The Gulf War Syndrome: Is It Really a New Disorder?
Roberto Masferrer, MD
Division of Neurological Surgery, Barrow Neurological Institute, Mercy Healthcare Arizona, Phoenix, Arizona
Current address: 1625 Medical Center Point, Colorado Springs, CO
Since the end of the Persian Gulf War (January 17, 1991 to February 28, 1991), approximately 50,000 United States reservists deployed to the theater of operations have fallen victim to a “mysterious illness” labeled the “Gulf War syndrome.” The syndrome is associated with a multitude of symptoms that ranges from diarrhea to chronic fatigue. These patients otherwise appear healthy both by physical and laboratory examinations. The media and special interest groups have become involved in finger-pointing campaigns, cover-up, and conspiracy theories. National scientific task forces have been created to study the new illness, and federal funds have been allocated to investigate the syndrome. Multiple agents, ranging from environmental factors to biological weapons and depleted plutonium, have been implicated in the production of the symptoms. A review of the literature on war-related illness since the Conquest of Mexico suggests that the symptoms are not new or related to weapons of mass destruction. More than anything else, the symptoms are a manifestation of the stresses of combat and the personal, economic, and emotional losses that accompany and follow young men when they are deployed to participate in a military campaign.
Key Words : combat neurosis, Gulf War syndrome, Operation Desert Storm, Persian Gulf War, posttraumatic stress disorder, war illness
On February 28, 1991, the guns in the Arabian Peninsula became silent. An armistice was signed and the “Mother of All Battles” ended with a devastating defeat for the army of Saddam Hussein. All of us deployed to the theater of operations were ecstatic about the possibility of a rapid redeployment back home. Every American family with a relative or friend in the Persian Gulf had a reason to give thanks for the prompt resolution of the armed conflict. The military leadership immediately assumed hero stature, which was passed to every member of the Armed Forces who participated in Operation Desert Storm. President Bush was poised for re-election, and all the psychics of the world predicted the immediate downfall of Saddam Hussein.
By February 1997, President Bush was remembered for having assembled one of the toughest coalitions in modern history, for being the Commander-in-Chief of one of the largest and fastest deployment forces in modern history, for convincing Israel to stay out of the battlefields, and for winning the war. Despite these credits, he lost the peace and his bid for re-election.
By the summer of 1997, 6 years after the end of the Gulf War, Saddam Hussein remains in power as defiant of American resolve as ever. The price of gasoline has never returned to its prewar value. The democratization of heroism failed to make returning troops feel better for their emotional, work-related, or economic losses as a result of their involvement in the war, and thousands of American reservists are falling victim to a “mysterious illness,”7, 17 referred to as the “Gulf War syndrome.7,13,27
Historical Aspects of the War
In the summer of 1990, with mixed signals from the U.S. Embassy in Baghdad, a message was conveyed to Saddam Hussein that the United States would not become involved in the internal affairs of the Arab States. Convinced that this U.S. foreign policy regarding the Middle East was absolute, Iraq launched a “Blitzkrieg” offensive and invaded Kuwait. In the weeks that followed, the American signals to Iraq changed from objection and disapproval, to threats of boycott and economical sanctions, to definite deployment of troops and armed conflict.
Operation Desert Shield
On August 3, 1990 Saddam Hussein proclaimed Kuwait an Iraqi province, based on maps of the ancient Babylonian empire, despite world-wide condemnation through the United Nations. Intelligence agencies from Israel, Saudi Arabia, and the United States worried and predicted that this was a preliminary step, and that next Saddam Hussein would invade Saudi Arabia achieving control of most of the Mideastern oil flow. As a result of these events, and as a deterrent against further Iraqi invasions, Operation Desert Shield was launched on August 7, 1990. The largest and fastest deployments of American troops and military equipment since World War II began on August 8, 1990. 3,24,30,36
As the deployment of troops grew, it became obvious that the build up was no longer a military exercise but a frank preparation for war. The Armed Forces Reserves were activated. During this period, many individuals also volunteered to serve. In the medical field alone, more than 600 volunteers reported for duty. This figure included nurses, physicians, dentists, and technicians (personal communication, Major Genaro Reyes, US Army, MPC, San Francisco, CA). There were also volunteers in other fields, including lawyers, engineers, and chaplains in noncombat roles and soldiers, sailors, and pilots in combat roles. It is estimated that approximately 5% of the deployed force consisted of volunteers (personal communication, Major Genaro Reyes, US Army, MPC, San Francisco, CA, 1997).
