GULF WAR and HEALTH
HEALTH EFFECTS OF SERVING IN THE GULF WAR
THE NATIONAL ACADEMIES PRESS
THE NATIONAL ACADEMIES PRESS
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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
This study was supported by Contract V101(93)P-2155 between the National Academy of Sciences and the Department of Veterans Affairs. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.
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COMMITTEE ON GULF WAR AND HEALTH: A REVIEW OF THE MEDICAL LITERATURE RELATIVE TO GULF WAR VETERANS’ HEALTH
LYNN R. GOLDMAN, MD, MPH, (chair) Professor,
Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
MARCIA ANGELL, MD, Senior Lecturer on Social Medicine,
Department of Social Medicine, Harvard Medical School, Boston, MA
W. KENT ANGER, PhD, Associate Director for Occupational Research,
Center for Research on Occupational and Environmental Toxicology, Oregon Health and Science University, Portland, OR
MICHAEL BRAUER, ScD, Professor,
School of Occupational and Environmental Hygiene, University of British Columbia, Vancouver, British Columbia
DEDRA S. BUCHWALD, MD, Director,
Harborview Medical Center, University of Washington, Seattle, WA
FRANCESCA DOMINICI, PhD, Associate Professor,
Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
ARTHUR L. FRANK, MD, PhD, Professor, Chair,
Department of Environmental and Occupational Health, Drexel University School of Public Health, Philadelphia, PA
FRANCINE LADEN, ScD, Assistant Professor of Medicine,
Channing Laboratory, Harvard Medical School, Boston, MA
DAVID MATCHAR, MD, Director,
Center for Clinical Health Policy Research, Duke University Medical Center, Durham, NC
SAMUEL J. POTOLICCHIO, MD, Professor,
Department of Neurology, George Washington University Medical Center, Washington, DC
THOMAS G. ROBINS, MD, MPH, Professor,
Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, MI
GEORGE W. RUTHERFORD, MD, Professor, Vice-Chair,
Department of Epidemiology and Biostatistics, Division of Preventive Medicine and Public Health, School of Medicine, University of California, San Francisco, CA
CAROL A. TAMMINGA, M.D., Professor,
Department of Psychiatry, University of Texas, Southwestern Medical Center, Dallas, TX
CAROLYN FULCO, Senior Program Officer
ABIGAIL MITCHELL, Senior Program Officer
DEEPALI PATEL, Senior Program Associate
MICHAEL SCHNEIDER, Senior Program Associate
JUDITH URBANCZYK, Senior Program Associate
HOPE HARE, Administrative Assistant
PETER JAMES, Research Associate
DAMIKA WEBB, Research Assistant
RENEE WLODARCZYK, Intern
NORMAN GROSSBLATT, Senior Editor
ROSE MARIE MARTINEZ, Director,
Board on Population Health and Public Health Practice
MIRIAM DAVIS, Independent Medical Writer,
Silver Spring, MD
Tulane School of Public Health and Tropical Medicine, New Orleans, LA
This report has been reviewed in draft form by persons chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following for their review of this report:
ARTHUR K. ASBURY, MD, Department of Neurology, University of Pennsylvania, Philadelphia, PA
SHARON COOPER, PhD, Professor and Chair, Department of Epidemiology and Biostatistics, Texas A & M University School of Rural Public Health, College Station, TX
PETER J. DYCK, MD, Director, Peripheral Nerve Research Laboratory, Mayo Clinic College of Medicine, Rochester, MN
DAVID GAYLOR, PhD, MS, President, Gaylor & Associates, LLC, Eureka Springs, AR
JACK M. GORMAN, MD, President and Psychiatrist in Chief, McLean Hospital, Belmont, MA
PHILIP GREENLAND, MD, Executive Associate Dean for Clinical and Translational Research, Northwestern University Feinberg School of Medicine, Chicago, IL
HOWARD KIPEN, MD, MPH, Director, Clinical Research and Occupational Medicine Division, Environmental & Occupational Health Sciences Institute, UMDNJ-Robert Wood Johnson Medical School, Piscataway, NJ
JOSEPH LADOU, MD, Editor, International Journal of Occupational and Environmental Health, Professor, Division of Occupational and Environmental Medicine, University of California, San Francisco, CA
ELLEN REMENCHIK, MD, MPH, Assistant Professor, Occupational and Environmental Medicine, The University of Texas Health Center, Tyler, TX
KATHERINE S. SQUIBB, PhD, Associate Professor & Head, Division of Environmental Epidemiology & Toxicology, University of Maryland School of Medicine, Baltimore, MD
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by David J. Tollerud, Professor and Chair, Department of Environmental and Occupational Health Sciences, University of Louisville and by Harold Sox, editor, Annals of Internal Medicine, American College of Physicians of Internal Medicine. Appointed by the National Research Council, Dr. Sox was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
The 1990-1991 Persian Gulf War was brief and entailed few US casualties in comparison with other wars, and yet it had a profound impact on the lives of many of the troops. Among the 700,000 US military personnel deployed in the battle theater, many veterans have reported chronic symptoms and illnesses that they have attributed to their service in the gulf. Numerous studies have been conducted to characterize the long-term adverse health consequences of deployment to the Persian Gulf.
