Introduction
A large Iraqi force invaded the independent nation of Kuwait on August 2, 1990. Within 5 days, the United States began deploying troops to the Persian Gulf in Operation Desert Shield. On January 16, 1991, UN coalition forces began intense air attacks against the Iraqi forces (Operation Desert Storm). By February 1991, more than 500,000 US troops were present and ready to engage the Iraqi army. A ground attack was launched on February 24, and within 4 days Iraqi resistance crumbled. After the fighting, the number of US troops in the area began to decline rapidly. By June 1991, fewer than 50,000 US troops remained.
Almost 700,000 US troops participated in Operations Desert Shield and Desert Storm. The composition of these troops differed from any previous US armed force. Overall, they were older, a large proportion (about 17%) were from National Guard and Reserve units, and almost 7% of the total forces were women.
US casualties were low during the Persian Gulf War. There were 148 combat deaths, with an additional 145 deaths due to disease or accidents. Despite the low number of fatalities and injuries, service personnel in the Persian Gulf were exposed to a number of stresses. These included environmental factors such as pesticides, diesel fumes, microbes, and oil well fires; and psychosocial factors such as the sudden mobilization for military service (especially for military reserves), the different cultural traditions of the region, and the primitive living conditions into which some troops were placed.
Following the war, most troops returned home and resumed their normal activities. However, a number of active-duty military personnel and veterans have reported various health problems they believe are connected to their Persian Gulf deployment. Symptoms commonly described include fatigue, memory loss, severe headaches, muscle and joint pain, and rashes (Iowa Persian Gulf Study Group, 1997). As reports of a purported "Persian Gulf Illness"
circulated, public concern grew. Both the Department of Defense (DoD) and the Department of Veterans Affairs (VA) developed a registry to track the health of Persian Gulf veterans and clinical programs to diagnose and treat program participants. In June 1994, the DoD instituted the Comprehensive Clinical Evaluation Program (CCEP), the purpose of which is to diagnose and treat active-duty military personnel who have medical complaints they attribute to service in the Gulf.
In 1994, the DoD asked the Institute of Medicine (IOM) to assemble a group of medical and public health experts to evaluate the adequacy of the CCEP. This committee met four times and prepared three reports between October 1994 and January 1996 (IOM 1995, 1996a,b). A general discussion of this committee's findings appears in the section entitled, "CCEP: The Initial IOM Report" (page 8). A complete list of the first CCEP committee's recommendations appears in Appendix A. Given these recommendations and an analysis by the DoD of information derived from the CCEP, the IOM was asked to continue its review of the CCEP with special emphasis on three areas: (1) approaches to addressing individuals with difficult-to-diagnose or ill-defined conditions, (2) diagnosis and treatment of stress and psychological or psychiatric conditions, and (3) identifying health problems of those who may have been exposed to nerve agents.
Given the intense interest in and concern about the potential health effects of possible exposure to nerve agents, DoD asked the committee to focus first on addressing the health problems of those who may have been exposed to such agents. To do so, a 1-day workshop was held at which leading researchers and clinicians presented the latest scientific and clinical information regarding possible health effects of low-level exposure to nerve agents and chemically related compounds, as well as the tests available to measure the potential health effects of such exposures.