Two interesting phenomena occurred during this period. First, rather than deploying active duty personnel as in other armed conflicts, reservists filled a significant number of noncombat and combat support roles. This trend was especially evident in the medical and nursing corps where all the positions could have been filled with active duty personnel. Similar situations occurred for dentists, veterinarians, lawyers, and engineers. Most activated reserve units were deployed directly to the Persian Gulf. An estimated 17% of the deployed forces were in the Reserves. 17,28,34 Second, the details of the deployment went “live on CNN” and other cable and TV networks. Materials that would have been considered highly classified during World War II were aired on local and national TV and radio stations without military censorship. The “loose lips sink ships” policy of World War II was not enforced for Operation Desert Shield. CNN even opened an office in Baghdad and reported propaganda from the Iraqi capital as well as military news from Home Town, USA. 3,24,30
As the fall gave way to winter, the number of deployed U.S. troops became staggering. In every town across the country, one or more reservists from different communities were being mobilized to active duty. The details of the units being mobilized were well publicized. In some cases, tactical specifics such as the names and strengths of the units were even provided.
By January 1, 1991, 540,000 U.S. troops had been relocated to the Persian Gulf region in the largest and fastest military deployment of modern times. 3,8,14,25,30,34 Most of the deployments were to the Arabian Peninsula and its bordering seas, but there were also significant deployments to areas outside the theater of operations (i.e., Turkey, Greece, Germany, and Great Britain). 3,24,30,36 By this time, the military build up in the theater of operations encompassed 4,000 armored personnel carriers (APCs) and tanks, 1,800 airplanes, 1,700 helicopters, and more than 100 ships. 3,14,24,36 Included in this “armada” were the U.S.S. Mercy and U.S.S. Comfort, which are two fully self-contained hospital ships capable of caring for approximately 400 patients each. Thirty-five neurosurgeons were included among the medical teams deployed, constituting the largest mobilization of neurological surgeons since World War II (personal communication, Major Genaro Reyes, US Army, MPC, San Francisco, CA, 1997).
Among the neurological surgeons affected by the events were four graduates from BNI programs: Major Daniel Nehls, Major Mark Hadley, and myself as graduates of the neurosurgical residency program, and Lt. Commander Ronald Hargraves, a former Neurovascular Fellow at the BNI. Doctors Nehls, Hadley, and Hargraves were still on active duty assigned to different military hospitals within the continental United States. I was in private practice in Massachusetts. Dr. Hadley was assigned to Dickby Royal Air Force Base in Lakenheath, England as a Medical Liaison Officer for the USAF. I was assigned to Muscat, Oman, as Chief of Neurological Surgery for the Military Medical Center, Oman. This was a 1,200-bed hospital formed by the combination of resources from the U.S. Army 365th Evacuation Hospital and the United States Air Force 1705 Contingency Hospital. Doctor Nehls and Doctor Hargraves were never deployed.
Operation Desert Storm
On January 15 at 24:00 hours, the United Nation’s deadline for the withdrawal of Iraqi forces from Kuwait expired. 3,24,36
On January 17, 1991 at 03:00 hours, Operation Desert Storm began with a massive air assault. The air assault was preceded at 02:30 hours by a commando strike, in which eight AH-64 Apache-type helicopters of the U.S. Army 101st Airborne Division neutralized the advanced warning radar stations in a preselected corridor in Iraq. 3,30 Simultaneously the USAF 37th Tactical Fighter Wing, with its entire contingency of F-117 Stealth bombers, penetrated Iraqi air space and performed “surgical strikes” to disable additional warning centers together with command and control centers. 3,24,30 These two combined actions allowed 700 coalition combat aircraft positioned outside the range of Iraqi radar to penetrate undetected into Iraqi territory to destroy other strategic military targets. 3,24,30,36
The Lighting and Thunder phase of Operation Desert Storm began without any losses for the USAF. Within the first week of the initiation of the Gulf War, the coalition had achieved total air superiority and complete air control with minimal losses. The number of downed aircraft during the Gulf War was only 0.4%. This figure is extremely low compared to the losses from air operations in Vietnam (2%) and World War II (up to 25% in some missions). 3,14,30
The 6-week air campaign was preparation for the ground campaign and consisted of systematic aerial destruction of Iraqi strategic military installations. Combining tomahawk missiles, “smart” bombs, and regular ordnance, a total of 88,500 tons of explosives were delivered with 80% or higher accuracy. 3,24,30,36 The Iraqi Air Force was effectively neutralized with half of its assets destroyed and the other half “hidden” in neutral Iran or in areas with high concentrations of civilians. This phase of the war proved completely demoralizing for the Iraqi ground forces. 3,24,30,36 By February 15, 1991 the “strongest and fiercest army” in the Middle East and the “fourth largest army in the world” was debilitated, demoralized, and without a will to fight.
