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[casi] The Economist: Gulf-war syndrome - The fog of war

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
countries. Although many cases have been explained by
post-traumatic stress disorder, roughly a fifth remain

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.


Gulf War Veteran Resource Pages

America's Centers for Disease Control

Division of Epidemiology at Southwestern Medical Centre

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