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Health Consequences of Service During the
Persian Gulf War: Recommendations for
Research and Information Systems
Committee to Review the Health Consequences of Service
During the Persian Gulf War
Medical Follow-up Agency
Institute of Medicine
NATIONAL ACADEMY PRESS
Washington, D.C. 1996
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NATIONAL ACADEMY PRESS · 2101 Constitution Avenue, N.W. · Washington, D.C. 20418
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 competencies and with regard for appropriate balance.
This report has been reviewed by a group other than the authors according to
procedures approved by a Report Review Committee consisting of members of the
National Academy of Sciences, the National Academy of Engineering, and the Institute
of Medicine.
The Institute of Medicine was chartered in 1970 by the National Academy of
Sciences to enlist distinguished members of the appropriate professions in the
examination of policy matters pertaining to the health of the public. In this, the Institute
acts under both the Academy's 1863 congressional charter responsibility to be an adviser
to the federal government and its own initiative in identifying issues of medical care,
research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine.
Support for this study was provided equally by the Department of Veterans Affairs
and the Department of Defense (Contract Not V101~93)P-1417~.
International Standard Book No. 0-309-05536-9
Additional copies of the report are available for sale from:
National Academy Press
Box 285
2101 Constitution Avenue, N.W.
Washington, D.C. 20055
Call 800-624-6242 or 202-334-3313 (in the Washington metropolitan area)
Copyright 1996 by the National Academy of Sciences. All rights reserved.
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The serpent has been a symbol of long life, healing, and knowledge among almost
all cultures and religions since the beginning of recorded history. The image adopted as
a logotype by the Institute of Medicine is based on a relief carving from ancient Greece,
now held by the Staatlichemuseen in Berlin.
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COMMITTEE TO REVIEW THE HEALTH
CONSEQUENCES OF SERVICE DURING THE
PERSIAN GULF WAR
JOHN C. BAILAR III,* Committee Chair, Professor and Chair, Department of
Health Studies, University of Chicago, Chicago, Illinois
CHRISTOPHER C. GREEN, Executive Director, Research and Development,
General Motors Corporation, Warren, Michigan
RICHARD B. HORNICK, Vice-President of Medical Education, Orlando
Regional Healthcare System, Medical Education Administration, Orlando,
Florida
KARL T. KELSEY, Associate Professor of Occupational Medicine and
Radiobiology, Harvard School of Public Health, Boston, Massachusetts
WAYNE M. LEDNAR, Corporate Medical Director, Eastman Kodak Company,
Rochester, New York
THOMAS A. LOUIS, Professor and Head, Division of Biostatistics, University
of Minnesota School of Public Health, Minneapolis, Minnesota
GARY M. MARSH, Professor, Department of Biostatistics, Graduate School of
Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
DAVID P. RALL,* Institute of Medicine Foreign Secretary, Washington, D.C.,
Director, Emeritus, National Institute of Environmental Health Sciences,
National Institute of Health, Bethesda, Maryland
PHILIP K. RUSSELL, Professor, Department of International Health, School of
Hygiene and Public Health, Johns Hopkins University, Baltimore,
Maryland
DAVID A. SAVITZ, Professor and Chairman, Department of Epidemiology,
School of Public Health, University of North Carolina, Chapel Hill, North
Carolina
G. MARIE SWANSON, Director, Cancer Center, and Professor, Department of
Family Practice and Medicine, Michigan State University, East Lansing,
Michigan
GUTHRIE L. TURNER, Jr., Chief Medical Consultant, Department of Social
and Health Services, Division of Disability Determination Services,
Washington State, Olympia, Washington
MARK J. UTELL, Professor, Department of Medicine and Environmental
Medicine and Director, Pulmonary/Critical Care and Occupational
Medicine Divisions, University of Rochester School of Medicine,
Rochester, New York
JAMES H. WARE, Dean for Academic Affairs, Harvard School of Public
Health, Boston, Massachusetts
DAVID H. WEGMAN, Professor and Chair, DeparUnent of Work Environment,
University of Massachusetts, Lowell, Massachusetts
*Member, Institute of Medicine
. . .
zi!
