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Environment and Exposures
OVERVIEW
There have been special concerns about a range of both naturally occurring
and either purposeful or accidental environmental exposures of troops during Me
Persian Gulf War (POW) that are discussed in this chapter.
Objective indicators of harmful environmental exposures in the Persian
Gulf (PG) were limited in scope during the POW and are not readily usable for
research purposes. Monitors of air and soil contaminants were not operating for
the full period of Operation Desert Shield/Storm (ODS/S), and other kinds of
exposures were not measured. Exposure indicators of other than air or soil were
not available. Autopsies of animals and humans and follow-up examinations of
military working dogs (MWDs) have not indicated the presence of excessive
toxic or heavy metals, particularly when data before and after the oil well fires
are compared. Official reports of acute health consequences from exposure to
air pollutants were rare.
It is clear from written descriptions and reports by veterans that the PG was
a hostile environment. Desert conditions, the absence of amenities,
uncomfortable temperatures and humidities, extremes in rainfall, blowing sand,
insects, animals, fumes, and smoke all contributed to adverse living
conditions. In addition, wartime conditions, including measures uniquely
designed to protect the troops, necessitated other exposures such as vaccines
against possible biological warfare (BOO) agents, pyridostigmine bromide (PB)
to protect against possible chemical warfare (COO) agents, and pesticides to
36
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ENVIRONMENT AND EXPOSURES
37
protect against bites from insects carrying diseases such as sandfly fever and
leishmaniasis. Depleted uranium (DU), used in munitions and tank armor, was
a limited but real wartime exposure. Unfortunately, there was no systematic
accumulation of data on these exposures, making research into their possible
health effects exceptionally difficult, if not impossible.
In the midst of these adverse environmental and wartime-related exposures,
soldiers were vulnerable to all of the exposures connected with their particular
occupations in the Gulf, such as chemical-agent-resistant coatings (CARCs),
solvents, and vehicle exhaust fumes. Information about "unofficial" exposures,
such as the combustion products of leaded fuels in heaters that were sometimes
unventilated or nonregulation, wearing flea collars to protect against insect bites,
and ingesting alcohol substitutes in the absence of approved alcohol
consumption is available only from self-reports.
Not surprisingly, the above scenario creates a picture of an extremely
stressful environment, filled with the dangers and trauma of war, combined with
a hostile living and work environment. Contributing to this stress were the lack
of sanitary conditions and privacy (particularly when men and women were
serving together); the speed of being "called-up" to duty and thrown into this
environment; "watchful waiting" for the shooting war to begin or SCUD
missiles to explode; apprehension heightened by drills and training exercises
relating to the threat of chemical and biological warfare (CBW); intense
workloads; and sleep deprivation. Additionally, issues related to unit cohesion,
leadership, morale, and knowledge of family stresses back home varied among
individuals but are important for full understanding of the experience of the
entire deployed cohort.
Although a wide range of possible exposures might be associated with
adverse health outcomes in PG veterans, data on these exposures are often not
available; when they are available, they are poorly documented. This lack of
exposure information is at the core of the frustration in obtaining answers from
epidemiologic studies. Self-reports of exposure and estimates of individual
exposure from unit-level measurements will be subject to so much error that
they are likely to yield inconclusive results and additional questions.
This situation leads us to recommend improvements in collecting data on
exposure assessment in future military deployments. We divide our more
detailed discussion of exposures into two broad categories: the physical
environment, which includes both the natural and the man-made environments,
and psychosocial exposures. Generally, it is relatively straightforward to list
potential causative agents, but exposure estimates related to POW operations are
crude and unreliable. Efforts are under way to obtain additional estimates and
improve current estimates, but there is little potential for substantial
improvement.
The working conditions and exposures that veterans encountered in the PG
include the natural environment of the POW theater of operations, as well as
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38
HEALTH CONSEQUENCES OF THE PERSIAN GULF WAR
occupational and combat-related exposures and situational stresses that combine
all of the aforementioned. The environment and exposures of interest included
those enumerated earlier, as well as dirt, sanitary conditions, endemic infectious
diseases, flora and fauna, oil well spills and fires, pesticides, oil and petroleum
products (especially jet fuel and diesel fuel containing lead additives), mycotoxins,
and decontamination solutions. Occupational exposures were related mainly to
general maintenance operations and include battery repair, cleaning and
degreasing, electronic and radio repair, generator repair, grinding and sanding,
sandblasting, lathing and milling, painting (especially with isocyanate-based
paints), refrigeration servicing, vehicle repair, weapons repair, and welding and
cutting. Work shifts were often longer than peacetime work schedules (e.g., 12-
16 hours), with fewer "time-off' periods (e.g., weekends and holidays), so that
permissible exposure levels based on 8-hour shifts may not afford protection
similar to that in civilian settings.
The environment also was made more complex by the exposure of a large
number of troops to potentially life-saving vaccinations, to medications
administered in an effort to protect troops from chemical warfare (e.g.,
pyridostigmine), to clothing treated with permethrin, and to insect repellents
(especially N. N-diethyl-m-toluamide Deem. All of this took place in a
background of the barrage of news reports that reinforced the unknown nature
of the threat the soldiers faced. The possibility of CBW was considered very
real; most combatants expected the Iraqis to launch attacks by missiles
containing both explosives and chemical or biological weapons. In addition,
some accustomed ways of-relieving stress were simply absent. For example,
interchange with the indigenous population was almost entirely forbidden, and
there were severe restrictions on the availability of alcoholic beverages. The
ease of communication with home, while in certain respects providing
emotional support, also served to keep some people focused on what they had
left, as well as on their current task. Finally, the level of casualties was very
low; the lack of battle casualties in the PG may have diminished the possibility
of rationalizing an acceptable trauma as a way to explain puzzling tensions and
anxieties. The absence of this traditional military avenue for both experience
and release of stress, and for explanation of the psychological symptoms being
experienced, may have unmasked emotional conflicts that were perhaps harder
to understand than when or if they had been experienced in previous conflicts.
Thus, service personnel stationed in the Gulf were exposed to an
extraordinary array of environmental conditions. Their complex experiences
combined to yield what is truly a varied and sometimes confusing picture of
exposure that has proven difficult to understand, much less reconstruct. Herein,
we delineate the relevant exposures by reviewing available data, recognizing
that these exposures combined to produce an environment that is more complex
than can be easily described or evaluated.