Serious preparations for the ground campaign began on February 17, 1991 with “ground softening” using B-52 and C-130 bombing raids aimed to destroy mine fields that were part of the “obstacle courses” laid by the Iraqi army. Napalm raids were used to destroy the “oil trenches” that Saddam Hussein had ordered to be positioned as “fire traps” for the advancing coalition forces in the battle for Kuwait City. 3,24,36
On February 20, 1991 the United States Marines captured Faylakah Island at the entrance of Kuwait Bay. 3,30 The U.S. marines deployed 31 ships with an amphibious landing force of 17,000 men to create the impression that an impending Normandy-type of invasion was imminent. Simultaneously, the U.S. Army VIIth Armored Corps and the XVIIIth Airborne Corps, together with the British First Armored Division and the French 6th Light Armored Division, began a flanking maneuver. Altogether, 250,000 troops with 60 days of supplies, ammunition, and equipment were deployed 200 miles west of their original positions in record time. 3,30
On February 22, 1991 at 04:00 hours, the ground campaign of Operation Desert Storm began with a front penetration by the United States Marines 1st Expeditionary Force and Arab Nation Coalition Forces. 3,30,36 The American-Franco-British flanking maneuver, described by the American press as the Schwarzkopf “Hail Mary pass” but in reality a military feat of historic proportions, reduced the Iraqi war machine “from the fourth largest army in the world to the second largest army in Iraq.” 30 Approximately 6 days later on February 28, 1991 at 08:00 hours, the Iraqi Armed Forces surrendered to General Norman Schwarzkopf. 3,24,36
The all-out invasion of the beaches of Kuwait “a la Normandy,” never happened. The effectiveness of the air campaign denied the Iraqi military intelligence the “eyes in the sky” needed to detect the movements of the coalition forces. The capture of Faylakah Island by the U.S. Marines, as well as the deployment of the Medical Corps with ample television coverage emphasizing the preparation for mass casualities, were decoys designed to convince Hussein that the “Mother of All Battles” would go the way he had predicted. These two strategies allowed Generals Powell and Schwarzkopf to launch their own American version of “Blitzkrieg”: the coalition forces flanked the Republican Guard units, cut all supply lines from Baghdad, and defeated the entrenched regular army units. The war ended in record time with a minimal number of casualties for the Allied Forces. 3,24,30,36
Operation Desert Storm was over in 43 days and most of the physicians deployed never saw a war-related casualty. There were 528 U.S. combat casualties: 189 troops were killed in action (including 6 females and 2 physicians) and 339 troops were wounded in action (including one female physician). No U.S. troops were listed missing in action or as prisoners of war by the end of the conflict. 3,14,24,30,36 Of the 35 neurosurgeons deployed, only one performed a craniotomy for a gunshot wound to the head (personal communication, Savvas Papazzoglou, MD, Lt. Col. U.S. Army, Riyadh, Saudi Arabia, 1997). We won the war in record time with minimal casualties due to enemy fire.
Some of our casualties as well as casualties of other coalition forces were caused by “friendly fire.” 3,14 The term is a misnomer because there is nothing friendly about it for those at the receiving end. As a result of human error, however, this unfortunate situation has occurred in all major conflicts and has been described since the Battle of Waterloo. During the Civil War, for example, General “Stonewall” Jackson was a casualty of friendly fire during the battle of Chancellorsville. In both of these recorded historical events, the common denominator was the same: poor visibility. It has been estimated that 20% of allied casualties during Operation Desert Storm were due to friendly fire. 14 This figure might appear to be embarrassingly high for those who have never been involved in combat. The figure, however, is low compared to other conflicts, especially when the conditions of low visibility that characterized much of the Gulf War are considered. 3,14,24,30
After the war the triumphant American Forces returned home to a hero’s welcome. As all the “Welcome Back Heroes” signs wore off and the deployed personnel returned to their normal civilian and/or previous military roles, casualties from a “mysterious illness” related to active duty in the Persian Gulf began to appear, especially among reservists. Patients with this “new disease” otherwise appeared healthy but complained of varied and different combinations of symptoms such as fatigue, numbness, chest pain, dyspnea, memory loss, headaches, diarrhea, irritability, skin rashes, myalgias and arthralgias, depression, dyspareunia, and sleep disturbance (Table 1). 7,13,17,25,27,28,34
Task forces to study the illness were created. 25,28,34 A poorly informative media campaign followed 8 and promptly triggered the involvement of politicians. Undoubtedly, some of the people involved were well intentioned but totally ignorant of what they were dealing with or looking for. As publicity increased so did the number of reported cases, and the terms Persian Gulf syndrome or Gulf War syndrome were coined. 10,13,27
Ever since the dawn of humanity, mankind has been involved in wars as documented in anthropological studies of primitive tribes and societies, as well as in early literary works spanning from Gilgamesh and The Odyssey to El Cid and Historia Verdadera de la Conquista de la Nueva España (True History of the Conquest of New Spain). More contemporary works such as All Quiet on the Western Front , A Bridge Too Far , and Everything We Had have captured the anguish of the common soldier faced with the brutality of contemporary warfare.
