The following lecture has been approved for University Undergraduate Students

1. 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

2. craig.jackson@uce.ac.uk 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

3. Headlines of Gulf War BABY IS GULF WAR SYNDROME VICTIM JABS LINKED TO GULF WAR SYNDROME MORE THAN 10,000 DEAD FROM GULF WAR SYNDROME!

4. 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

5. 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

6. 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 SOLDIER HAILS GULF CASE WIN

7. 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

8. 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 veterans

9. 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.

10. 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”

11. 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)

12. 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

13. 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

14. 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 Syndrome'

15. 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

16. 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

17. 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

18. Theory #3 Oil Fire Smoke

19. 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

20. Theory #4 Chemical / Biological Warfare Agents The Theory. . . Nerve Gas Sarin - Cholinesterase Inhibition VX Headaches, Diarrhoea, Paralysis Lewisite Bacteria Virus Toxins

21. 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

22. 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

23. 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

24. 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 paralysis)

25. 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

26. 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 / Insecticides

27. 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 inoculations

28. 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

29. Health Perceptions of Vets Characteristics of Vets responding To the survey Chalder et al (2001)

30. Health Perceptions of Vets Relationship between GWS and other outcomes Chalder et al (2001)

31. 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?

32. The Future for GW1 Vets Organised Medical recognition Legal recognition Care for GWS sufferers Info dissemination

33. 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