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ENVIRONMENTAND EXPOSURES
NATURAL ENVIRONMENT
39
Characteristics of the natural environment in the PG were discussed in the
committee's first report and are summarized as follows. Mean daily low and
high temperatures, respectively, were 80°F and 108°F in July (temperatures
could reach 130°F on a summer day [Young et al., 1992~) and 45°F and 65°F in
the winter in the coastal region. Temperatures in the northwest desert were
reported to be lower. Except in coastal regions, the relative humidity was less
than 40% during the summer (less than 6% inland [Young et al., 19923), but more
than 60% during the rainy season (December through March). Solar heat was
intense in the summer. Rain was minimal but sometimes caused tents to flood.
Many troops were located in desert settings. Sand was ubiquitous and often
powdery, and persons with respiratory conditions sometimes reported pulmonary
symptoms. Whether these symptoms were properly attributed to sand rather than
to the type of living structure (tent versus air-conditioned building) or other
problems has not been determined (Richards et al., 1993b).
Review of sanitation in the PG theater is not currently possible from available
records. The following has been reported as a summary of the sanitary conditions
(O'Donnell, 1994~:
Staging areas near ports of entry were characterized by crowded tent living with
strains on latrine facilities, showers, and feeding. The prototype four-seat latrines
were mass produced by contract in country. Latrines were designed for suction
removal of waste by contractors or but out. Early designs permitted ingress of
flies. In the desert environment, daily burning out of waste cans employed
mainly diesel filer. Smoke from such fires was common, though rapidly
dispersed by prevailing winds. Solid waste disposal was handled by contract in
the staging areas and by burning in pits in the desert. Locations for bum pits and
latrines were usually chosen carefully to minimize nuisance from smoke, smells,
and flies. When shower/bath units were not available, many field expedients
were improvised. Likewise for laundry. As shower setups became available or
were improvised, an unforeseen problem was heating the water once the cooler
weather set in. Time intervals between showers and unicorn laundering were
sometimes lengthy.
Anecdotal reports suggest that living and working areas were subject to smoke
from waste fires for the duration of the fire. Efforts to minimize the nuisance of
latrines and burn pits were not always successful because of wind shifts.
The possibility that troops were exposed to contaminated water or food was
low, because local drinking water was processed and treated before use. Troops
were usually provided with sealed containers of drinking water; food was provided
at mess halls or as a meal ready-to-eat (MRE) sealed in plastic; personnel generally
did not eat food produced in local areas.
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HEALTH CONSEQUENCES OF THE PERSIAN GULF WAR
An exposure of concern to troops in the PGW was the bite of the sand fly,
which may carry the parasite that causes leishmaniasis and sandfly fever. Many
cases of cutaneous leishmaniasis were expected, and a small number were in
fact observed. What had not been expected was the appearance of a new
manifestation of leishmaniasis caused by Leishmania tropica (Magill et al.,
1993; MMWR, 1992~; L. tropica usually causes cutaneous disease but was
described with visceral symptoms as viscerotropic leishmaniasis. Visceral
leishmaniasis usually is caused by L. donovani, but exposures during ODS/S
included L. tropica, which is hard to detect and makes the diagnosis or
exclusion of leishmaniasis more difficult. At least 12 cases of visceral disease
have been reported, but diagnosis is difficult and requires isolation of the
parasite from bone marrow and no sufficiently selective and specific serology
and skin tests have yet been developed. It has been postulated by some that this
new form of the disease may be an explanation for some of the undiagnosed
illnesses in PGW veterans.
The committee's first report recommended support of continued research
on leishmaniasis, especially to develop improved techniques for diagnosis, and
further study of the ecology of the disease. Both the Department of Veterans
Affairs (DVA) and the Department of Defense (DoD) have continued to support
basic scientific research in response to these recommendations (see Appendix
F), particularly the development of a skin test to diagnose leishmaniasis.
Other exposures to fauna also have been described (O'Donnell, 1994~:
Filth flies were a universal problem in the warm months. Latrines and food
sources were attractants. The use of screening, self-closing doors, fly traps, fly
bait, and pesticides were moderately successful suppressants. Various types of
scorpions and snakes such as the horned viper were common in the desert, and
envenomation of personnel occurred occasionally. Although biting spiders were
present, they were not a problem. Mosquitoes were a factor only in the Euphrates
Valley. Bared flies were present, as evidenced by the cases of leishmaniasis, but
were difficult to find even when searched for. Sheep and camels were commonly
observed in the desert. Dead sheep were open reported, but veterinary inquiries
disclosed no signs of unexpected causes of death. Unit pets or mascots were
officially banned but some small units adopted stray dogs and obtained veterinary
care through Saudi sources.
There have been numerous and persistent reports in presentations by
individuals who were present during the PGW of finding large numbers of dead
sheep, goats, camels, and other animals in the region. One published report
assessed the histopathologic and chemical analysis of 26 feral cats exposed to
the Kuwait oil fires (Moeller et al., 1994~; the analysis concluded that there was
little evidence of harm from the environment. This has engendered some
concern that the cause of death of these animals was chemical and/or biological
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EN, FIR ONMENT AND E)fP OS URES
41
weapons used in the Gulf at the time of the war. Additionally, veterinarians in
Kuwait found no animal deaths due to chemical or biological weapon use,
although many animals were killed by Iraqi soldiers and many died from water
deprivation. In an effort to evaluate this matter further, the committee has
attempted to locate and review as much relevant material as possible, including
internal documents of the U.S. armed services that were generated both at the
time of the PGW and later.
The Army was well aware at the outset of the PGW that zoonotic diseases
could be a major issue. Defense against chemical and biological weapons was a
high priority. As a result, Army veterinarians, Air Force Special Operations
Medical Officers, Army Chemical Warfare Specialists, and physicians
specializing in infectious diseases were in the theater to evaluate any unusual
animal deaths. An investigation of thousands of dead sheep was conducted
early in Operation Desert Storm (ODS) after dead animals had been observed in
various locations and at different times by Army medical personnel. The team
estimated that the animals had been dead for various periods, ranging from days
to months. Several investigative teams concluded that the areas in which the
animals were found seemed to be dumping grounds for those that had
succumbed to indigenous bacterial illness. Biological samples from this site
were analyzed by the U.S. Army Medical Research Institute of Infectious
Diseases (USAMRIID) and found to be negative for anthrax. Other reports of
dead sheep were received but were not investigated due to poor weather
conditions and inadequate description of the location of the dead animals.
However, the U.S. agriculture attache advised military authorities that a 5-10
percent death rate from endemic infectious agents in sheep was common and
that dead sheep were routinely stacked along common roadways to allow
government inspectors to check ear tags and arrange for indemnity payments.
