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Title: The following lecture has been approved for

The following lecture has been approved for
University Undergraduate Students This lecture
may contain information, ideas, concepts and
discursive anecdotes that may be thought
provoking and challenging It is not intended
for the content or delivery to cause
offence Any issues raised in the lecture may
require the viewer to engage in further thought,
insight, reflection or critical evaluation
Gulf War Syndrome Dr. Craig
Jackson Senior Lecturer in Health
Psychology School of Health and Policy
Studies Faculty of Health Community Care
University of Central England
Headlines of Gulf War
History of Gulf War Aug 1990 Iraq invades
Kuwait Aug 1990 - Jun 1991 Allied Troop
Deployment 697,000 by USA 53,000 by United
Kingdom 4,500 by Canada Feb 1991 Iraq
expelled from Kuwait
History of Gulf War Symptoms Within months of
end of war some veteransreported symptoms Some
studies tried to identify the key clinical
features of ill health in veterans US Government
invited ill veterans to join voluntary medical
registries Many presented with non-specific
symptoms Most common primary diagnoses among
20,000 veterans were musculoskeletal disorders
(18.6) psychological conditions
(18.3) multisystem conditions (17.8). No
evidence of a unique illness Joseph 1997
  • History of Gulf War Symptoms
  • Collection of symptoms in soldiers who served in
    Persian Gulf War (1990-1991)
  • Highly variable
  • Include
  • Rash
  • Fatigue
  • Muscle pain
  • Joint pain
  • Headache
  • Irritability
  • Depression
  • Sleep disturbance
  • Gastrointestinal problems
  • Respiratory problems
  • Cognitive deficits

Dilemma of Gulf War Symptoms The studies
demonstrate an increase in reporting of symptoms
in veterans who served in the Gulf conflict,
compared to those not deployed or who have served
elsewhere. However, similar symptoms were
reported in all control groups No obvious
unique collection of symptoms in Gulf War
veterans Data rely on self-reported symptoms,
and lend themselves to response biases
Dilemma of Gulf War Symptoms Variety and
multiplicity of symptoms no consistent pattern
exists . . . . . . Therefore impossible to
suggest a common underlying disease
process This makes it unlikely that a single
cause will explain ill health in Gulf
veterans No study has found consistent abnormal
clinical or laboratory findings among ill Gulf
  • The Veterans Case
  • 1. Military authorities exposed service personnel
    to unreasonable medical and
  • environmental hazards
  • 2.Military authorities have since failed to
  • generate, record and act on information of
    relevance to veterans illnesses
  • have withheld and destroyed information
  • have distributed misleading information
  • and have obstructed enquiries by others.
  • 3. Diagnosis and treatment of illness has been
    impeded by the unprecedented
  • nature of the medical conditions, but also by the
    military authorities own
  • obstructive behaviour.

