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http://www.economist.com/science/displayStory.cfm?story_id=2003325 Gulf-war syndrome - The fog of war As casualties from the war in Iraq mount, a battle is still raging over the causes of Gulf-war-related illnesses Aug 21st 2003 The Economist WAR is not a healthy business. Since hostilities began in March, more than 330 American and British soldiers have died in Iraq. All such losses are regrettable, but two deaths in particular are a puzzle. They were among 18 servicemen who have developed severe pneumonia in the past six months, part of a wider but milder outbreak that has affected another 74 American soldiers. Pneumonia is no stranger to army life, so these 90-odd cases are not surprising. What is unusual is the seriousness of the 18 cases, says Greg Gray, an epidemiologist at the University of Iowa. This mystery pneumonia has put healthy warriors on breathing machines. And although pneumonia can be infectious, there is no sign that soldiers are spreading it to each other; indeed, the severe cases are found in units deployed as far apart as Iraq, Kuwait, Qatar, Djibouti and Uzbekistan. American army medical teams are trying to track down the cause of this outbreak. Patients have been given questionnaires to see if they share any medical history or subtle physiological features. Researchers from the Centres for Disease Control and Prevention are working with the army on blood and sputum tests to screen victims for a range of bacteria, viruses, fungi and parasites, as well as signs of auto-immune abnormalities. The patients do not share a common occupation and tests seem to have eliminated microbial suspects such as the bacteria that cause tuberculosis and Legionnaires' disease, as well as the SARS virus and Hantavirus. One interesting finding, says Dr Gray, is that roughly half the severe pneumonia cases have elevated levels of eosinophils, a type of white blood cell normally associated with fungal or parasitic infections. Army officials believe that pathogens, or other environmental factors, are more likely causes than biological or chemical weapons. Despite the mystery, rooting out the cause of these pneumonias will be easier than unravelling the epidemiological enigma of the 1991 Iraq war: Gulf-war syndrome (GWS). GWS refers to an odd assortment of symptomsˇXjoint pain, fatigue, headache, memory and sleep problemsˇXreported by thousands of Gulf-war veterans in several countries. Although many cases have been explained by post-traumatic stress disorder, roughly a fifth remain undiagnosed. As Simon Wessely, a researcher at the Institute of Psychiatry in London, points out, there is no question that the symptoms of GWS are genuine. The problem is thatˇXdespite over a decade of research in many countries and more than $200m spent in America aloneˇXmost experts are hard-pressed to come up with a clear definition of a unique syndrome that can explain them. Or a particular cause to account for themˇXbe it vaccines against biological agents, nerve-gas antidotes or depleted uranium from shell casings. Certainly, some well-defined diseases have cropped up. Ronald Horner, a researcher at the National Institute for Neurological Disorders and Stroke in Maryland, found that 1991 Gulf-war veterans have twice the risk of developing amylotrophic lateral sclerosis, an extremely rare and fatal neuro-degenerative condition, compared with soldiers outside the region. GWS, though, is far less clear-cut than this. One answer may be found in the work of Craig Hyams, at the United States Department of Veteran Affairs in Washington, DC. He has looked at military illnesses through history and found similar complaints as far back as the American civil war. Might GWS be just a modern-day version of the traditional impact of war? Robert Haley, a researcher at the University of Texas Southwestern Medical Centre in Dallas, thinks not. He reckons that GWS is a defined physiological disorder caused by exposure to chemical weapons. Dr Haley's research, using magnetic resonance spectroscopy, has shown biochemical differences in parts of the brain called the basal ganglia and brainstem. He argues these are a sign of damage varying according to the type of trouble experienced by veterans, be it memory loss or body pain. Dr Haley's research has also shown that sick and well Gulf-war veterans have different levels of a key blood enzyme called para-oxonase. He contends that this may make particular soldiers more vulnerable to the effects of some nasty chemicals. Many researchers, however, question Dr Haley's work. In part, this is because his tests were performed on only 43 servicemen (23 of whom were ill). This is a rather small study group, and further work is now under way to replicate these studies in larger groups of soldiers. Researchers at several army and navy medical centres, the Institute of Medicine and the General Accounting Office are also investigating exposure to chemical weapons. Of particular interest is a place called Khamisiyah, an Iraqi munitions dump blown up by American soldiers in 1991 and later found to include rockets loaded with sarin, a deadly chemical. How much sarin was released, how far it spread, how many soldiers were exposed and what sort of medical problems they have encountered are all matters of debate. Although many scientists and defence officials on both sides of the Atlantic dispute the very existence of GWS, allied forces in the recent Iraqi war did err on the safe side. Britain, for example, changed its vaccination schedule for soldiers, giving more jabs before troops were deployed rather than in the field. The use of the whooping-cough vaccine was also eliminated. This was used in the first Gulf war to boost the action of anthrax vaccine. It has been suggested that this combination of jabs may be linked to some symptoms of GWS. In addition, ˇ§combat stress teamsˇ¨, including social workers and psychologists, have been sent out with the troops to help them deal with the physical and mental pressures of the conflict. The biggest change for both forces was better information management. One of the greatest obstacles to solving the puzzle of GWS has been a lack of reliable data. This time round, both armies have tried to improve the way they brief soldiers on health risks, and have kept medical records up-to-date. Health assessments have already begun on those who have returned. Environmental surveillance technicians have also been sent to Iraq, with portable kits to test encampments for chemical contaminants. And soil, air and water samples have been sent back for analysis. There is also a network of medics carrying portable handheld computers at the front line, and doctors with laptops in field hospitals. This information is analysed using software which automatically detects unusual patterns of illness. At the very least, these measures will help epidemiologists to work out the cause of the pneumonia outbreak. They should be of use in picking up emerging medical problems, including symptoms associated with GWS. Dr Hyams has no doubt that this year's conflict, like those before it, will throw up some baffling illnesses, given the ˇ§horrific and varied exposuresˇ¨ of war. No matter who or what the enemy is, forewarned is forearmed. Websites Gulf War Veteran Resource Pages http://www.gulfweb.org/doc_subindex.cfm?ID=1 America's Centers for Disease Control http://www.cdc.gov/nceh/veterans/default2.htm Division of Epidemiology at Southwestern Medical Centre http://www.swmed.edu/home_pages/epidemi/gws/ _______________________________________________ Sent via the discussion list of the Campaign Against Sanctions on Iraq. To unsubscribe, visit http://lists.casi.org.uk/mailman/listinfo/casi-discuss To contact the list manager, email firstname.lastname@example.org All postings are archived on CASI's website: http://www.casi.org.uk