This information was disseminated to U.S. Army veterinarians, and based on a
lack of clinical signs in animals grazing nearby, no further clinical investigations
were conducted during ODS. During the ground war, one on-site investigation
of dead sheep was conducted and was negative for chemical or biological
weapon use.
After the war, discussions with local veterinarians confirmed that the
practice of placing dead sheep by roadsides is common. Local practitioners
have been consistently unaware of any unusual occurrences of death of sheep
during or after ODS. Veterinarians and other medical personnel reported nearly
unanimously that animal deaths from enzootic disease and trauma were
common on the open range, even in the absence of military forces. These
enzootic diseases are not known to be transmitted to people under the
circumstances that existed during ODS/S (Stevens, 1995~.
Approximately 140 MWDs were deployed to various locations in the PG
(Dutton, 1995~. Since the PGW, 3 1 of these dogs have been euthanized because
of arthritis, senility, cancer, temperament, multiple organ failure, and visual or
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42
HEALTH CONSEQUENCES OF THE PERSIAN GULF WAR
inner ear problems; 5 died of natural causes (1 of heart failure and 4 of twisted
stomach). No evidence of unusual morbidity or mortality was reported.
The committee reviewed a protocol for a study of 129 MWDs identified as
deployed to the Gulf between August 1, 1990, and February 28, 1991. From
this cohort of deployed dogs, pathological specimens will be examined for
approximately 20 MWDs that had died or been humanely euthanized and
approximately 20 matched MWDs that had not been deployed to the Gulf.
Additionally, MWDs deployed to the Gulf will be compared to a similar number
not deployed to the Gulf (including follow-up until death or humane euthanasia)
for pathologic, clinical, and demographic differences.
MAN-MADE ENVIRONMENT
Pesticides
Reports to this and other panels (such as the DVA's PG Expert Scientific
Panel) have been made on the use and safety of pesticides in the PG and in general
(Berte, 1994~. The pesticides available in the PG during ODS/S included (in
pounds) malathion (45,770), chlorpyrifos (8,410), D-phenothrin (1,858),
methomyl (903), and lindane (539~. Pyrethrin, dichlorvos (DDVP), carbaryl,
propoxur, and diazinon were also available but in amounts less than 330 pounds.
It is not known how much of this inventory of pesticides was actually used or what
troop exposures may have resulted (Bolton, 1995~.
The use of pesticides in the Gulf was reported to have followed strict
guidelines (Bolton, 1995~. They were used only after arthropod surveys that
identified individual pests and estimated arthropod prevalence. Distribution of
pesticides was prohibited unless approved by the local commander. Distribution
or use for other than personal purposes was restricted to trained or certified
personnel or contractors. There were some reports by troops of rash from misuse
of dog flea collars.
The insect repellent permethrin was used to treat uniforms in the PG; the
material used to make the uniforms used during ODS/S was not pretreated in the
factor with permethrin. Some troops were reported to have both used Deet on
their skin and treated their clothing with permethrin between August and October
1990 (the peak occurrence of arthropods). From October 1990 to February 1991,
the need for Deet and permethrin decreased as the population of arthropods
declined (Bolton, 19959.
Personal application of the insect repellent (33 percent Deet) provided to
soldiers for use on the skin has been calculated based on the amount of repellent
ordered for the Gulf operation and the amount returned (Bolton, 1995~. An
average of approximately 2.7 tubes of repellent was available for use per
soldier. The recommended deployment issue was two tubes per person, with
each 60-ml tube containing an estimated 24 applications, or enough for
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ENVIRONMENT AND EXPOSURES
43
approximately 12 days. Similar calculations indicate an average of 0.1 bottle (2
ounces) of 75 percent Deet per soldier to be used for personal application to
clothing; this material could also have been applied to skin.
The virtual absence of reports of sandily fever (Richards et al., 1991) and
negative findings for sandily fever in tests of pre- and postdeployment sera
(Richards et al., 1993a) suggest that vector control was generally good. This
inference has been reinforced in reports that the deployed troops had no known
outbreaks of sandily fever, no evidence of typhus or spotted fever-group rickettsia
infection, 1 case of West Nile fever, 20 cases of cutaneous leishmaniasis, 12 cases
of visceral leishmaniasis, and 7 cases of malaria (Bolton, 1995; Hyams et al.,
1995).
There has been some concern about the delayed effects of pesticide exposure.
This concern is particularly prominent for organophosphorus pesticides, which
have been reported to be associated with a delayed neurotoxicity (Abou-Donia and
Lapadula, 1990~. The early biochemical events associated with organophosphate-
induced delayed neurotoxicity (OPIDN) remain unidentified. There are striking
species differences in susceptibility to OPIDN, as well as differences in the
potency of organophosphate compounds (Abou-Donia and Lapadula, 1990~.
Where comparative assays have been developed, the chicken is a commonly used
model system to assess the potency of compounds to induce OPIDN (Abou-Donia
and Lapadula, 1990~. In humans, symptoms of necrologic dysfunction typically
begin within 2 weeks of cessation of overexposure. Patients generally complain
initially of symmetric lower extremity weakness, with subsequent progression
lasting 3 - months after onset of symptoms. The patient may then enter a
"stationary" phase of the illness, often lasting 3-12 months. Improvement may be
observed ~18 months after onset of initial symptoms. Even in the most severe
cases, there is usually improvement in the upper extremity impairment. Spinal
cord damage can be permanent in the most severely affected patients.
Specific agents have been studied to determine their ability to induce this
condition. Chlorpyrifos, one of the pesticides used in the POW, was reviewed
recently by Richardson (1995), who concluded that exposure as a result of "normal
use" is unlikely to result in OPIDN. However, a report of eight cases of reversible
necrologic disease in individuals with an exposure to an unknown amount of
chlorpyrifos has raised some concern that a mild reversible sensory
neuropathology may be associated with subchronic administration. In general, it
appears that the average personal usage of the pesticides available in the POW
theater of operations was low and unlikely to be associated with the induction of
chronic disease.
