Scientific research published since the 2008 Committee report supports and further substantiates the conclusions of the 2008 report that Gulf War illness is a serious physical disease, affecting at least 175,000 veterans of the 1990-1991 Gulf War, that resulted from hazardous exposures in the Gulf War theater. Important progress has been made in improving scientific understanding of Gulf War illness. Research has begun to identify probable underlying mechanisms, promising treatments and biomarkers. However, much work remains to be done. We support the scientists and clinicians working to improve the health of Gulf War veterans and to protect the health of current and future American servicemen and women at risk of similar exposures. Effective treatments for Gulf War illness could also lead to treatments for other exposure-related occupational health problems. The Committee recommends a robust federal research effort to monitor and improve the health of Gulf War veterans, with the identification of treatments for Gulf War illness the highest priority. A wide-ranging scientific literature review of this problem published after 2008, the Institute of Medicine's 2010 Gulf War and Health report, also recommended a renewed federal research effort and concluded that treatments and hopefully preventions can likely be found with the right research. What is Gulf War illness and how common is it? Gulf War illness refers to the chronic symptoms that affect veterans of the 1990-1991 Gulf War at markedly elevated rates compared to other veteran groups and to the U.S. population as a whole. The individual symptoms experienced by ill Gulf War veterans can vary from person to person, but overall the types of symptoms reported are similar in the many groups of ill veterans that have been studied since the war. Symptoms typically include some combination of widespread pain, headache, persistent problems with memory and thinking, fatigue, breathing problems, stomach and intestinal symptoms, and skin abnormalities. In the early years after the war, this disorder was commonly called "Gulf War Syndrome" by the media and has since been referred to by a variety of names such as undiagnosed illness, Gulf War illness, chronic multisymptom illness and other terms. "Gulf War illness" is the term most commonly used by scientists, clinicians, veterans' groups and the Department of Defense and is used in this report to refer to the illness associated with military service in the 1990-1991 Gulf War. Based on its review of the research that has been published since 2008, the Committee concludes that Gulf War illness has been consistently reported in all studies of Gulf War veterans and that it is seen in about 25-30% of Gulf War veterans, or about 175,000 to 250,000 of the 700,000 troops deployed to the war in 1990-91. The same conclusion was reached in 2008. Little new information has become available on whether the health of ill Gulf War veterans has improved over time. The research published in the 2008 RACGWVI report suggests that there is little to no improvement among veterans with Gulf War illness. The effect that aging will have on this vulnerable population remains a matter of concern. What other kinds of health problems are experienced by Gulf War veterans? Studies published since 2008 continue to find that veterans from the 1990-91 Gulf War have poorer general health and greater disability than other veterans of the same era who did not deploy to the Gulf. Studies reviewed in this report show that Gulf War veterans who were most exposed to the release of nerve gas by the destruction of the Khamisiyah Iraqi arms depot have significantly elevated rates of death due to brain cancer. Veterans who were exposed to the highest level of contaminants from oil well fires also have increased rates of brain cancer deaths. Studies conducted prior to 2008 show that Gulf War veterans experienced higher than expected rates of amyotrophic lateral sclerosis (ALS). Very little other research has yet been conducted to determine rates at which Gulf War veterans have been affected by other medical conditions of possible concern, including neurological diseases such as multiple sclerosis or Parkinson's disease, other cancers, sleep disorders, adverse pregnancy outcomes or rates of birth defects in veterans' children. Persons with disorders like chronic fatigue syndrome, fibromyalgia and multiple chemical sensitivity have similar symptoms to veterans with Gulf War illness, but most Gulf War illness patients cannot be diagnosed with these disorders using standard diagnostic rules. Gulf War illness is a distinct disorder and Gulf War veterans who can be diagnosed with these disorders often differ significantly from non-veteran populations who are diagnosed with them. Studies of psychological and psychiatric disorders in Gulf War veterans since 2008 continue to show that combat and other stressors are associated with post-traumatic stress disorder, anxiety, depression and alcohol abuse in Gulf War veterans but that these disorders are clinically distinct from Gulf War