Examining Gulf War Illness
Many soldiers returning from the Gulf War in 1990 reported a whole constellation of non-specific medical symptoms that's come to be known as Gulf War Illness. It turns out to be a controversial diagnosis, as some say it's real and some say not so fast. Today we're going to separate the fact from the fiction surrounding this mysterious condition.
The Gulf War, which ran from the end of 1990 through the beginning of 1991, saw the largest coalition of international military forces — 35 in all — since World War II. The largest single deployment was by the United States, which sent some 670,000 personnel to the Middle East. The war exposed many to conditions no major forces had yet faced in the real world, such as oil fires on a Biblical scale, depleted uranium ammunition, pesticides, prophylactic treatment against nerve agents, and others. When the troops returned home, some began reporting unexplained physical ailments, including fatigue, muscle and joint pain, cognitive and sleep problems, skin ailments, and gastrointestinal issues. Eventually, as many as a third of all returning veterans reported it to some degree. It's come to be known as Gulf War Illness, and today it is a leading cause of disability among US veterans. The only problem is that some researchers aren't sure that it exists at all — and most of the rest still have more questions than answers.
Initially known as Gulf War Syndrome, today Gulf War Illness (GWI) is a major focus of the US Department of Veterans Affairs, which pays out hundreds of millions of dollars each year in benefits to veterans who are at least 10% disabled due to symptoms associated with GWI. By itself, GWI is not a condition veterans can claim compensation for; they must have a demonstrated disability and that's what the compensation is for. So that's an important fact for us to establish up front: These people are suffering from genuine, proven disabilities. We should be very, very clear on that point: the reality of GWI as an actual cluster of symptoms or as a syndrome that is associated with some cause encountered in the Gulf War is one question; and whether the disabled veterans' suffering is real is a separate question. It is common for some people to confuse a look into the reality of GWI with doubt of the reality of the veteran's disabilities. That is not the case.
The severity of the symptoms varies widely, and is generally overstated. While it's true that up to 1/3 of Gulf War troops have reported symptoms associated with GWI, only about 2% have applied for compensation. This means they function reasonably well, statistically about as well as the rest of us who didn't deploy to the Gulf War. But it is important to keep those 2% in mind, and to learn what we can about their disabilities and make sure we do not, in any way, trivialize them.
The number of papers that have been published on Gulf War Illness is staggering — it's literally in the thousands. Journals in diverse sciences have published articles; not just medical journals, but also environmental, pharmacologic, military, geopolitical, and journals that specialize in every physiological system that's included in the cluster of symptoms: neurology, psychology, ophthalmology, pain, gastroenterology, cardiology, pulmonology, dermatology, and of course fibromyalgia and chronic fatigue. So for anyone (myself included) to set out to survey the literature is a bit of a fool's errand. On top of that, whatever else it might be, Gulf War Illness is big business. There are hundreds of thousands of potential patients and the world's largest wallet paying not only for their treatment but also paying disability compensation. Do a Google search and you'll find the Internet is loaded with ads from ambulance chasing lawyers trying to get veterans to sue for benefits. With so much money at stake, we should expect to see lots of researchers giving this plenty of attention for the foreseeable future.
But luckily for independent researchers wanting to learn more about this, there is one obvious place to go for the closest thing to a summary, and that's a program within the US Department of Defense called CDMRP, Congressionally Directed Medical Research Programs. One of these programs is the GWIRP, Gulf War Illness Research Program. Their role is to fund research into GWI, to better understand it, improve diagnosis, and ultimately to improve the quality of life for sufferers. A lot of their funding comes from the VA, and each year, the VA provides a summary to Congress. So by turning to these sources, the closest things we have to consensus white papers, we can get a pretty good idea of the GWI landscape. And, unfortunately, it's still not a very clear picture. Not even close.
This highlights the difficulties associated with studying GWI, or even with writing about it, for that matter. The most obvious is that the symptoms attributed to it are those generally termed "symptoms of life", meaning things that happen to everyone to some degree: fatigue, headaches, joint pain, sleep problems, cognitive lapses, pretty much every box that GWI checks. Nearly all of us feel some of these things some of the time. But to complicate it even more, the percentage of deployed Gulf War veterans who report GWI is approximately the same as the percentage of people in the general population who report the same symptoms. This leaves us in something of a logical limbo: if the veterans hadn't deployed to the Gulf War at all, they would still be just as likely to experience the same symptoms they report now. So how can we assert that the deployment was the cause?
