have been exposed, although survey results might be limited by recall bias. Models have been refined to

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