2
Background

On August 2, 1990, Iraq invaded the independent nation of Kuwait. Within 5 days the United States had begun to deploy troops to the Persian Gulf in Operation Desert Shield. Intense air attacks against the Iraqi forces began on January 16, 1991 (Operation Desert Storm), and a ground attack was launched on February 24, 1991. Within 4 days Iraqi resistance crumbled. Almost 700,000 U.S. troops participated in the Persian Gulf War. Following the fighting the number of U.S. troops in the area began to decline rapidly. By June 1991 fewer than 50,000 U.S. troops remained in the Persian Gulf region.

The demographic characteristics of the Persian Gulf troops differed from those involved in previous military engagements. Overall, they were older, a large proportion (about 17 percent) were from National Guard and Reserve units, and almost 7 percent of the total forces were women.

U.S. casualties during the Persian Gulf War were low. There were 148 combat-related deaths, with an additional 145 deaths due to disease or accidents. Despite the low numbers of U.S. fatalities and injuries, the deployed personnel were exposed to a number of stressors. The rapid mobilization for military service led to the sudden disruption of the lives of large numbers of people. The involvement of large numbers of reservists and National Guard personnel created particular concern because, in addition to their rapid mobilization and deployment, they would be returning directly to civilian life at the conclusion of the war.

U.S. troops were exposed to oil smoke, diesel and jet fuel, solvents and other petrochemicals, chemical agent resistant coating paint, depleted uranium, sand, endemic infections such as leishmaniasis, extreme heat, and primitive living conditions. In addition, some soldiers were given vaccines against anthrax and botulinum toxins, and some soldiers ingested pyridostigmine bromide pills as protection against chemical warfare agents.

Other conditions affecting the troops were the unfamiliar character of the region, the requirement that U.S. military personnel have virtually no interaction with the indigenous populations, the waiting for the fighting to begin, the fear that chemical warfare agents would be used by the Iraqis, and the immense destruction visited on the nations of Kuwait and Iraq.

After the war most veterans returned home and resumed their normal activities. Within a relatively short time, however, some active-duty military personnel and veterans began to report various health problems that they believed were connected to their service in the Persian Gulf. Symptoms commonly described included fatigue, memory loss, severe headaches, muscle and joint pain, and rashes (Iowa Persian Gulf Study Group, 1997).

In 1992, DVA developed and implemented the Persian Gulf Registry. Its original purposes were to facilitate the entry of returning veterans into the DVA health care system, to create a registry containing medical and other data on PGW veterans that would assist in addressing questions about



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--> 2 Background On August 2, 1990, Iraq invaded the independent nation of Kuwait. Within 5 days the United States had begun to deploy troops to the Persian Gulf in Operation Desert Shield. Intense air attacks against the Iraqi forces began on January 16, 1991 (Operation Desert Storm), and a ground attack was launched on February 24, 1991. Within 4 days Iraqi resistance crumbled. Almost 700,000 U.S. troops participated in the Persian Gulf War. Following the fighting the number of U.S. troops in the area began to decline rapidly. By June 1991 fewer than 50,000 U.S. troops remained in the Persian Gulf region. The demographic characteristics of the Persian Gulf troops differed from those involved in previous military engagements. Overall, they were older, a large proportion (about 17 percent) were from National Guard and Reserve units, and almost 7 percent of the total forces were women. U.S. casualties during the Persian Gulf War were low. There were 148 combat-related deaths, with an additional 145 deaths due to disease or accidents. Despite the low numbers of U.S. fatalities and injuries, the deployed personnel were exposed to a number of stressors. The rapid mobilization for military service led to the sudden disruption of the lives of large numbers of people. The involvement of large numbers of reservists and National Guard personnel created particular concern because, in addition to their rapid mobilization and deployment, they would be returning directly to civilian life at the conclusion of the war. U.S. troops were exposed to oil smoke, diesel and jet fuel, solvents and other petrochemicals, chemical agent resistant coating paint, depleted uranium, sand, endemic infections such as leishmaniasis, extreme heat, and primitive living conditions. In addition, some soldiers were given vaccines against anthrax and botulinum toxins, and some soldiers ingested pyridostigmine bromide pills as protection against chemical warfare agents. Other conditions affecting the troops were the unfamiliar character of the region, the requirement that U.S. military personnel have virtually no interaction with the indigenous populations, the waiting for the fighting to begin, the fear that chemical warfare agents would be used by the Iraqis, and the immense destruction visited on the nations of Kuwait and Iraq. After the war most veterans returned home and resumed their normal activities. Within a relatively short time, however, some active-duty military personnel and veterans began to report various health problems that they believed were connected to their service in the Persian Gulf. Symptoms commonly described included fatigue, memory loss, severe headaches, muscle and joint pain, and rashes (Iowa Persian Gulf Study Group, 1997). In 1992, DVA developed and implemented the Persian Gulf Registry. Its original purposes were to facilitate the entry of returning veterans into the DVA health care system, to create a registry containing medical and other data on PGW veterans that would assist in addressing questions about