It's this similarity in prevalence to the general population that is the first real difficulty in studying GWI. When we look at hospitalization rates comparing the 670,000 who deployed to members of the military who did not deploy to the population at large, we find that the studies report numbers that are all over the place. What's clear is that there is no broadly-agreed upon increased incidence of hospitalization among deployed Gulf War veterans.
Another difficulty is that soldiers coming home from wars throughout history have always brought home such symptoms, nothing about the numbers or the symptoms are unique to Gulf War veterans. Through most of history we didn't know the cause. For the first two World Wars we typically called it shell shock, though today we'd diagnose it as anything ranging from acute stress all the way to post traumatic stress syndrome. After the Vietnam war, when soldiers came home with essentially the same cluster of symptoms, we pinned the blame on Agent Orange. Now all of this is to be expected, as being in a war is quite obviously a traumatic experience; and it's a very arguable point that governments have a responsibility to treat that trauma — or compensate for it — for all who fought. The physiological cause for that trauma is acute stress, with its many tentacle-like causes and effects. Acute stress is well known to cause all of the physical symptoms attributed to GWI. This leaves us in another logical no-man's land: How can we attribute the symptoms to something specific to the Gulf War, when they were also reported by people who went to every war?
Yet another difficulty is that after more than a quarter of a century of research, military health authorities still have not found an acceptable match between the symptoms and a cause. They have, however, found a number of unacceptable causes. For a long time, they've have pesticide exposure listed as a cause, and also a drug given in advance to protect against a nerve gas attack called PB, or pyridostigmine bromide. While these both sound plausible, and deployed veterans were indeed exposed to these substances, serious problems remain with them. The PB association is particularly problematic. PB has been a prescription drug since the 1950s, and no long-term health problems have ever been found to be associated with it. Further, only about half of deployed veterans took PB, most only briefly, and there were no reported overdoses taken. And further still, PB has actually been used experimentally as a treatment for some of the conditions on the GWI list. About 2/3 of the troops used pesticides to one degree or another, but there doesn't appear to be any association between those who did and those who report GWI symptoms.
Researchers have also nominated lots of other causes. One was depleted uranium penetrators, of which nearly a million were fired during the conflict. The danger from this comes not from radioactivity as many people think, as it isn't significantly radioactive; but from heavy metal toxicity. Exposure to this would have required that you be right next to a round when it strikes a target and vaporizes in the air. This would have happened to very very few survivors of the Gulf War, certainly not a third of everyone deployed; and its symptoms are not a match for those attributed to GWI. One of the pesticides nominated was the bug repellent DEET. However, millions of backpackers, hikers, and fishermen have been practically bathing in DEET for decades with no ill effects; and yet this hypothesis would require that from only a few months of normal intended usage, a third of veterans were permanently disabled by it. The proposed causes for GWI simply don't fly.
A final difficulty with studying GWI is that it has no symptoms or groups of symptoms which are unique to it. As already discussed, these symptoms are all common in the general population, both individually and combined with one another; including people diagnosed with conditions like chronic fatigue and fibromyalgia, and people with no diagnosis at all. It is, in fact, thin ice to even declare that there's anything at all that can be said to characterize GWI. Any doctor attempting to make a diagnosis of GWI with any given patient must face the fact that there are plenty of people with exactly the same symptoms who have totally different diagnoses, and plenty with no diagnoses. The only difference between them is a non-medical one: it's that this person was deployed to the Gulf War.
From my review of the literature, I found that Gulf War Illness has a lot in common with many other elusive phenomena that we talk about on Skeptoid. It's the search for a bogeyman that we can blame when there's a problem that we can't easily solve. The disabling symptoms experienced by so many veterans are certainly a very real problem, but they are so diverse and so common that they almost certainly do not represent a single condition with a single cause. Our human nature compels us to search for easy, graspable answers to complicated questions. The compounding issue of so much money being at stake in this case means that there is a lot of motivation from countless people to find and identify and crucify that bogeyman. Without any doubt, deployed soldiers were exposed to stressful and traumatic experiences that go beyond anything those of us who stayed home went through, and it is absolutely appropriate to consider the question of compensation and provide it wherever appropriate. But that is one question; the reality of a "Gulf War Illness" is another question. It is one that has a pretty apparent answer: it has all the signs of being little more than a spectral bogeyman. Moreover, it's a bogeyman that's simply not needed, given the reality of acute stress and the real physiological harm that it has caused these veterans, and which can absolutely be disabling. As in so many other aspects of life, often it is more productive and useful to focus on the solution, rather than hunt for a bogeyman we will never catch.
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