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LOUIS JOLYON WEST, Professor, Department of Psychiatry and
Biobehavioral Sciences, University of California, Los Angeles, School of
Medicine, Neuropsychiatric Institute, Los Angeles, California
ELIZABETH A. WILLIAMS, Associate Professor, DeparDnent of Internal
Medicine, James Quillen College of Medicine, East Tennessee State
University, Johnson City, Tennessee
NANCY FUGATE WOODS,* Director, Center for Women's Health Research
and Professor, Family and Child Nursing, University of Washington,
Seattle, Washington
Study Staff
DIANE J. MUNDT, Study Director
AMANDA H. MURRAY, Research Associate
CARLISS PARKER-SMITH, Project Assistant
IV
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Preface
The Committee to Review the Health Consequences of Service During the
Persian Gulf War was charged to assess actions taken by the secretaries of the
Department of Defense (DoD) and the Department of Veterans Affairs (DVA)
to collect and maintain data on the health of Persian Gulf veterans, to make
recommendations to improve the collection and maintenance of such data, and
to determine whether there is a sound scientific basis for an epidemiologic study
of the health consequences of service and, if so, to recommend the types of
studies that should be undertaken.
The committee presents 14 findings and 16 recommendations that are
intended to improve the nation's understanding of the health consequences of
military service in the Persian Gulf, to ameliorate or prevent future health
consequences to troops deployed there or in other conflicts, and to improve and
accelerate the collection of the information necessary for studying potential
problems in the future.
As we publish this report, it will have been about 6 years since
approximately 697,000 Americans were deployed to the Persian Gulf, while a
nation watched the war unfold on the various news networks. Many questions
remain about the health of Persian Gulf veterans and the possible causes of the
medical symptoms that many veterans have reported. Some persons believe that
a new "Gulf War Syndrome" has appeared and that the symptoms and illnesses
that are unexplained are in fact a new disease.
v
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Vl
PREFACE
In January 1995, this committee published a first report, Health
Consequences of Service During the Persian Gulf War: Initial Findings and
Recommendations for Immediate Action (Washington, D.C.: National Academy
Press), that was critical of the initial actions taken by the DoD and DVA to
address these questions, but we are encouraged that these and other
organizations have improved their approach to dealing with the medical and
social issues in a more organized, coordinated, sympathetic, and effective
manner. However, there is still much to do and we trust that the additional
recommendations in this report will contribute to further improvements.
The questions of whether a Gulf War veteran is ill and whether that illness
was caused by Persian Gulf service are separate and distinct. Our charge and
this report address ways to approach the latter question. The former question,
although not in the committee's charge, was ever present in its deliberations.
The committee was provided with ample evidence that there are veterans who
are sick, and we are concerned that they all be provided with proper diagnosis
and care.
Those of us who were not in the Gulf can only imagine what it was like for
the thousands of men and women who were uprooted from families, jobs, and
daily existence; to be suddenly transported to a harsh climate; to be injected
with vaccines not previously used in the active military; to wait many months
for "action" to occur; to wonder whether the war would involve chemical and
biological warfare; to witness a brief but intense battle with many enemy
casualties; and then, just as suddenly, to return to their earlier routine of daily
living in the United States. ~ ~~ ~ ~~
Men and women served side by side under
conditions that increased the stresses connected with being in these grim
surroundings. How all these Gulf experiences relate to the health of veterans is
a complex and challenging question.
Although determination of whether a new disease or new syndrome has
appeared was not in the committee's charge, we frequently discussed this issue
because it helped to enlighten and focus our discussions about the matters we
were asked to address. There is a long history in medicine of controversy over
the existence of conditions that had not been seen earlier or had not been
recognized as separate disease entities. Some of these claimed conditions have
faded away, whereas others have become established and generally accepted.
Recent examples of the latter are AIDS, Legionnaires' disease, and toxic shock
syndrome. For a disease designation to be accepted as valid, criteria need to be
set for the diagnosis of that disease so that there will be consistency in reporting.
At this time, although studies of Gulf War veterans suggest that these veterans
suffer from a variety of recognized diseases, such studies do not establish the
existence of a new disease. It is possible that additional findings from research
in progress will suggest a new medical entity. Further efforts to identify a Gulf
War Syndrome, if it exists, will require substantial new evidence from any
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PREFACE
. .
V11
research undertaken, but again this issue is separate from whether these ill
people need medical care.
Signs and symptoms without a diagnosis or apparent cause are found in
every medical practice; clinical medicine is neither perfect nor all-knowing.