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--> possible future effects of exposure to air pollutants and other environmental agents, and to serve as the basis for future medical surveillance. Exposures, particularly those associated with the oil well fires, were included as part of the history taking. As time passed it became apparent that a number of exposure issues and a host of symptoms needed further investigation. As concern over the health problems of those deployed to the Persian Gulf escalated, DoD also decided to develop and implement a Persian Gulf clinical program for PGW veterans. DoD and DVA met and used experts to develop clinical protocols. By 1994 both had implemented similar and parallel clinical evaluation programs. The DVA clinical program is called the Persian Gulf Registry and Uniform Case Assessment Protocol (PGR/UCAP), while the DoD program is called the Comprehensive Clinical Evaluation Program (CCEP). By early 1997 almost 100,000 veterans had been examined through either the DVA (about 67,000) or the DoD (about 33,000) Persian Gulf Registry program. Concern about the health of PGW veterans has led to a number of investigations and reports, many of which contain recommendations for research or for improving the diagnostic programs of DVA and DoD. Several population-based studies regarding the health of PGW veterans have been conducted. Most of these focus on specific components of health status or outcome, for example, mortality and hospitalizations. A major study of self-reported health complaints was jointly undertaken by the Centers for Disease Control and Prevention and the University of Iowa, but it was limited to Iowa residents. Another effort aimed at determining the health outcomes of troops deployed to the Persian Gulf compared to those of troops not deployed to the Gulf is the DVA National Health Survey of Persian Gulf Veterans and Their Family Members, the results of which are not yet available. Despite these efforts to study the health of PGW veterans, many individuals in the U.S. Congress, in the federal government, and among the public believe that no study has yet been designed that adequately measures the health of those deployed to the Persian Gulf. A recently released General Accounting Office (GAO) report concluded that “although efforts have been made to diagnose veterans' problems and care has been provided to many eligible veterans, neither DoD nor VA [DVA] has systematically attempted to determine whether ill PGW veterans are any better or worse today than when they were first examined” (GAO, 1997). The report also concluded that DoD and DVA have no systematic approach to monitoring the quality, appropriateness, or effectiveness of care provided to PGW veterans after their initial examination and that these agencies need to develop a plan to collect longitudinal information on the health outcomes and treatment effectiveness of PGW veterans. After reviewing the GAO findings, the U.S. House of Representatives Appropriations Committee issued Report 105–175 which states that DoD and DVA should develop and implement a plan to provide (1) data on the effectiveness of the treatments received by these veterans and (2) longitudinal information on the health of veterans who reported diagnosed and undiagnosed illnesses after the war. In response to these recommendations, the DVA and the DoD asked the IOM to conduct a study aimed at developing a research design to measure the health of Persian Gulf veterans. The first meeting of the Committee on Measuring the Health of Persian Gulf Veterans included a workshop designed to collect information regarding the health problems of those deployed to the Persian Gulf War and some of the efforts that have been made to study those problems. The following sections of this report provide a summary of that workshop.