Fuels and Decontamination Solution
Many different fuels were used in the PG both for vehicles and for heaters,
cooking stoves, and portable generators. The exhaust produced by these fuels
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HEALTH CONSEQUENCES OF THE PERSIAN GULF WAR
(particularly the reported use of unventilated heaters in living quarters that might
have contained mixtures of diesel and jet fuel) could have caused a variety of
exposures to combustion products, including lead. Information received in
response to a request to DoD on whether leaded fuel was used in tent heaters stated
that U.S. Central Command records indicated that approximately 145,000 gallons
of gasoline (leaded and from local sources) were consumed per day in the theater
between August 1, 1990, and March 30, 1991. These records did not indicate
whether the fuel was used for heating tents; it was intended for use in vehicles,
cooking, and power generation. The individual services provided information on
the use of leaded gasoline in tent heaters as follows: Air Force, electric heat
exclusively; Navy, kerosene and diesel fuel only; Marine Corps, diesel only;
Army, "has no record of leaded fuel use in tent heaters" (Cusick, 1996~.
To investigate further possible effects from this exposure, in combination with
other exposures that were prevalent at various times in the Gulf, DoD has funded a
laboratory study in rats to evaluate the toxicity of simulated PGW exposures. This
research initiative has as its chief aim the investigation of rodent responses to
exposure conditions similar to those experienced by PGW veterans. In an effort
to construct a rodent model of unexplained illness in PGW veterans, Sprague-
Dawley rats will be subjected to controlled experimental exposure to Deet,
pyridostigmine, and a mixture of diesel and jet fuel followed by an electrical
shock; controls will help to delineate possible effects of chamber exposures
alone, compared with exposures with stress-producing electrical shock.
Postexposure testing will include examination of central nervous system (CNS)
integrity (auditory startle and adaptation to auditory stimulus and
photosensitivity), testing of motor skills (grip and total activity),
neurotransmitter analysis at sacrifice, two-dimensional gel electrophoresis to
investigate whether novel stress-related proteins are produced in stressed
animals, clinical chemistry, and measures of immune function.
This ambitious protocol, as reviewed, may produce hypothesis-generating
data. However, generalization of any results to veterans will necessarily be
problematic. No variation in dosing will be done, and no dose-rate
considerations are included. Although these animals are useful models for some
known human conditions, the applicability of any adverse (or the opposite)
outcomes noted in these studies will inevitably be questioned.
Oil Well Fires and Spills
Many agencies were involved in monitoring and measuring various aspects of
the oil well fires and smoke (EPA, 1991; U.S. Gulf Environmental Technical
Assistance, 1992; WMO, 1991, 1992~. Several efforts have been made to
determine whether the oil well fires and spills created by retreating Iraqi forces
affected the health of U.S. troops (DoD, 1993; USAEHA, 1992, 19949. One major
effort at environmental assessment and health impact was undertaken by the
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ENVIRONMENT AND EXPOSURES
45
former U.S. Army Environmental Hygiene Agency (USAEHA), currently known
as the U.S. Army Center for Health Promotion and Preventive Medicine
(USACHPPM). Although exposures began when the first oil well fires were
ignited by the Iraqi armed forces during their retreat in February 1991, and some
lasted until November 1, 1991, USAEHA could not launch a successful air-
sampling effort until the beginning of May, after the more stagnant air conditions
of the winter months had passed. Those who undertook the sampling efforts did
so with this knowledge. They intended to address the problem as thoroughly as
possible by the use of meteorological modeling. A geographical information
system (GIS) is being developed to integrate information over space and time on
airborne and soil-based exposures, on meteorological conditions throughout the
study interval, and on unit troop movements during ODS. Once this model is
available, exposure of individual troops can be estimated throughout the region,
although further work will still be needed to validate the model and estimate its
. .
precision.
There were as many as 10 fixed air-sampling stations in the theater, but 2 of
them operated for less than 2 weeks and 2 more operated for only 2 months. Three
were in operation through the end of December 1991. These fixed sites were
located where troops were concentrated, and soil was sampled from the same
areas. The results are to be combined with National Oceanic and Atmospheric
Administration (NOAA)-assisted modeling and records of troop movements using
the GIS to estimate reasonable maximum individual exposures (RMEs) to the
chemical substances sampled. Data available include air and soil pathway analysis
and industrial hygiene sampling. Air and soil quality was estimated not to have
deteriorated during the sampling interval, and a reference to earlier sampling
suggests that air quality at some sites was even higher than before the war.
Increases in toxic metals in soil were not found during sampling except for metals
unrelated to Kuwaiti crude oil.
Air pollutants expected from the oil fires were classified into four categories:
reactants (uncombusted crude oil components), combustion products (e.g., carbon
dioxide and water), incomplete combustion products (e.g., carbon monoxide), and
products of secondary reactions (photolysis). The substances included short-chain
and low to medium molecular weight aliphatics such as butane and heptane (both
straight and branched chain) in the range of C2 to C40, simple and polycyclic
aromatic hydrocarbons (PAHs), benzene, heterocyclic compounds including
naphthalene and xylene, and substituted compounds such as methylated and
halogenated compounds. Air samples were assayed for suspended particulates,
both total and less than 10 Em in diameter, and for a series of volatile organics,
PAHs, and metals. A subsample was examined for sulfur dioxide, nitrogen
dioxide, coal-tar pitch volatiles, and acid aerosols. These agents were chosen as
likely to provide a reasonable estimate of the most important particulates of the oil
well fires and spills. The sampling was designed so that results could be used to
estimate risks of cancer and subchronic noncancer diseases.
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HEALTH CONSEQUENCES OF THE PERSIAN GULF WAR
So far, based on our present knowledge, none of the individual agents
sampled or detected seems likely to cause symptoms that would persist for months
or years after return from the PG. However, the modeling now in progress may
offer some improved understanding of the general environment of troops located
in different parts of the war zone or may raise questions about interactive effects or
combined exposures.
The USAEHA sampling (after May 1991) documented little deterioration of
general air quality during that period of air monitoring. Although substantial
increases were noted in particulates, concentrations were still considered "normal"
for this area of the Middle East. Exposures to organic compounds were similar to
levels observed in Houston and Philadelphia, cities with major petrochemical
industries. There were relatively high concentrations of naturally occurring
metals, apparently from wind-blown surface soils.
There was some concern about ingestion and dermal absorption of air
pollutants that had settled out, and these routes of exposure have been
considered (USAEHA, 19949. However, no measurements were taken, so
possible exposures through these additional routes can be estimated only by
mathematical models.
Further work by USAEHA is expected to provide a model of exposure
distributions and to incorporate information from earlier, more limited sampling
that might improve estimates of exposures at troop encampments. This work also
will examine the frequency and duration of exposures. The model will have to be
validated and its precision estimated before evaluating the relevance of the data.