Although physicians may fail to provide a medical reason for some of these
signs and symptoms, the illnesses and related disability have to be addressed as
well as possible, independent of efforts to understand causes. All of us in the
health care and public health fields are committed to using the scientific study
methods available to us in an attempt to understand and better explain what is
presently unknown. Only in this way can we make progress in defining,
preventing, and treating disease.
Observations, information, and reports by individual veterans provide
insight into what it was like to serve in the Gulf, and studies that are now being
designed should continue to seek out and consider input from those who were
there. Unstructured reports can direct attention to problems that need study, but
only rarely can they provide definitive evidence about the appearance of a new
medical problem. That is the case with the Gulf War Syndrome. The numerous
moving personal stories about illness in returned veterans have rightly generated
concern, followed by preliminary research studies. Investigators still will need
to use appropriate study designs and methods to obtain the best possible
information, conduct equally appropriate analyses, and systematically evaluate
the evidence. Knowledge gained in this way will not only benefit the Persian
Gulf veterans, but will also help guide DoD and DVA to identify preventive
actions that could lessen the likelihood of adverse health outcomes of future
deployments. There may also be important extensions to the diagnosis and
treatment of exposures and stresses in the civilian population.
Our report is intended to be an evidence-based assessment, so conclusions
are inevitably shaped by the evidence that was available at the time the report
was written. A substantial research effort is under way, and understanding of
the health effects of the Persian Gulf War will evolve as new findings emerge.
At the time this report was sent for external review in June 1996, the committee
learned that a bunker destroyed in March 1991 may have contained a chemical
warfare agent and that troops located 3 or more miles away might have been
exposed. DoD officials appearing at a press conference indicated that
investigation of this and other incidents is ongoing. Details have since been
added (Transcript from President's Advisory Committee on Persian Gulf
Veterans' Illnesses, Chicago, Illinois, July 8-9, 1996, and Denver, Colorado,
August 6, 1996; Persian Gulf Veterans' Illnesses Investigative Team posting on
the Internet, August 6, 1996~. The late reporting of this incident and the press
conference statement that the investigation of records from the war is still not
finished continue to raise questions about the completeness of exposure
information provided by DoD to date. We encourage disclosure of all
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. . .
V111
PREFACE
information that may inform the public understanding about the health effects of
Persian Gulf service.
As a committee, we are concerned about the health effects of military
service, and we are hopeful that DoD and DVA will consider our
recommendations to improve the body of information and preventive
interventions for the health of Persian Gulf War and future veterans.
Many persons helped the committee in the preparation of this report. First,
we have been blessed with an unusually strong staff. Dr. Diane Mundt, as study
director, brought to this task a great store of knowledge about epidemiology,
biostatistics, military health records, chemical hazards in the field, and related
matters, but even more important were her constant oversight of each part of our
work and of the role of each committee member; her gently persuasive urging to
complete this task, improve on that one, and start a third; and her remarkably
comprehensive knowledge about other efforts to understand and improve the
health of Gulf War veterans. While the committee wrote the text and takes full
responsibility for it, Dr. Mundt's comprehensive attention to improving how we
presented our work has made it a far stronger document. Appendixes E, F. and
G are among her many contributions. Ms. Amanda Hull Murray was tireless in
supporting Dr. Mundt and the committee, with special responsibilities for the
critical tasks of learning about and obtaining countless documents (only a
fraction could be cited here), coordinating the many presentations to the
committee, and aiding veterans and others who had information of potential
value to us. Ms. Carliss Parker-Smith supported the work of the office and
arranged the details of our 14 committee meetings no mean task with 18
sometimes fractious committee members and countless other persons
simultaneously clamoring for attention to their questions and contributions.
We also thank Ms. Laura Baird and Ms. Susan Fourt for library assistance;
Mr. Michael Edington, Ms. Janet Ross, and Ms. Florence Poillon for editorial
assistance; many government and nongovernment agencies and organizations
for information provided; and countless individuals, including the Persian Gulf
veterans who provided both input and insight. Appendixes C and D give some
specifics about the persons and organizations who were helpful in this respect.