The basic instinct for most soldiers is to return alive from any armed conflict. Psychological factors come into play when the stresses from the environment are untenable or intolerable. Some individuals develop psychosomatic disorders as a means of avoiding combat. These reactions have occurred in all armed conflicts and in all armies, regardless of the ethnicity or nationality of the combatants. These events have been portrayed both in the arts as well as in the medical literature from Homer and Plutarch to Da Costa and Kardiner. 35 It is easier for an individual’s psyche to accept illness as an excuse to move away from the battlefield rather than fear with its implications of cowardice.
The Conquest of Mexico
The earliest reference in the American continent regarding a psychosomatic dysfunction related to military duties does not come from the medical literature but from the journal of a Spanish conquistador. In his diary relating the conquest of Mexico, Bernal Diaz del Castillo describes several cases ofmal de lomos (ailment of the back), which probably represent the first recorded cases of camptocormia. His account precedes the medical description of this disorder by almost 300 years, confirming the timelessness of these “fear reactions” and the accuracy of Marie Antoinette’s milliner’s phrase that “nothing is new, only what has been forgotten.”
In the Historia Verdadera de la Conquista de la Nueva España , Diaz del Castillo, a seasoned Spanish soldier described four “inexperienced recruits” that developed a bent-forward abnormal posture that prevented them from being deployed from the safety of their Spanish galleon to shore duties in hostile “Indian” territory. When later the ship was attacked and all the conquistadores were in imminent risk of death, these younger soldiers “forgot their malady” and “put up a good fight.” This description is remarkably similar to another event that involved patients with camptocormia on a British ship during World War I. In this instance all patients recovered from their “paralysis of the muscles of the back” and performed their duties when a German submarine torpedoed the ship placing all passengers in immediate risk of death. 23
The Civil War
During the American Civil War, Jacob Da Costa performed the first systematic analysis of a war-related illness at the United States Army Hospital for Injuries and Diseases of the Nervous System on Turner’s Lane in Philadelphia. Most of the troops affected were young and otherwise healthy, but they were significantly disabled by their symptoms (i.e., chest pain, dyspnea, and palpitations). Da Costa called the illness “irritable heart.” 37-39 Later, it became known as “soldier’s heart syndrome.” During this same conflict, David Peters also identified a primarily psychological dysfunction, which he labeled “nostalgia.” 17,20 This latter disorder was considered a severe form of homesickness (i.e., obsessive thoughts, apathy, loss of appetite, and sleep disturbance). Diarrhea could be a symptom of either condition. 5,17,37-41
The Spanish-American War
During the Spanish American war, disability from symptoms similar to the ones described by Da Costa and Peters in Civil War soldiers also afflicted U.S. troops deployed from the Caribbean to the Philippines. Again, the symptoms were thought to be a “new form of disease” related to the weather conditions in the tropics. The new syndrome was labeled “tropical asthenia.” 20
World War I
During the First World War, these syndromes appeared again but with different names. The syndrome with predominantly physiologic manifestations was called either “the soldier’s heart syndrome,” “the effort syndrome,” “neurocirculatory asthenia,” or “Da Costa syndrome.” 5,17,20,37-39,41
Camptocormia made its debut during this war as a new syndrome that manifested itself primarily as an abnormal posture and was considered a new disorder of the musculoskeletal system. The term, which comes from the Greek camptos meaning bent and kormosmeaning trunk, literally means bent trunk . 23 Organic bases were sought for the disorder. By the end of the war, however, it was established that the paralysis of the muscles of the back had a psychiatric basis and was a form of conversion reaction. 9,17,23,35 It is probably the same disorder mentioned by Diaz del Castillo 300 years earlier.