The Armed Forces Institute of Pathology (AFIP) has completed a study of
351 autopsies of U.S. personnel who died between August 1990 and November
1991 in Southwest Asia (SWA) during ODS/S and shortly thereafter. Reviewed
were written autopsy records, histopathologic specimens, and toxicologic
findings. A group of 149 individuals who died before the oil fires were lit was
compared with a group of 202 who died after the fires were lit. No evidence
was found to support an association between autopsy, histopathologic, and
toxicologic findings and any environmental exposures, including smoke from
oil well fires. Analysis for heavy metals from blood and tissue obtained at
autopsy did not indicate elevated levels attributable to exposure in the Gulf
environment (Peterson and Kalasinsky, 1996~. The initial findings (AFIP, 1994)
reviewed by this committee indicated that lead levels were elevated in some of
the specimens (IOM, 1995a). Since that time, investigators from AFIP have
stated that with respect to lead, no valid toxicological conclusions can be drawn
because some specimens were reportedly drawn and stored in collection vessels
containing lead. The methods and findings of this study are being prepared for
submission to a peer-reviewed journal.
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HEALTH CONSEQUENCES OF THE PERSIAN GULF WAR
use of DU-containing systems. Studies have shown that with the exception of
warehouses in which large quantities of DU munitions were stored, the estimated
annual exposure did not exceed the current standard of 100 mrem/year for the
general population (GAO, 1993a). Where this limit might be exceeded, standard
radiation protection programs were in place (Daxon, 1994~.
The radiological and toxicological hazards associated with long-term
exposure to imbedded fragments are uncertain. There are no known studies of the
long-term effects of DU metal implanted in tissues. Few ODS/S personnel were
exposed to DU. Activities of the 144th Service and Supply Company in fighting
fires, recovering vehicles, and cleaning the 29 tanks damaged by DU munitions led
to the potential exposure of 27 soldiers. Results from testing 12 of these soldiers
were reported as negative (GAO, 1993a), and the remaining 15 soldiers chose not
to be tested (DSB, 1994~. It is possible that there was wider exposure to DU of
troops who entered destroyed enemy vehicles either on duty or as sightseers or of
combat-support troops who were exposed to battle dust after tank battles or to
contaminated smoke from explosion and fire in the destruction of ammunition
storage.
~ friendly fire incident wounded approximately 35 U.S. soldiers, of whom
approximately 22 were suspected to have retained DU fragments (Daxon, 1993~.
These wounded soldiers were offered close follow-up after the war as part of a
DVA-funded medical surveillance program. Thirty-three of these 35 soldiers
continue to be followed and studied. After 3 years, 15 of the 33 soldiers had
detectable shrapnel. The initial work has demonstrated no evidence of toxicologic
effects, but it has been noted that uranium excretion is significantly higher in
soldiers with known retained shrapnel, supporting the contention that the shrapnel
is not inert (Keogh, 1995~.
Currently, two animal studies funded by DoD are under way to evaluate the
long-term effects of DU. The first study is designed to investigate a rodent
model of DU tumorigenesis and is being conducted by investigators at the
Armed Forces Radiation Research Institute. Since little is known of the precise
tumorigenic potential of this material, these researchers propose to conduct a
long-term study in male F344 rats. The protocol includes a low- and high-dose
2- to 3-year exposure to implanted natural uranium wires. At the same time a
companion study of the renal toxicity of DU is also proposed. This study will
investigate the kinetics of renal excretion of uranium and possible toxicity from
long-term exposure.
These studies are useful in that they provide additional information about
the chronic toxicity of uranium compounds. However, since the investigators
must use nondepleted uranium and since available data indicate that the
carcinogenicity of this compound is likely to be low, it is not known whether
these experiments will add important new information.
The second study, conducted at the Inhalation Toxicology Research
Institute, is a 3-year rodent study utilizing three doses of DU with implanted
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ENrVIRONMENT AND EXPOSURES
57
tantalum and nonimplanted sham controls to study the behavioral effects of DU
and the histologic and biochemical effects of implanted exposure and to
evaluate uranium distribution throughout the body. CNS effects of exposure
will be studied by evaluation of autonomic, sensorimotor, and neuromuscular
alterations. Excitability and arousal also will be measured. Peripheral nerve
conduction will be measured and hippocampal electrophysiology will be
studied. Blood and urine samples will be collected and chemistries done. The
bones (femur), hippocampus, sciatic nerve, kidney, liver, spleen, and muscles
will be studied histologically. Renal function will be examined in detail.
Finally, the tissue distribution of uranium will be quantified.
This protocol will provide detailed information on the toxicity of DU in
rodents, which is useful information. However, studies already completed
suggest that there is little evidence that DU will produce any novel toxic picture.
PSYCHOSOCIAL EXPOSURES
A wide array of potentially toxic environmental agents has been considered
in relation to health and ODS/S service. These include not only physical and
chemical hazards but also the personal, social, and organizational context of
service in the Gulf, the stressors present or generated in each domain, and the
effects of these stressors on service personnel. Both physiological and
psychological stress responses occur when humans are confronted with demands
to adapt, change, or reorganize their lives or ways of thinking about themselves
and those about them (Stretch et al., 1996~. Stressors are those events or
circumstances that produce challenge or threat.
It is not easy to compare the levels of stress, or the responses to stress, in
the POW with those in previous military engagements. One difference is that
PG military personnel did not have the level of detachment possible in prior
conflicts. Easy telephone communication to family and friends, up-to-date news
services, even the very rapid mobilization itself tended to keep people's "heads"
back home while their bodies were in the Gulf theater. Another difference was
that some of the accustomed ways of relieving stress were simply absent, among
them interchange with the indigenous population (almost entirely forbidden)
and access to alcoholic beverages (also forbidden). Further, the stress was
acute, and it was everywhere, even far from the front lines. Entry into that
situation was rapid, with little opportunity to prepare or be prepared. Similarly,
reentry into U.S. society was rapid, with very little time or opportunity to
accommodate.
A further difference of the POW from most earlier conflicts is that U.S.
combat troops in the PG experienced very low levels of casualties and benefited
from vastly improved means of dealing with infectious diseases. Puzzling
reactions and symptoms seen during and after prior conflicts may have been
incorrectly attributed to battle casualties and infectious diseases that were
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HEALTH CONSEQUENCES OF THE PERSIAN GULF WAR
considered unavoidable and even relatively acceptable outcomes of war. Thus,
the lower prevalence of battle injuries and infections in the Gulf theater may
have unmasked psychophysiological symptoms that were present in earlier
conflicts but attributed to injury and casualty.