Potential exposures to numerous hazardous substances have been identified in association with the Gulf War. Most alarming are the smoke from oil-well fires that were set by Iraqis as they retreated at the end of the war and the potential exposures arising from the US military bombing of a poison-gas munitions dump at a location called Khamisiyah. Military personnel have also been reported to have had other exposures, such as to fuels, vaccines, pharmaceuticals, and pathogens. Most recently, the Department of Defense published a report documenting a large amount of pesticide use in the war theater. For most of those exposures, it is difficult or impossible to reconstruct doses because of lack of exposure measurements on either the individual or group level. The situation is compounded by the stress experienced by many veterans during deployment and in some cases after deployment. Stress is known to have serious acute and chronic health effects, but at the time of the Gulf War relatively little attention was given to reduction of stress and its consequences.
The Department of Veterans Affairs (VA) and the US Congress have secured the assistance of the Institute of Medicine (IOM) in evaluating the scientific literature regarding possible health outcomes associated with exposures that might have occurred in the Gulf War, IOM has published several volumes that review the clinical diseases that might be associated with exposures, such as exposure to sarin gas, depleted uranium, pesticides, solvents, rocket propellants, fuels, and combustion products. Such reviews continue and will provide information about illnesses related to exposure to pathogens, stress, and chemical agents. The congressional request regarding the possible association between illness and exposures in the gulf is similar to the approach Congress took after the Vietnam War to address the potential adverse health effects of exposure to Agent Orange.
The current report, however, takes a different approach, which is to identify the adverse health effects, if any, that are occurring among Gulf War veterans and thus might warrant further attention, either on the individual level or for the Gulf War veterans as a whole. Many of the relevant studies are limited by the lack of objective exposure information. Although there is a blood test that can provide an indication of exposure to Agent Orange and dioxin that occurred many years ago, there is not biological measure that can be employed today to assess exposures during the Gulf War. Another limitation is that most studies have relied on self-reports of symptoms and symptom-based case definitions to determine whether rates of diseases were increased among Gulf War veterans. Nonetheless, some studies do point to psychiatric disorders and neurologic end points that might be associated with Gulf War service and for which it might be possible to develop new approaches to prevention and clinical treatment that could benefit not only Gulf War veterans but also veterans of later conflicts. Our committee does not recommend
that more such studies be undertaken for the Gulf War veterans, but, there would be value in continuing to monitor the veterans for some health end points, specifically, cancer, especially brain and testicular cancers, neurologic diseases including Amyotrophic Lateral Sclerosis (ALS), and causes of death. Therefore, despite the serious limitations of the available studies as a group, they do point the way to actions that might benefit Gulf War and other combat veterans.
I am deeply appreciative of the expert work of our committee members: Marcia Angell, W. Kent Anger, Michael Brauer, Dedra S. Buchwald, Francesca Dominici, Arthur L. Frank, Francine Laden, David Matchar, Samuel J. Potolicchio, Thomas G. Robins, George W. Rutherford, and Carol Tamminga. Although our committee developed conclusions independently of input from IOM and its staff, we deeply appreciate their hard work and attention to detail and the extensive research that they conducted to ensure that we had all the information that we needed from the outset. It has been a privilege and a pleasure to work with the IOM staff directed by Carolyn Fulco and with our consultant, Miriam Davis. Without them, this report would not have been possible. Most of all, our committee appreciates the veterans who served in the Gulf War and who have volunteered again and again to participate in the health studies that we reviewed. It is for them that we do this work. We hope this report will inform those who have given so much to our nation about what researchers have been able to learn about their health.
LYNN R. GOLDMAN, MD, MPH
JOHNS HOPKINS UNIVERSITY