Two syndromes with a mixture of psychiatric and organic manifestations also appeared during World War I, producing significant disability among British troops. Trench neurosis and shell-shocked syndrome were considered new illnesses. Causes for the new entities included infectious diseases, exhaustion, brain damage from the concussive effect of the new long-range cannons or the effects of poisonous gas, also a new development in warfare at that time. 6,9,17,20,35
The British Army Medical Corps preferred the entry “not yet diagnosed, nervous” for all these “war neuroses” to avoid giving the afflicted soldier the impression that he had a disease for which he could be removed from the front lines, returned home, and compensated. 6,9,17,20 Nonetheless, by the end of the war, 44,000 cases of Da Costa syndrome had been recorded in the British Armed Forces, making it the third most common cause of disability and compensation in England.17
World War II
During Second World War, the terms acute combat stress reaction and combat fatigue were coined. 6,9,17,20 These acute situational reactions were differentiated from the most serious psychiatric dysfunctions, including camptocormia. Definite treatment modalities (i.e., rest, sedation, and prompt return to duty) were established for patients afflicted by the acute situational reaction (combat fatigue). 9,20 Definite psychiatric therapy away from the theater of operation was reserved for patients with severe neuroses and/or psychoses. 6,9,20 In general, patients suffering from combat fatigue were considered to be normal individuals who had reached a psychological breakdown point while patients experiencing a more severe psychiatric problem, including camptocormia, were considered to have an underlying (not war-related) psychiatric disorder. 6,9,20,35
A better understanding and treatment of these problems and the relatively brief period between World War II and the Korean War were probably the reasons why a “new” syndrome was not reported during the deployment of American Forces to the Korean Peninsula. 17,20 The Diagnostic and Statistical Manual of Mental Disorders (DSM-I) was developed during this period, and the class of “gross stress reactions” provided military physicians a diagnostic code for these patients. These reactions were considered to be “reversible,” secondary to “severe” physical or emotional stress imposed on a “normal personality structure.” The combat fatigue-type of syndrome was defined as “transient” in the original DSM-I classification. However, physicians treating and studying these reactions believed that they could evolve into more pervasive, chronic forms. 6,35 Rather than separate entities, a more generalized concept of a “fear syndrome” was starting to develop among military and civilian psychiatrists studying these combat-related reactions. 6,35
The Vietnam experience was associated with acute situational reactions as well as with a “new” postwar syndrome initially labeledpostVietnam syndrome and now known as posttraumatic stress disorder (PTSD). 6,17,20 The combat experience and all the hardships and unfairness of war were not left behind when the war was over. Now it could be brought home and blamed for future failures in life and justified with a medical diagnosis. This new postwar-related syndrome not only disabled the veteran and his family, but it also made the government responsible for it. 15 The denial of their own postwar syndrome to the Vietnam veteran did not quell their anxieties, which continued to fester and finally erupted in the Agent Orange debates, which were also reported by the press in a way similar to the reporting of the Gulf War syndrome. 15
Outcomes of Combat-Related Reactions
Although not well documented in the medical literature, veterans from all conflicts most likely have had difficulties readjusting to civilian life after “their” war was over. 4,31 It is well known that the soldiers from World War I who were diagnosed as shell shocked or as having Da Costa syndrome and who returned to England with these diagnoses remained disabled for life. 6,17 During World War II, this medical fact prompted the management of soldiers with combat fatigue in the field rather than moving them to rear echelons or returning them home. 6,9,20 The previous war had taught military physicians that the possibilities for rehabilitation and return to a normal and productive civilian life were severely impaired when soldiers who experienced an acute situational reaction were diagnosed with a “war illness” and returned home. 6,9,17,20,35
From retrospective studies of prisoners of war from both World War II and the Korean War, it appears that the PTSD of Vietnam veterans was not a new syndrome either. 6,17,20,21,35 When conflict is over, the severe physical and psychological stresses of war are sometimes difficult to overcome and can follow the combatants to their civilian environments. These stresses are most obvious for prisoners of war, especially when held captive by an army that is ethnically and culturally very different from one’s own. The incidence of PTSD symptomatology among prisoners of war from the European theater during World War II was low compared to the symptoms of prisoners of war of the Imperial Japanese Army or the North Korean Army in the following war. 21 The Viet Cong did not improve the track record regarding the treatment of American prisoners of war in Southeast Asia during the Vietnam War.
Although PTSD has not been well documented in previous conflicts, it probably existed after every war and is not a specific response to the Vietnam War. Furthermore, PTSD is not a condition exclusively related to military conflict. It also occurs in civilian populations after nonwar-related disasters and mass casualties as well as in victims of rape, child abuse, or spousal abuse. 35
The Gulf War Syndrome
The democratization of heroism for American forces returning from the Persian Gulf at the end of the war was an act of good will from the nation, the press, and the political establishment to make the members of the Armed Forces feel good about their participation in Operation Desert Storm. Perhaps, it was also an exorcism of guilt for having spat and pointed fingers at the troops returning from Vietnam for having done their duty in a war that became unpopular.
Despite this “Welcome Home Heroes” attitude and despite the Soldiers and Sailors Act designed to protect those who are called to duty from losing their jobs or their homes, the reservists from the Gulf War discovered, as have previous veterans, that reincorporation into society sometimes is difficult. 4,31 They also discovered that emotional and economic losses are part of the stresses of postwar life. During and after the war, marriages dissolved, jobs were lost, and bankruptcy was a real threat for many veterans. The ensuing sense of defeat in civilian life is sometimes more frustrating than the anguish of impending combat.
By the summer of 1994, a series of articles in the Washington Post identified a “faceless enemy” responsible for a “mysterious illness” among Desert Storm veterans who were “triumphant in the desert, but stricken at home.” 7,24,27 These articles prompted congressional inquiries, followed by White House involvement, and the appointment of task forces to find the causes of the “new illness.” 25,28,34 As the publicity grew so did the number of new cases, which had peaked at almost 50,000 cases by 1997. 7,12,17,18,28
Is this illness really new ? Or, is Da Costa syndrome being resurrected with a new name?