The individual's perception and appraisal of events play a strong role in
shaping the impact of stress. Most personnel who served in the PG would
probably concur that the constant threat of CBW was stressful, that SCUD
attacks and uncertain risk of other attacks or counterattacks by the Iraqi army
were stressful, and that field conditions were often stressful. At the same time,
each individual perceived the specific events associated with his or her
experience in the POW as more or less stressful. Moreover, events in the theater
were experienced in the context of life situations predating the POW, and the
novel stressors of deployment were superimposed on the unique physical,
physiologic, and mental state of each person.
In anticipation of the psychological stress that would be created by a high-
threat deployment to a harsh environment for ODS/S, DoD initiated a series of
studies of the stress of deployment by sending a research team to SWA during
September 1990 as the theater was being established. Beginning with that initial
study, a 2-year program of studies after ODS/S has been conducted under the
leadership of Dr. David Marlowe, Chief, Department of Military Psychiatry,
Walter Reed Army Institute of Research (WRAIR). This program has focused
on the stresses and psychological consequences of ODS/S and, more recently,
has addressed symptoms experienced by the troops.
This program has gathered data describing the stressors associated with
ODS/S deployment from a variety of sources, as follows:
1. data collected before combat from active army in SWA (approximately
1,200 persons in individual and group interviews, plus 2,850 by questionnaire);
2. data collected after combat, time 1 (approximately 800 persons in
individual and group interviews, plus 9,800 deployers and 830 controls by
questionnaire);
3. data collected after combat, time 2 (4,585 deployers and 2,249 controls
by questionnaire);
4. data collected from Pennsylvania and Hawaii, 2 years after combat
(1,739 deployed and 2,512 not deployed by questionnaire); and
5. additional data collected 2 years after combat from U.S. Army National
Guard and U.S. Army reserve troops (1,420 deployed to SWA and 1,995 not
deployed) and U.S. Army Individual Ready Reserves (IRR) (500 deployed to
SWA and 695 not deployed to SWA by questionnaire).
These studies are discussed in sequence below. Studies of active duty units
included men only; studies with reserve units included men and 8-9% women
(Marlowe, 1996~.
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59
Stressors Associated with Deployment
Studies of stress experienced by POW veterans deployed prior to the
beginning of the ground war were conducted during September and October
1990 (Marlowe et al., 1990a) and during November and December 1990
(Marlowe et al., 1990b); major findings are presented. Active Army members
participated in individual or small-group interviews with others of the same
rank. The purposes of these studies were to determine how stressful the
deployment was and the sustainability over time of the force in the theater. The
most consistently reported source of stress during this period was lack of
knowledge of probable tour length and return date, as well as lack of knowledge
of whether the troops would be called on for a protracted siege or combat in
other words, uncertainty about the parameters of deployment.
Examples of other stressors for some persons or groups in the theater
include separation from family and concerns about home; difficulties with mail
or telephone communications with home; heavy workload and sleep
deprivation, especially for combat support and service units; unsatisfactory
living conditions, including extreme crowding with resultant interpersonal
pressure and hostility; apprehensions about being in imminent danger; social
and psychological isolation of members of combat arms units; leadership issues
including poor morale; the lack of recreation facilities; heat, sand, and the desert
environment; and the severity of climatic conditions. Once telecommunications
were in place, soldiers could benefit from communicating with their families at
home, which remained a primary source of support (Wright et al., 1991~.
Major contributors to the stresses of ODS deployment included the high
estimation of Iraqi military capabilities and media anticipation of very high
casualties, the threat of CBW with related fears about the adequacy of MOPP
(mission objective protective posture) gear, and concerns about terrorism and
infiltration. For support troops, particularly those arriving later in the theater,
there was increasing apprehension about Iraqi capacities and the effectiveness of
U.S. gear. Confusion about and multiple changes in deployment departure dates
were also contributing factors (Marlowe, 1995~.
Anticipation of Combat
As conditions in the theater matured, access to amenities improved,
deprivation decreased, and events became more focused. Soldiers began to
experience more stress related to the anticipation of combat. The most salient of
these anticipated stressors were having a buddy killed, attack by enemy aircraft,
attack by enemy tanks, being wounded or killed, attack by enemy artillery,
COW attack, and inadequate medical care. The most prevalent of these were
chemical or biological attack (65%) and having a buddy killed (55%) (Marlowe,
1995~. Confusion about media estimates of potential casualty rates was a major
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HEALTH CONSEQUENCES OF THE PERSIAN GULF WAR
concern for those in combat units, whereas concern about failure of weapons
systems at critical points in the event of combat was more evident among
support units (Wright et al., 1991~.
It was evident to researchers at this early time that deployment was more
disruptive for reservists and their families than for active duty service members.
Unexpected, relatively sudden changes in circumstances created significant
financial and job-related concerns for many reasons. The ODS experience of
support units, many of whom were reservists, also differed from that of combat
units, most of whom were on active duty. Many support units had heavier
workloads, crowded and primitive living arrangements, and less clearly defined
roles and missions (Wright et al., 1991~.
Time spent in SWA prior to the initiation of war increased stress, probably
because of the stringent conditions of deployment for combat alms troops.
Anticipation of combat was stressful, but commencement of the ground war
actually relieved the stress that had built up over months of anticipation
(WRAIR, 1992~.
Combat Exposure
Major fears during the initial assault were of CBW, augmented by
conflicting information about the effective life of MOPP gear and conflicting
beliefs about the effects of antichemical and antibiological medications. As
many as 40% of soldiers in all units studied experienced incoming indirect fire;
40% of one unit and 70% of another reported experiencing mines and booby
traps; 40% in two units claimed to have fired rounds at the enemy and 30% to
have engaged in a firelight; about 18% in two units claimed a confirmed "kill";
about 80% in one unit and 60% in another saw enemy killed or wounded in
action; and about 44% in one unit and 36% in another saw civilians killed or
wounded in action (WRAIR, 1992~. Less than 2% of the soldiers in all three
brigades were injured or wounded themselves. About 14% in two units reported
seeing an American soldier wounded; fewer reported seeing an American
soldier killed. More than 10% reported a buddy wounded or injured. About
25% in one brigade, and 8 and 10% in two others, reported seeing an American
wounded by friendly fire; 1-3% of persons in these units indicated they had
seen an American killed. More than 20% in two units felt at some point that
they were in imminent danger of being killed (WRAIR, 1992~. Although actual
casualty rates were low, perceptions of danger were widespread due to fears of
CBW. The most stressful events were those involving lethality or injury. The
greatest combat trauma was in circumstances of "intimate violence" (e.g.,
vehicles in which a crew member was killed or wounded). Friendly fire had the
greatest emotional impact when it involved parties from the same company or
battalion. There were few combat stress casualties requiring intervention in the
field (WRAIR, 1992~.