illness. They are typically reported to occur in less than 10% of Gulf War veterans, far below the rate of these disorders in veterans of other recent wars and far below the rate of Gulf War illness in Gulf War veterans. Very little is known about whether service in the Gulf War or having Gulf War illness affects veterans' life expectancy. Much more needs to be learned about this. Despite specific recommendations over many years from both RACGWVI and Institute of Medicine panels, research in this area remains seriously inadequate. Which exposures and experiences in the theater caused ill health and functional disability in Gulf War veterans? Once it became clear that veterans of the Gulf War had returned home with persistent health problems, the question immediately arose as to the cause or causes of ill health in this veteran group. Although a highly publicized initial argument was that their ill health was due to deployment related stressors and psychological trauma, scientific studies consistently demonstrated that Gulf War illness was associated with chemical, pharmaceutical and other environmental exposures in theater, rather than stress. Research in this area has expanded since 2008 and has included investigations of effects of veterans' exposures to specific chemicals and drugs during the war as well as extensive exploration of the persistent effects of single and combined Gulf War-related exposures in animal models. Further, many studies have shown that environmental and occupational exposure to pesticides in other populations are associated with health problems similar to Gulf War illness. The research reviewed in this report supports and reinforces the conclusion in the 2008 RACGWVI report that exposures to pesticides and pyridostigmine bromide are causally associated with Gulf War illness. Evidence also continues to demonstrate that Gulf War illness is not the result of psychological stressors during the war. Hazardous exposures in theater are also related to certain other health problems seen in Gulf War veterans. Exposure to the nerve gas agents sarin and cyclosarin has been linked in two more studies to changes in structural magnetic resonance imaing that are associated with cognitive decrements, further supporting findings on the nervous system effects of these agents reported in the 2008 report. New evidence has emerged suggesting that oil well fire exposures may be important in the development of Gulf War illness and brain cancer. It is unclear if vaccine exposures may also be contributing to Gulf War veteran health symptoms, because current results have been conflicting and include weak associations. Although exposure to depleted uranium has been demonstrated, with continuing levels in body tissue, its contribution to ill health is unclear: studies on this substance have focused on small groups of individuals. How are basic body functions affected in veterans with Gulf War illness? Studies reviewed in the 2008 RACGWVI report and research published since then have shown that Gulf War illness is associated with changes in the brain, autonomic nervous system, endocrine system and immune system. Other health problems have also been demonstrated in subgroups of veterans who experienced exposures to specific chemicals in the Gulf War theater. What effective treatments are available for patients with Gulf War illness and how should new treatments be developed? Treatment research has increased significantly since 2008, particularly reflecting the efforts of the Gulf War Illness Research Program (GWIRP) of the DoD Office of Congressionally Directed Medical Research Programs (CDMRP) to fund such research. However, most of these studies are still underway, with few results yet available. Promising preliminary reports from the limited trials to date indicate possible benefits provided by coenzyme Q10 (a dietary supplement), acupuncture and use of continuous positive airway pressure (CPAP) during sleep in veterans with sleep apnea. The Committee believes that the first priority of federal Gulf War illness research must be the identification of effective treatments to improve the health of Gulf War veterans and to protect the health of current and future American servicemen and women at risk of similar exposures. Treatment approaches based on what is known about the underlying physiological changes that occur in veterans with Gulf War illness may be the most effective. Promising laboratory research is underway to develop cutting-edge treatment approaches by studying the effects of Gulf War exposures in animals and then targeting and testing treatments for these effects. Effective treatments of Gulf War illness could lead to treatments for exposure-related occupational and environmental health problems in other groups of people. It may be possible to leverage support from other federal health agencies interested in exposure-related diseases and disorders for this effort.
Research Advisory Committee on Gulf War Veterans' Illnesses, Boston University School of Public Health, 715 Albany Street (T-4W), Boston, MA 02118