Clinical Manifestations of the Gulf War Syndrome
The symptomatology of the Gulf War syndrome is interesting and varied. Symptoms are present in a population that otherwise appears healthy. In most cases, ancillary laboratory and radiological testing is negative. In each case the syndrome varies and includes different combinations of the following symptoms: excessive fatigue or easy exhaustion, paresthesia, myalgias and arthralgias, skin rashes, diaphoresis, diarrhea, chest pain, palpitations and tachycardia, dyspnea, headaches, memory loss or forgetfulness, impaired concentration, irritability, dizziness and fainting, depression, sleep disturbances, and dyspareunia (Table 1). 7,11-13,17,18,25,27,28,34 These symptoms sometimes resemble chronic fatigue syndrome, which is also an ill-defined and poorly explained symptom complex. 32,33
Origins of Gulf War Syndrome
Causes for this varied symptom complex have been sought, and the list of potential culprits is equally varied. Agents or factors thought to be responsible for the symptoms include pesticides and insect repellants, chemical warfare agents, depleted plutonium, prophylactic medications (including pyridostigmine bromide, ciprofloxazine and chloroquine), immunizations, ultrafine desert sand particles, toxic fumes, smog, or a combination of some or all of the above. 7,11,13,17,18,25,27,28,34 Malingering, chronic fatigue syndrome, and PTSD have been implicated in a shy way. 25,34
In 1993, several cases of leishmaniasis produced by Leishmania tropica were reported among Desert Storm veterans. The clinical manifestations were protean: prolonged fever, adenopathy, abdominal pain, intermittent diarrhea, general malaise, and chronic fatigue with adenopathy and/or hepatosplenomegaly. 17,22 None of these patients, however, had the cutaneous lesions that are the typical manifestation of infections with L. tropica. Although cases of visceral leishmaniasis by this parasite have been reported in the African and Mideastern medical literatures, these references were basically unknown to general practitioners in the United States before the Gulf War. 8,17,22
On August 3, 1994, four years after the disastrous proclamation of the annexation of Kuwait by Saddam Hussein, the National Institutes of Health published the conclusions of the Technology Assessment Workshop Panel regarding Gulf War syndrome. This unbiased panel, composed of highly respected scientists, stated that “no single disease or syndrome is apparent, but rather multiple illnesses with overlapping symptoms and causes.” 25 The panel also acknowledged that “chronic symptoms of viscerotropic leishmaniasis and PTSD were found to be compatible with some cases of unexplained illness.” 26
Other authors focused on the problem by comparing the morbidity and mortality rates of the troops deployed to the theater of operations with those of nondeployed military personnel during the same period. 19,42 Hospitalizations and mortality rates after the war also have been analyzed and compared among these two populations. 10 None of these retrospective studies provide evidence of either increased morbidity or mortality rates among Desert Storm troops either during or after the conflict. 10,19,34,42
Of epidemiologic and psychiatric interest is the fact that the Gulf War syndrome appears to have affected predominantly reservists. 11-13,26,34 It is therefore highly unlikely that a chemical or biological agent is responsible for the problem. However, it is very likely that psychological factors related to the disruption of civilian life as a result of recall and then disruption of military life after the war could be responsible for the syndrome. 4,31 Active duty personnel went through debriefings and participated in support groups that helped them to integrate into their new or old units still within the system. In contrast, reservists returned to civilian environments unresponsive to their stresses and or losses.
In the quest for a cause to explain the Gulf War syndrome, researchers sponsored by the Perot Foundation further complicated the issue by describing six syndromes 11-13,27 which are now included under the generic label Gulf War Syndrome Unexplained Illness (GWSUI). 18 Using a computer model, they grouped the symptoms into six clusters and identified each cluster as a distinct syndrome (Table 2).
Interestingly, these researchers did not reference any of the authors who studied previous war syndromes in which all of the symptoms of the GWSUI have been described (Table 3).
Another group of researchers, also sponsored by the Perot Foundation, created an experimental model trying to prove co-exposure to chemical agents (i.e., multiple insecticides and insect repellants combined with chemical warfare prophylaxis with pyridostigmine bromide) as the cause of Gulf War syndrome. 1,2,27 Unfortunately, the doses used in this study were three times higher than the estimated doses soldiers would have been exposed to. Their animal model, which used chickens, is flawed not only by being a different species but also by being a different order in the taxonomical classification. Furthermore, chickens happen to be very sensitive to some of the agents used in the experimental model. The Perot Foundation researchers also stated that the use of flea collars as insect repellants was widespread among Desert Storm troops. 11 Based on my experience with different units in the theater of operations, however, the use of flea collars was specifically forbidden, at least in all the units with which I was associated.