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ENVIRONMENT AND EXPOSURES
61
Additional factors that some troops identified as stressful during
postcombat debriefings included having to take "untried experimental" drugs
and vaccines (PB, anthrax vaccine) with rumored "terrible" side effects,
continued attacks on civilians by Iraqis, oil fires and smoke, concern about time
of return home, accidental losses of unit members, concern about family and
family adjustment on return, and memories of traumatic events (Marlowe,
1995).
Aftermath and Long-Term Adjustment
Stress related to combat was only one of several categories of stressors
affecting soldiers after their return home from ODS. Stressors that were part of
the aftermath of combat experienced by the VIIth Corps 6-12 months after ODS
included the following in descending order of significance: unitlworkplace
climate, ODS-related stressors, reassignment and movement, downsizing of
military, and family issues (Marlowe, 19954. ODS-related stressors include
concerns with ODS experiences in the field and problems after return from the
theater.
Two years after return from ODS, four intercurrent stress factors, in
descending order of significance, were reported by members of the XVIIIth
Corps as follows: ODS-related issues, health and finances, unit climate, and
downsizing or job future issues (Marlowe, 1995~. Although major sources of
stress 1 and 2 years after ODS were related to current life issues for most
soldiers, a significant subgroup still saw their life problems as arising out of
ODS/S experiences (Marlowe, 1995~.
During 1993, at the request of Congress, DoD conducted additional studies
of veterans in Pennsylvania and Hawaii. A total sample of 4,334 veterans
responding to a survey was studied (31% response rate): 1,739 were deployed
during ODS/S (1,524 to the PG and 215 to other locations), 2,512 were not
deployed, and 83 had an unknown deployment status. There were 715 active
duty soldiers and 766 reservists among the deployed and 1,576 active duty
troops and 948 reservists among the nondeployed (Stretch et al., 1995, 1996~.
Although the response rate is low, opening the possibility of bias in the findings,
the general orders of magnitude of the stressors may be reliable.
Stressor clusters of deployment identified retrospectively in the
Pennsylvania and Hawaii study by reservists included possible exposure to
traumatic events, actual exposure to traumatic events, stresses of waiting for
deployment, stresses in the theater, and stresses at home. The pattern of
stressors was similar for the active duty component, with the exception of their
exposure to explicit stressors of combat such as being fired on by the enemy and
engaging the enemy in firefights. Exposure to oil fires and concern about that
exposure also have been stressors. Two years after the end of ODS/S, 50% of
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HEAL TH CONSEQ UENCES OF THE PERSIAN G ULF WAR
those who claimed exposure to oil well fires had at least moderate concern over
that exposure (USAMRMC, 1994~.
When asked to rate their current stress levels (two years after ODS), 66 and
67% of the active duty and reserve study participants who were deployed said
they were experiencing moderate to extreme stress compared with 59 and 55%
of the nondeployed active duty and reserve troops. When asked about the
effects of stress on their lives, 46 and 41% of the active duty and reserve troops
who were deployed responded that the effects were moderate or greater,
compared with 35 and 30%, respectively, of the nondeployed (USAMRMC,
19943.
In sum, "deployment of American forces to SWA created an interacting
nexus of acute, subacute, and enduring chronic stressors and stress responses"
(USAMRMC, 19949. Troops had been prepared for prolonged imminent danger
from combat and simultaneously had to deal with a variety of other war-related
changes, including a demanding workload.
Stressors identified in DoD studies were also indicated in DVA studies.
Reserve troops studied after they returned from ODS/S (N= 215) by Sutker et
al. (1993) identified (as stressful) separation from home, family, and friends
(18%~; SCUD missile attacks (15%~; austere physical environment (13%~; loss
of control, uncertainty, and fear of the unknown (8%~; lack of leadership (7%~;
protracted delays in return home after hostilities (5%~; inadequate supplies and
equipment (5%~; prolonged truck transport in the desert (4%~; lack of
information (4%~; and financial difficulties (3%~. These findings were borne
out by Wolfe et al. (1992c, 1993) in studies ofthe Fort Devens Reunion Survey.
Concems that existing scales to assess war stress are not sensitive to
experiences of women, ethnically diverse groups, or married and older military
personnel (a rapidly growing segment of the volunteer-based U.S. forces)
prompted Wolfe et al. (1993) to assess 2,344 POW veterans (including 208
women) to investigate the following three major stressor categories: traditional
wartime activities, nontraditional wartime events, and non-war zone
deployment-related experiences (domestic, vocational, and psychosocial
stressors). Veterans returning through Fort Devens, Massachusetts (including
active duty personnel, reservists, and National Guard men and women), were
evaluated within 5 days of their return from ODS/S and before they rejoined
their families. Stressors predictive of posttraumatic stress disorder (PTSD) were
measured by the Lauffer combat exposure scale score, a checklist expanded to
reflect ODS war zone experiences, and an open-ended format where
respondents described the most distressing incident of their deployment (Wolfe
et al., 1993~. These same stressors were associated with Mississippi Scale
scores (PTSD) and Brief Symptom Inventory (BSI)/General Severity Index
(GSI) scores indicating general psychological distress (Wolfe et al., 1993~.
Sutker et al. (1993) found that high levels of war zone stress, estimated by the
ODS war zone stress exposure scale (developed by J. Wolfe and described
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ENVIRONMENT AND EXPOSURES
63
earlier) were associated with greater numbers of psychological symptoms,
negative moods, PTSD symptoms, and physical or somatic symptoms among
215 veterans evaluated in New Orleans.
Sutker et al. (1994a,b) also evaluated the influence of particularly gruesome
war zone trauma in studies of troops mobilized to the PG for graves registration
duty. This duty involved handling the dead, as well as mutilated body parts
(e.g., matching body parts to the remainder of a corpse). Among 24 personnel
studied, 46% met criteria for PTSD. This study was replicated with a larger
sample (N= 60) of reservists who had been activated for service. Among those
who were deployed to the PG, 48% had a current diagnosis of PTSD and 65%
had PTSD in their lifetime. Among those who were not deployed there were no
reports of current or lifetime PTSD (Sutker et al., 1994b). These DVA-
sponsored studies have contributed uniquely to understanding the stressors
related to the transition home from the theater, and the data may be useful in
planning support for troops (especially reservists) in the future.
