In the 25 years since Desert Storm, about 250,000 of the almost 700,000 involved in the Gulf War 1 theater have suffered from some version of the complex of symptoms now called Gulf War Illness. This illness was discussed in a recent symposium co-hosted by the Brookings Institution and Georgetown University Medical Center.
While Desert Storm battle casualties were light, military personnel were exposed to various chemical and biological agents. These included Pyridostigmine Bromide, to prevent the effects of nerve gases which had been used previously by Iraq; organophosphate pesticides (such as DEET) which were embedded in clothing; particulate airborne matter from oil fires; and, possibly sarin exposure from a plume arising from an Iraqi munitions depot at Khamasiyah.
Some years after Desert Storm, especially from 2000-2009, veterans began utilizing Department of Veterans Affairs (VA) health facilities in higher numbers and complaining of chronic symptoms such as fatigue, joint pain, indigestion, insomnia, dizziness, respiratory disorders, memory problems, and migraine headaches. While the symptoms resembled the known conditions of fibromyalgia, Chronic Fatigue, and Irritable Bowel Syndrome, they were difficult for physicians to deal with and there were no diagnostic tests or specific treatments.
Care for these veterans was bedeviled by a lack of understanding of the nature and causes of Gulf War Illness, and more generally, of the importance of battlefield exposures. There was also an initial attitude among officialdom and medical institutions that Gulf War 1 veterans suffered from psychosomatic illness, or that they were malingering or pandering for benefits, a profound disrespect. In addition, the plight of Gulf War 1 veterans has not been well recognized by the public.
Current Attitudes and Research
Over the years, the adverse attitudes about what is now called Gulf War Illness began to change. Officialdom now accepts the illness as a physical and not psychosomatic condition, which has led to positive steps. The formation of three congressionally mandated VA War Related Illness and Injury Study Centers (starting in 2001) was one such step. The Centers, which offer medical expertise and teams that work with VA and community providers, have provided a comprehensive registry examination to over 160,000 Gulf War veterans. However, while these and similar efforts are worthwhile initial steps, they have not penetrated the VA system as a whole and outside of the VA, where most Gulf War veterans seek care, there is an even greater problem.
Veterans with Gulf War Illness make up a small proportion of both the U.S. patient population and the VA’s 9 million enrollees. Therefore, it is difficult to develop a substantial and widespread expertise, even in the VA (where about a third of these veterans are enrolled). Treating the illness outside of the VA is more difficult because civilian physicians are less familiar with veterans’ issues, especially given the declining number of veterans in the U.S. population.
Controversies surround Gulf War Illness research. For one there is a false perception that the research only concerns psychosomatic illness. However, that supposition is decidedly not the case. For more than 10 years, VA research on Gulf War Illness has consisted of strictly biologic and not psychosomatic studies. Both VA and Department of Defense (DoD) research have identified abnormalities in the brain and exercise abnormalities, which confirm the physical and not psychosomatic basis of Gulf War Illness, certain effective treatments (exercise, cognitive therapies, nighttime positive pressure breathing), and clues to biomarkers. However, it has not nearly filled the many gaps in knowledge on exposures or their treatments.
Industry research on Gulf War Illness has also been limited. Perhaps therapies for Gulf War Illness could also be effective in more common pain and intestinal syndromes, providing a larger population for such treatments.
Because research has not discovered very many treatments for Gulf War Illness, the clinical approach is generally directed towards treating symptoms. As noted above, exercise and nighttime positive pressure breathing can be specifically effective treatment for the symptoms of Gulf War Illness including pain. The use of cognitive-type therapies is a sensitive topic for Gulf War veterans because of the historic perception of psychosomatic causation. However, cognitive therapies and mindfulness, which are often effective in serious conditions like cancer pain, have been proven effective for Gulf War Illness as well.
Looking Towards the Future
In order to address Gulf War Illness and protect the health of future veterans we must not repeat our past mistakes. According to Representative Michael Coffman, who gave the keynote address at the recent symposium and is the only Gulf War 1 and 2 veteran in Congress, if veterans felt the country was doing everything it could, there would be some closure. Perhaps then there could be a crucial decline in mistrust.
In 2016, VA will spend $14 million and DoD $20 million (via the Congressionally Directed Medical Research Program) for research on imaging, biomarkers, treatments, and other aspects of the illness. There will be funding for public health databases to collect more complete data on the illness. Further research may also be able to make use of an already established data source: the VA’s Million Veteran Program, which could help identify which exposures contribute to Gulf War Illness. Studies of Gulf War Illness symptoms in the Kuwaiti population, who may have been exposed to some of the same agents as the U.S. military, are also being discussed.
A fundamental research question in the distribution of limited research resources for Gulf War Illness is whether funding should continue to focus on identifying the initial exposures that cause the illness or on treatments, genetics, and biomarkers. Because 25 years have passed since Desert Storm, there may be little hope for identifying the exposures that caused it. However, leads from focused animal studies on battlefield exposures may have value for future veterans who may be exposed to the same substances.
Another medical research issue is the effect of aging on Gulf War veterans. With the passing of time, veterans are moving into older age groups where long-term effects of exposures may become apparent and where the coexisting problems of aging may compound the problem. Other questions involve special considerations of gender or ethnicity.
All of these initiatives are important steps. Going forward, we should:
- foster a broad research program;
- assess future battlefield exposures along with providing good vehicles for sharing the information;
- advance Centers of Excellence and other approaches that provide specialized help and enhance provider understanding of Gulf War Illness;
- utilize home caregiving; and,
- assure that a proper clinical approach to Gulf War Illness is part of quality assessment in all systems that care for these veterans.
We also need more collaboration among investigators, funding agencies, and systems of care and especially with veterans themselves and their organizations. And, for the veterans of Gulf War 1 and those with similar risks in the future, we should not let this be a forgotten problem from a war that we are already beginning to forget.