The Ministry of Defence The Ministry of Defence
accepts some veterans have become ill Many
believe this ill health unusual and directly
related to service in the Gulf UK Gulf veterans
report more ill-health than other comparable
groups (Unwin et al 1999) This is not unique to
Gulf veterans as the same symptoms are seen in UK
military personnel who did not deploy to the
Gulf Gulf Conflict veterans report having more
of the symptoms and are suffering more severely
from them Some veterans have recognised medical
conditions, but a large number of non-specific,
multi-system, medically unexplained symptoms are
also reported
Theory 1 Vaccine Overload The Theory. .
. GW1Vs received at least 17 different
Vaccines e.g. Pyridostigmine Established
vaccines Poliomyelitis Yellow
fever Cholera Experimental vaccines Anthrax
Botulinum toxoid Pertussis MOD says UK
troops received 10 types Adjuvants and viral
genomes! Squalene polymer antibodies Rook
Zumla (1997)
Theory 1 Vaccine Overload The Evidence GWS
symptoms X3 more likely in vaccinated vets GWS
in 34 vaccinated vets 12 vaccinated but
non-deployed vets 4 in non-vaccinated
vets GWS lowest in troops on ships
(21) GWS highest in those in Iraq / Kuwait
(42) Steele 2001
Theory 1 Vaccine Overload The
Evidence Compared with troops in Bosnia
conflict, and those not deployed in Gulf GWVs
reported significantly more symptoms Twice as
likely to have GWS diagnosis Number of
vaccinations increased likelihood of
GWS Vaccination before conflict less
problematic than vaccination during
conflict Ismail 2002
Theory 1 Vaccine Overload The Evidence US
Department of Defence (1997) Initiated Anthrax
Vaccination Immunization Program 2.4 Million
military personnel Adverse reactions in
personnel were similar to symptoms of
GWS French troops were not exposed to the same
cocktail of drugs as British and US service
personnel, and have not reported any 'Gulf War
Theory 2 Depleted Uranium The Theory. . . DU
Low-level radioactive material Nephrotoxic
when internalised in large quantities Amour
piercing Those handling munitions were
appropriately protected and no adverse health
effects have been reported in these troops
Theory 2 Depleted Uranium The Evidence. .
. Elevated incidence of renal dysfunction have
not been observed in personnel exposed to DU
during the conflict MoD is continuing research
via an independent oversight board Several
major reviews have concluded that it is
unlikely to be implicated in Gulf veterans'
illnesses Three-fold increase in birth defects
in Iraq since 1991 The Royal Society 2003
Theory 3 Oil Fire Smoke The Theory. . . After
ground war hundreds of oil wells were set
alight Plumes of smoke across the
battlefields Smoke is known to cause respiratory
tract irritation Personnel involved in tackling
the blazes were appropriately protected Health
of individuals working in the proximity of the
fires was closely monitored
Theory 3 Oil Fire Smoke
Theory 3 Oil Fire Smoke The Evidence. .
. Monitoring studies found no evidence of
increased levels of toxic gases Was an increase
in the level of fine particulate matter Gulf
veterans have commonly reported respiratory
symptoms Little evidence of pulmonary damage
attributable to oil well smoke
Theory 4 Chemical / Biological Warfare
Agents The Theory. . . Nerve
Gas Sarin - Cholinesterase Inhibition VX Headac
hes, Diarrhoea, Paralysis Lewisite Bacteria Viru
s Toxins
Theory 4 Chemical / Biological Warfare
Agents The Evidence. . . There is no objective
evidence that Iraq utilised any chemical or
biological warfare (CBW) capability Documented
that many detection devices alarmed during the
war Many personnel believed they were under
chemical attack Frequent false alarms occurred
as the devices were exquisitely sensitive,
obtained at the expense of some specificity
Theory 5 Post Traumatic Stress Disorder The
Theory. . . Many attribute ill health to
post-traumatic stress disorder 12 of all the
veterans who attended were suffering from PTSD
and somatic symptoms (MoD's Medical Assessment
Programme) Gulf veterans were under
considerable stress, not least from the constant
threat of chemical and biological weapons Each
conflict is associated with a unique environment
/ type of warfare and a unique combination of
physical and psychological stressors that may
contribute to ill health
Theory 5 Post Traumatic Stress Disorder The
Evidence. . . Large numbers of veterans
suffering from symptoms who do not have
psychological dysfunction - suggests that stress
alone cannot account for ill health in all
veterans Symptoms in Gulf veterans are similar
to those reported after other conflicts (Hyams et
al 1997) The Gulf War cannot compare with
previous wars in terms of human casualties and
other environmental factors Impossible to
compare research done on different wars owing to
changing nature of medicine, technology, and
cultural factors Media reporting in society
contributes factors for ill health reporting
Theory 6 Pesticides / Insecticides The Theory.
. . Widespread use of pesticides containing
organophosphates (Ops) to combat desert pests
Pyridostigmine bromide was given
prophylactically as a counter-measure against
chemical attacks Pyridostigmine reversibly
inhibits acetylcholinesterase at the
neuromuscular junction and prevents
subsequent binding of nerve
agents Causes cholinergic crisis (nerve
Theory 6 Pesticides / Insecticides The
Evidence. . . The associations between reported
exposure to pesticides and measures of ill health
showed no significant difference between Gulf and
Bosnia Era veterans (Unwin et al 1999) Usually
gross evidence of toxic effects of high doses of
OPs, there were no obvious acute effects in the
war theatre Delayed effects of low-level
exposure are not fully understood Is plausible
that there may be some role in veterans'
illnesses The MoD maintains it is unlikely to
play a major role, but has commissioned a
detailed study into the effects of OPs
Possible Theories (Multiple) Vaccines Theory
of a combination of stress and vaccinations
Post Traumatic Stress Disorder having effects
Hotopf et al (2000) DU Oil Fire
Smoke Chemical/ Biological Agents Pesticides /
Complications. . . Military populations
generally healthier than civilians (Healthy
Warrior effect) Gulf vets death rates are not
higher than non Gulf vets (including suicide and
cancer) Gulf vets have more accidents than non
Gulf vets ! ? ! Over decade after deployment
some GV still suffer ill-health No unique Gulf
war syndrome Only common GV related experience
involves perceptions of ill-health GVs
symptoms are worse for lower ranks Huge bias -
recalling more exposures, incidents, and
  • Health Perceptions of Vets
  • Military populations generally healthier than
    civilians (Healthy Warrior effect)
  • 17 of UK vets believe they have GWS (Chalder et
    al 2001)
  • Belief in having GWS linked to
  • Knowing someone else with GWS
  • Being ill afterwards
  • No longer in military
  • High number of vaccinations before deploy

Health Perceptions of Vets Characteristics of
Vets responding To the survey Chalde
r et al (2001)
Health Perceptions of Vets Relationship between
GWS and other outcomes Chalder et
al (2001)
The Future for GW1 Vets Legally, GWS exists - -
- - Medically, GWS does not exist Upto 9000 UK
troops (of 53,000 deployed) may have GWS 2800
(approx) UK vets have attended MOD assessment
programme This number is declining What of
GWII? Same problems to emerge? How will any
symptom reports be handled?
The Future for GW1 Vets Organised Medical
recognition Legal recognition Care for GWS
sufferers Info dissemination
References Joseph S, and the Comprehensive
Clinical Evaluation Program Evaluation Team. A
comprehensive clinical evaluation of 20,000
Persian Gulf War veterans. Milit Med,
162 149-55, 1997. Unwin C, Blatchley N, Coker
W, et al. Health of UK servicemen who served in
the Persian Gulf War. Lancet 353 169-78,
1999. Lee HA, Gabriel R, Bolton JPG, et al.
Health status and clinical diagnoses of 3,000
UK Gulf War veterans. J R Soc Med 95 491-497,
2002. Ministry of Defence. Gulf Update. Issue 4.
London MoD, 2002. Coker WJ. A Review of Gulf
War illness. J R Nav Med Serv 82 141-146,
1996. Rook G Zumla A. Gulf War Syndrome is it
due to a systemic shift in cytokine balance
towards a Th2 profile? Lancet 349
1831-1833,1997. Hotopf M, David A, Hull L, et
al. Role of vaccinations as risk factors for ill
health in veterans of the Gulf War
cross-sectional study. BMJ 320
1363-1367,2000. Hyams KC, Wignall FS, Roswell R.
War syndromes and their evaluation from the US
Civil War to the Persian Gulf War. Ann Intern
Med 125 398-405, 1997
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