When the symptomatology of the two war syndromes reported during the Civil War is compared to the Gulf War syndrome, some striking similarities become evident (Table 1). Although separated in time by almost 130 years, both syndromes have organic and psychological manifestations that are almost identical. In the “variations on a theme” associated with the armed conflicts that followed the Civil War, attempts were always made to explain the symptomatology by environmental conditions, infectious diseases, military equipment, newer and more potent weapons, or weapons of mass destruction. In each war the results have been the same: A new illness and/or new causes for the illness other than the physical or emotional stress of the combatants has never been discovered. 6,17,20,34,35,37-41
A review of the prevalence and incidence of disease among the more than 500,000 troops assigned to the theater of operations failed to reveal any trend to indicate the existence of a new disease or illness. 10,19,34,42 Furthermore, the expected mortality rate for those deployed is less than half of the expected mortality rate among the average civilian population during the same period of time, pointing to the overall good health of military personnel. 10,19,29 The mortality rate for this population during the war was lower than after the war, primarily due to motor vehicle accidents and common violence in the cities to which the troops returned. In other words, quartered military personnel without access to alcoholic beverages and/or highways have very low morbidity and mortality rates. 10,19,34
With time, some veterans of the Gulf War will develop medical problems, including cancer. Some females will become pregnant. And some of their babies will have congenital defects. To blame all of the future medical problems of this relatively large population on their deployment to the Persian Gulf would be unscientific and ill advised, 13,25,26,28,34 regardless of pressure from good Samaritan groups, reporters, or researchers who are unaware of or who have chosen to ignore the historical evidence that precedes the Gulf War.
The body of evidence from the medical literature before and after Operation Desert Storm supports the following conclusions. First, poorly understood war syndromes have affected U.S. military personnel in every major conflict since the Civil War. Similar syndromes have been reported in other armies from the conquest of Mexico to the Crimean War and both World Wars. Second, no previous “new” illness has been uncovered or discovered in any conflict other than illnesses related to the stress of war, now included in the broader concept of PTSDs. Third, visceral or systemic leishmaniasis should be included in the differential diagnosis of unexplained illness in veterans of Operation Desert Storm. Fourth, patients with the diagnosis of Gulf War syndrome should be evaluated and treated as any other patient—with an open and inquisitive mind, remembering Dr. C. Miller Fisher’s aphorism: “the patient is only doing the best he can.” Finally, based on previous war experiences, between 20 and 30% of these patients will have true organic diseases. Approximately 5% will be malingerers. The rest will have a form of psychological dysfunction including anxiety and phobic states, conversion and psychosomatic reactions, depression and/or PTSD.
To the men and women who have served in time of war, and especially to those who gave their life for our country.
The opinions contained in this article are exclusively those of the author and do not represent the official opinion of the U.S. Armed Forces, the U.S. Government, the Barrow Neurological Institute, or St. Joseph’s Hospital and Medical Center, Mercy Healthcare Arizona.
- Abou-Donia MB, Wilmarth KR: Neurotoxicity resulting from coexposure to pyridostigmine bromide, DEET, and permethrin: Implications of gulf war chemical exposures. J Toxicol Environ Health 48:35-56, 1996
- Abou-Donia MB, Wilmarth KR, Abdel-Rahman AA, et al: Increased neurotoxicity following concurrent exposure to pryidostigmine bromide, DEET, and chlorpyrifos. Fundam Appl Toxicol 34:201-222, 1996
- Allen TB, Berry FC, Polmar N: CNN War in the Gulf. Atlanta, GA: Turner Publishing, 1991
- Blanck RR, Bell WH: Special reports: Medical aspects of the Persian Gulf War. Medical support for American troops in the Persian Gulf. N Engl J Med 324:857-859, 1991
- Cohen ME, White PD: Neurocirculatory asthenia: 1972 concept. Mil Med 137:142-144, 1972
- Ettedgui E, Bridges M: Posttraumatic stress disorder. Psychiatr Clin North Am 8:89-103, 1985
- Ficarra BJ: Medical mystery: Gulf war syndrome. J Med 26:87-94, 1995