Gender Differences in Exposure to Stress
Women's health problems may be linked not only to their experiences with
the declared enemy in the POW but also to actions by U.S. troops (e.g., sexual
harassment or assault). Sexual harassment and assault during deployment
created social and physical stressors that may cause symptoms in the years after
the POW (Wolfe et al., 1992b).
Sexual assault and harassment were studied among 142 women reservists
who served in the Gulf and responded to a questionnaire 1 year after return.
These women were a self-selected sample of a larger group of 241 women
originally studied by Wolfe. Of the participants, 8% reported attempted or
completed sexual assault, 31% reported physical harassment, and 63% reported
verbal harassment during their Gulf War deployment (Wolfe et al., 1992b).
Issues raised regarding some additional stressors for women included
gender discrimination and low supplies of feminine sanitary products. Concerns
for privacy, important to both men and women, become particularly crucial
when men and women serve together in close proximity, as they did in the Gulf.
Studies currently under way are examining further the effects of stress from
harassment among women. In addition to studies of sexual harassment, this
committee supports the recommendations of another IOM committee that
recently reported in detail on research needs resulting from military women and
men living and working together in close quarters, in addition to those related to
sexual harassment, including the following (IOM, 1995b):
· the extent and impact of sex-role stereotyping of military women by
military officers, noncommissioned officers, and enlisted personnel;
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HEALTH CONSEQUENCES OF THE PERSIAN GULF WAR
the prevalence, contributing factors, and effect of physical arid sexual
assaults and sexual harassment of women in the Armed Forces;
· effects of promilitary sexual abuse or violence history and military
traumatic experiences on psychological health arid job performance;
· outcomes of treatment for traumatized servicewomen; and
.
strategies for harming sanitary needs.
DVA ENVIRONMENTAL HAZARDS RESEARCH
CENTERS
In January 1994, DVA announced a program to establish centers for basic and
clinical science studies of environmental hazards. Up to $500,000 per year for 5
years would be provided for support of the centers to engage in basic research on
environmental health effects, with special emphasis on the diagnosis and treatment
of medical problems currently being reported by POW veterans. The DVA was
especially interested in new initiatives that complemented current activities and
suggested that interorganizational agreements and scientific affiliations be
encouraged, if they were justified and properly set up; this would include
collaboration with non-DVA researchers.
The environmental hazards research centers (EHRCs) were established in July
1994 in the DVA Medical Centers (VAMCs) in Boston, Massachusetts; East
Orange, New Jersey; and Portland, Oregon. The environmental centers were fully
funded by the end of 1994.
The committee received written materials and heard oral presentations by
representatives from each of the DVA EHRCs. Overall, the research activities,
selected for funding by the DVA Central Office, are investigator-initiated,
reflect local interests and expertise, and will have some serious limitations in
broader use for either understanding causes of illness in returning PG veterans
or assisting in determining whether returning veterans had illnesses different
from or more frequent than might have occurred had these persons not been
deployed. It is unclear whether or how these funded research activities are
being managed by any research coordinating body of either DoD or DVA. The
committee learned, as this report was being finalized, that the centers were
reviewed on-site in March 1996 by external reviewers and that comments and
responses by the EHRCs will be reviewed by the Research Working Group
(RWG) of the PG Veterans Coordinating Board.
Research at the Portland EHRC is focused on unexpected illnesses as
reported by returning PG veterans, with a particular focus on threats to the
necrologic and musculoskeletal systems (reflecting complaints reported by
veterans with symptoms but without diagnoses). As is true elsewhere, few data
documenting actual exposures are available. Temporal segments of activity
(Operation Desert Shield only, Operation Desert Storm only, desert cleanup
only, etc.) are highly inaccurate surrogates for exposures and create the potential
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ENVIRONMENT AND EXPOSURES
65
for unknown heterogeneity and misclassification. A majority of Portland's
respondents to date have not elected to join the DVA PG Health Registry
(PGHR), further emphasizing that the PGHR is not an appropriate tool for
research. Use of sophisticated neuroendocrine tests performed many years after
the conflict can have only limited usefulness in characterizing risks of
deployment or reentry after the conflict.
Researchers at the East Orange, New Jersey, EHRC hypothesize that
chronic fatigue and chemical sensitivity are associated with many of the
unexplained symptoms and illnesses among returning PG veterans. Criteria for
chronic fatigue syndrome (CFS) changed from those proposed in 1988 to less
restrictive criteria in 1994. The syndrome is poorly characterized and not
universally accepted as valid. If chronic fatigue and chemical sensitivity
become accepted medical entities, the lack of population-based estimates of
frequency and severity will still complicate assessment of whether these
syndromes among returning veterans are associated with or caused by military
service. The use of extensive (and expensive) laboratory tests of immune
function, interferons, and cytokines and the numerous magnetic resonance
imagings (MRIs) of these people raise questions about resource allocation.
Developing objective measures of the effects of chemical exposures on possibly
chemically sensitive individuals has been proposed as one of the center projects
and may be of some utility in civilian settings, but it will have little practical
application in the mobilization and deployment of large numbers of healthy
troops unless future epidemiologic work, utilizing accepted diagnostic criteria,
demonstrates an increased prevalence among deployed veterans. Such measures
might then be used as Remobilization screening to assist in later diagnostic
evaluation of symptomatic individuals. The project that hypothesizes individual
differences in susceptibility to stress and vulnerability is intriguing, although the
challenges of interspecies extrapolation from rodent models will require careful
interpretation.
Studies at the Boston EHRC will, in part, continue to utilize the longitudinal
follow-up of a group of PG veterans who returned through Fort Devens,
Massachusetts. Although this appears to be a strength, the small number of
participants is likely to limit investigators' abilities to address their research
questions. Clinical studies of the hypotheses that higher exposures to
combustion products of oil well fires impair pulmonary function 5 years or more
after exposure are unlikely to be fruitful, in part because of the small sample
size. A state-specific study (Massachusetts) of differential cancer incidence
among returnees may have too few events to justify support, particularly given
the young age of most of the deployed force. If this were to be judged as an
important undertaking, a larger group-perhaps even the entire cohort of
approximately 697,000 returning veterans-could better address such questions
of cancer incidence and mortality.
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HEALTH CONSEQUENCES OF THE PERSIAN GULF WAR
In summary, the DVA-funded EHRCs facilitate the application of research
skills available at selected VAMCs across the United States, but these research
efforts will have limited ability, individually or collectively, to contribute to
understanding the health effects of military service in the POW. The committee
has not evaluated other uses of these research programs.
Representative terms from entire chapter:
gulf war