John C. Bailar III, Chair
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Contents
EXECUTIVE SUMMARY
Recommendations, 10
1. INTRODUCTION...............
An Emerging Problem, 15
Panels and Committees, 17
Conclusions, 20
Charge to the Committee, 21
Research and Data Issues, 22
The POW as the Less-than-Ideal Setting for Research, 23
Where Do We Go from Here?, 25
2. CHARGE TO THE COMMITTEE: ITS FINDINGS AND
RECOMMENDATIONS ......
Overview, 26
The Committee's Charge, 26
Charge 1, 26
Charge 2, 27
Charge 3, 27
Findings and Recommendations, 28
14
IX
26
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x
3. ENVIRONMENT AND EXPOSURES
Overview, 36
Natural Environment, 39
Man-Made Environment, 42
Pesticides, 42
Fuels and Decontamination Solution, 43
Oil Well Fires and Spills, 44
Occupational Exposures, 47
Diet, 48
Vaccines and Prophylactic Treatment, 49
Pyridostigmine Bromide, 52
Interactions of Exposures, 53
Depleted Uranium, 55
Psychosocial Exposures, 57
Stressors Associated with Deployment, 59
Anticipation of Combat, 59
Combat Exposure, 60
Aftermath and Long-Term Adjustment, 61
Gender Differences in Exposure to Stress, 63
DVA Environmental Hazards Research Centers, 64
4. HEALTH OUTCOMES ...............................................................................
Overview, 67
Mortality Studies, 72
Hospitalization Studies, 74
Diagnosed Diseases in PG Veterans, 78
DVA Persian Gulf Health Registry, 79
DoD Comprehensive Clinical Evaluation Program, 81
Predictors of Enrollment in the Persian Gulf Health Registry, 83
Studies of Self-Reported Symptoms, 83
Outbreak Studies, 83
Surveys, 89
Adverse Reproductive Outcome Studies, 93
Pathways for Environmental Influences on Reproduction, 93
Definition of Outcomes, 94
Frequency of Events in the General Population, 96
Confounding, 96
Reproductive Outcome Studies in PG Populations, 97
Mental Health Studies, 101
Issues in Studies of Mental Health, 101
Mental Health Problems and Military Experience, 102
Mental Health: Comparison of Deployed and Nondeployed Troops,
102
CONTENTS
...... 36
.67
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CONTENTS
Factors Associated with Mental Health Problems: Combat and Other
Stressors, 105
Factors Increasing Vulnerability to PTSD and Other Psychiatric
Disorders, 105
Factors Enhancing Resilience or Buffering Effects of Stress on Mental
Health, 106
Long-Term Mental Health Outcomes, 107
Physical Symptoms and Exposure to Stressors, 107
Discussion of Mental Health Issues, 109
Women, s Health Studies, 111
Health Effects of Combat Service for Women, 111
Gender Differences in Health, 113
Health Issues Related to Men and Women Serving Together in
Combat Situations, 116
5. SOME HYPOTHESES REGARDING ILLNESSES IN
PERSIAN GULF WAR VETERANS...............
Overview, 117
Chronic Fatigue Syndrome, 118
Multiple Chemical Sensitivity, 119
Oxidative Phosphorylation Disorder, 120
Dental Amalgams, 120
Bacterial Illness, 121
Mycoplasma and Chronic Fatigue, 121
Skeletal Muscle Bioenergetics, 122
Sarcoidosis and Lingual Abnormalities, 122
Brainstem Dysregulation Syndrome, 123
Microsporidia Infection, 124
Organophosphate-Induced Delayed Neurotoxicity, 124
Chemically Induced Porphyria, 125
Fibromyalgia, 125
Somatization Disorder, 125
Summary, 126
6. INFORMATION SYSTEMS............................................................
Overview, 128
Criteria for a Research-Oriented Health Information System, 130
Persian Gulf War Health Information Systems, 131
Health Information Systems for the Future, 133
Conclusions, 137
REFERENCES
Xl
117
.......... 128
....... 141
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. ~
X11
APPENDIXES
A.
B.
C.
D. Invited Presentations..........................................
E. Other Groups Reviewing Persian Gulf War Veteran Health Issues ...
List of Research and Related Activities on Health Problems of
Persian Gulf War Veterans ...
G. Selected DoD, Anny, Navy, Air Force, and DVA Databases
Relevant Sections of Public Law 102-585........
Statement of Task
Committee Meetings and Individuals Providing Information.....
ACRONYMS
CONTENTS
...159
...164
...165
..168
......... 171
.175
.184
.189