- Gasser RA, Jr., Magill AJ, Oster CN, et al: The threat of infectious disease in Americans returning from Operation Desert Storm. N Engl J Med 324:859-863, 1991
- Glass AJ: Psychotherapy in the combat zone. Am J Psychiat 110:725-731, 1954
- Gray GC, Coate BD, Anderson CM, et al: The postwar hospitalization experience of U. S. veterans of the Persian Gulf war. N Engl J Med 335:1505-1513, 1996
- Haley RW, Hom J, Roland PS, et al: Evaluation of neurologic functions in Gulf War veterans. A blinded case-control study. JAMA 277:223-230, 1997
- Haley RW, Kurt TL: Self-reported exposure to neurotoxic chemical combinations in the Gulf War. A cross-sectional epidemiologic study. JAMA 277:231-237, 1997
- Haley RW, Kurt TL, Hom J: Is there a Gulf War Syndrome? Searching for syndromes by factor analysis of symptoms. JAMA 277:215-222, 1997
- Helmkamp JC: United States military casualty comparisons during the Persian Gulf War. J Occup Med 36:609-615, 1994
- Holden C: Agent Orange furor continues to build. Science 205:770-772, 1979
- Hyams KC, Hanson K, Wignall FS, et al: The impact of infectious diseases on the health of U.S. troops deployed to the Persian Gulf during Operations Desert Shield and Desert Storm. Clin Infect Dis 20:1497-1504, 1995
- Hyams KC, Wignall FS, Roswell R: War syndromes and their evaluation: From the U.S. Civil War to the Persian Gulf War. Ann Intern Med 125:398-405, 1996
- Jamal GA, Hansen S, Apartopoulos F, et al: The “Gulf War syndrome.” Is there evidence of dysfunction in the nervous system? J Neurol Neurosurg Psychiatry 60:449-451, 1996
- Kang HK, Bullman TA: Mortality among U.S. veterans of the Persian Gulf War. N Engl J Med 335:1498-1504, 1996
- Kentsmith DK: Principles of battlefield psychiatry. Mil Med 151:89-96, 1986
- Kluznik JC, Speed N, VanValkenburg C, et al: Forty-year follow-up of United States prisoners of war. Am J Psychiatry 143:1443-1446, 1986
- Magill AJ, Grögl M, Gasser RA, Jr., et al: Visceral infection caused by Leishmania tropica in veterans of Operation Desert Storm. N Engl J Med 328:1383-1387, 1993
- Masferrer R, Rauch H, Sonntag VKH: Camptocormia in the United States personnel assigned to the Western Pacific. BNI Quarterly 5:8-13, 1989
- Mathews T, Waller D, DeFrank TM, et al: America at war: From the frenzied buildup to the joyous homecoming. Newsweek Spring/Summer: 32-102, 1991
- NIH Technology Assessment Workshop Panel: The Persian Gulf experience and health. JAMA 272:391-395, 1994
- Penman AD, Tarver RS, Currier MM: No evidence of increase in birth defects and health problems among children born to Persian Gulf War veterans in Mississippi. Mil Med 161:1-6, 1996
- Pennisi E: Chemicals behind Gulf War syndrome? Science 272:479-480, 1996
- Persian Gulf Veterans Coordinating Board: Unexplained illnesses among Desert Storm veterans. A search for causes, treatment, and cooperation. Arch Intern Med 155:262-268, 1995
- Rothberg JM, Bartone PT, Holloway HC, et al: Life and death in the US Army. In corpore sano . JAMA 264:2241-2244, 1990
- Schwarzkopf HN: It Doesn’t Take a Hero. Autobiography of General H. Norman Schwarzkopf. New York: Linda Grey, Bantam Books: 1992
- Solomon Z, Waysman M, Levy G, et al: From front line to home front: A study of secondary traumatization. Fam Proc 31:289-302, 1992
- Straus SE: History of chronic fatigue syndrome. Rev Infect Dis 13:S2-S7, 1991
- Straus SE, Komaroff AL, Wedner HJ: Chronic fatigue syndrome: Point and counterpoint. J Infect Dis 170:1-6, 1994
- The Iowa Persian Gulf Study Group: Self-reported illness and health status among Gulf War veterans. A population-based study.JAMA 277:238-245, 1997
- Tomb DA: The phenomenology of post-traumatic stress disorder. Psychiatr Clin North Am 17:237-250, 1994
- Waller D, Barry J, McDaniel A, et al: The day we stopped the war. Angry hours—how Bush made the call. Newsweek 119 (3):16-25, 1992
- Wood P: Aetiology of Da Costa’s syndrome. Br Med J 1:845-851, 1941
- Wood P: Da Costa’s syndrome (or effort syndrome). Br Med J 1:767-772, 1941
- Wood P: Da Costa’s syndrome (or effort syndrome). The mechanism of the somatic manifestations. Br Med J 1:805-811, 1941
- Wooley CF: Where are the diseases of yesteryear? DaCosta’s syndrome, soldier’s heart, the effort syndrome, neurocirculatory asthenia—and the mitral valve prolapse syndrome. Circulation 53:749-751, 1976
- Wooley CF: From irritable heart to mitral valve prolapse: British army medical reports, 1860 to 1870. Am J Cardiol 55:1107-1109, 1985
- Writer JV, DeFraites RF, Brundage JF: Comparative mortality among US military personnel in the Persian Gulf region and worldwide during Operations Desert Shield and Desert Storm. JAMA 275:118-121, 1996