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Gulf War illnesses … the story is still alive and well
  1. N Greenberg
  1. Correspondence to:
 Dr N Greenberg
 Surgeon Lieutenant Commander Royal Navy, King’s Centre for Military Health Research, Academic Dept of Psychological Medicine, GKT School of Medicine & Institute of Psychiatry, Weston Education Centre, Cutcombe Road, London SE5 9RJ, UK;

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Commentary on the paper by Kelsall et al (Occup Environ Med, December 2004)*

The story of Gulf War Syndrome (GWS) just won’t go away. It’s healthier now than ever. The controversy about whether a Gulf War specific syndrome exists and what may have caused it is one of claim and counter claim. In the UK the Ministry of Defence (MOD) has always strongly denied that anything amounting to a “Gulf War syndrome” exists, though it has accepts that some veterans have become ill and have been paid benefits accordingly. However, disgruntled veterans of the Gulf War have had a recent boost to their battered morale when a recent privately funded inquiry in the UK heard evidence in relation to the subject. The witnesses included scientists, senior military commanders, and veterans. Although the Law Lord who is presiding over the inquiry has yet to publish his report, it is hard to see how the findings will not fan the flames rather than douse the fire. Another source of flammable material in the debate was the recent report by the US Research Advisory Committee on Gulf War veterans’ illnesses which concluded that “a substantial proportion of Gulf War veterans are ill with multisymptom conditions not explained by wartime stress or psychiatric illness”.1

There can be no doubt that both physical and psychological ill health is associated with military service during the 1991 Gulf War. In common with studies from the UK and US,2–4 the recent OEM paper by Kelsall and colleagues5 shows that Gulf War veterans report a myriad of symptoms 2–3 times more commonly than service personnel that did not deploy. We also know that deploying to the Gulf War can impair quality of life and health perception. However, one of the key remaining unanswered questions concerns the issue of causation.

Kelsall and colleagues’ Australian cohort report experiencing numerous exposures that are associated with a high prevalence of self-reported health symptoms.5 Other studies have found similar associations.2,3 Those who claim that GWS exists implicate numerous environmental, military, and psychological stressors as being the “toxic” agents. Chemical weapons, depleted uranium, and multiple immunisations have all been put forward as causative agents of long term damage to the health of military personnel. Clearly if one could link war zone exposures to subsequent ill health, this would add significant weight to the argument in favour of GWS. There are, however, substantial difficulties in accepting that the reported associations are wholly valid.

Firstly, most of the studies that have examined ill health in GW veterans have been carried out many years after the end of the war. As well as the basic problem of remembering facts from an event many years ago, such memories are likely to be subject to recall bias. There is good evidence to suggest that when recalling hazards experienced during previous events, that recall is heavily influenced by current self-rated health perception. In other words, if you feel unwell when you are asked about possible exposures some years ago, you are more likely to recall that you were indeed exposed to suspected “toxins” than if you currently feel well.6 Unfortunately, gaining objective evidence of exposures is difficult to say the least. For example, when a group of UK service personnel who reported receiving vaccines in preparation for deployment to the Gulf War, but did not in fact deploy, had their records examined some years later, most showed that no vaccines of any sort were in fact administered.7

Staying on the issue of exposures, the Kelsall et al study finds, like others, that thinking that one has been exposed to chemical weapons is correlated with reporting symptoms of ill health.5 However, a series of expert review committees and panels have failed to be convinced by the suggestion of widespread use of chemical weapons during the Gulf War. If they are indeed correct, then how can we marry the fact that many people believe that they were exposed to chemical weapons when in fact they were not even used? Another anomaly is the Canadian experience using pyridostigmine bromide (PB) tablets, a prophylactic agent against some forms of chemical weapons and another “toxic” candidates for GWS. Two of the three ships they sent to the Gulf used PB prophylaxis, and one did not. Yet rates of illness were identical between the three ships.8 There are numerous other examples of exposures linking to the development of illnesses that simply do not make sense.

There is another, rather more important bias that works to muddy the already murky waters yet further: participant bias. As Kelsall’s group clearly points out, those who went to the Gulf have a clearly defined event in their mind to which they can attribute the onset of their symptoms.5 As a rule people search for meaning, and for many unwell veterans their Gulf service serves as the focus for their symptoms. Media fuelled speculation may have reinforced this belief, but once established, the belief is not prone to change. Indeed Hotopf and colleagues9 followed up a cohort of people who believed they had GWS, and found that four years later they remain unwell, although interestingly the health gap between the Gulf and the control (Era) group was narrowing. There can be no doubt that whatever the reason, a substantial number of those who went to the Gulf report poor health many years after the end of the war.

If, as it appears, psychological mechanisms may be responsible for the mismatch of perceived health status and actual physical functioning, then it might seem logical to assume that psychological factors could be to blame. Many studies, including that by Kelsall’s group, find an increase in the prevalence of post-traumatic stress disorder (PTSD) in Gulf veterans. However when the absolute risks are examined, the resultant attributable risk remains small—just 3% in Kelsall’s cohort.5 So although clearly relevant, PTSD alone cannot explain the increase in reported ill health.

It is clear that the extensive research into GWS has shown conclusively that a substantial number of GW veterans report feeling unwell. This finding has been replicated by scientists in numerous countries and cannot be doubted. However, research aiming to identify the elusive causative factor or factors has yet to deliver. Although no doubt there will be many more publications examining the health of those who served in the Gulf War, given the difficulties in verifying exposures and the difficulty in conducting research so many years after the end of the war, it is hard to see how this complicated jigsaw will ever be completed. Perhaps it is now time to examine what can be done to assist those who are suffering, and to continue to ensure that future conflicts leave those who serve without a legacy of ill health.

Commentary on the paper by Kelsall et al (Occup Environ Med, December 2004)*