Emeritus Professor of Medicinal Chemistry
School of Sciences, University of Sunderland UK
"There is an age when one teaches what one knows but there follows
another when one teaches what one does not know" - Roland Barthes
I became involved with the Gulf War Veterans, GWVs, through my association with the Autism Research Unit over many years. I met four GWVs at the Unit in 1997 and following discussions about their illnesses I agreed to help them in whatever way I could. This led to my being appointed as their Chief Scientific Adviser and subsequently to my membership of the Ministry of Defence, MoD, Independent Panel and the Gulf Support Group, GSG, run out of the Royal British Legion. This latter group involves MPs, members of the House of Lords, representatives of the Service Charities, and Military personnel from the UK and USA. Scientists involved in research into Gulf War Syndrome/Illness have given presentations to the GSG.
2. The Gulf War
The Gulf War is the without doubt the most toxic war in Western Military history. The following exposures to biological and chemical toxins have been recognised.
a. IN PREPARATION FOR THE WAR
(i) Pyridostigmine Bromide, PB, NAPS tablets.
(ii) Vaccinations in large numbers and of varied types.
b. IN THE THEATRE OF OPERATIONS.
(i) Further vaccinations.
(ii) Exposure to varieties of pesticides of different chemical classes, and DEET, an insect repellent.
(iii) Depleted Uranium, DU, particularly as a ceramic dust.
(iv) Chemical Warfare Agents
(v) Possibly some Biological Warfare Agents
(vi) Extensive exposures to Crude Oil and Smoke from the Oil Well fires.
(vii) Exposure to very fine sand which penetrated the outer layer of NBC (nuclear, chemical and biological) protective suits and might have toxins adsorbed on to it. The so-called El Askan disease.
It is apparent that a (i), (ii) and b (i-iii) are clearly a result of the preparation of troops for Operation Granby (UK) and Operation Desert Storm (USA). We exposed our own troops to major toxins. It can be argued from first hand accounts that the chemical warfare agents were largely liberated as a result of bombing of Iraqi production, distribution and storage sites for chemical and biological weapons. These exposures can be linked directly to the chronic illnesses Gulf War Veterans are experiencing. They impact on many different systems in the body causing multi-symptom, multi-organ, and multi-system adverse effects. Table 1, Hooper 2000a. For the official MoD line see their web site, http://www.mod.uk/gulfwar/. Evidence challenging the official line is available in Burton, 1997; Tucker, 1997; Thomas 1998; Hooper 2000a; and the House of Commons Select Defence Committee, 2000.
Table 1. Known Effects of the Gulf Exposures on the Different Systems of the Body
X = a known adverse effect by an agent on the system indicated.
CNS = Central Nervous System; PNS = Peripheral Nervous System; ANS = Autonomic Nervous System; CV = Cardiovascular System;
GI = Gastrointestinal System. PB = Pyridostigmine Bromide; OPs = OrganoPhosphates; CBs = Carbamates; Pyreth = Pyrethroids; Lind = Lindane; NA = Nerve Agents; Mus = Mustard agents; DU = Depleted Uranium; O/S = Oil and Smoke
The Gulf War has been presented as an example of a bloodless victory by the Coalition forces with very few casualties on the battlefield. The truth is rather different, Table 2.
Table 2. Numbers of Deployed, Dead, Wounded and Prisoners in Gulf War
|PRISONERS||NOT KNOWN||NOT KNOWN||100,000|
Although battlefield casualties were few almost 15% of the USA troops have been placed on registers of official Gulf-related illnesses and a 2-3 times greater reporting of symptoms of ill-health have been reported in both the USA, Iowa study, 1997, Fukuda et al, 1998 and UK, Unwin et al, 1999, Ismail et al, 1999. Fukuda et al, 2000 Some 26% of USA troops are now in receipt of benefits for Gulf War-associated illnesses according to a spokesperson for the Veterans' Administration, VA, Nugent, 2000. Excess deaths have been reported among USA personnel, Kang and Bullman, 1996, but the increase in UK deaths was not significant, Macfarlane et al, 2000, Table 2 and 3. In both mortality studies the time frame is too short to include any excess deaths that might arise from cancers. In the UK one GWV has died every week since the end of the Gulf War.
Table 3 Registered Numbers of GWVs in Receipt of Health Care and Litigation
|DEAD||9,000** (~16,000)||450 1/week|
*32, 000 cases pending. **VA figure but many GWVs are now outside the VA system.
The symptoms reported by the GWVs are described as of 'unknown origin', Merck 1999. and overlap significantly with the symptoms associated with Myalgic Encephalomyelitis-Chronic Fatigue syndrome, ME-CFS, Nicolson, 1996, and other chronic illnesses such as fibromyalgia, FMS, Multiple Chemical Sensitivity, MCS, and even Multiple sclerosis and AIDS, Table 4.
Table 4 Common Symptoms shared by a number of Chronic Diseases.
+ Literature Reported
Adapted from Jackie Burkhead but despite searching for a reference to the original table I have been unable to find one.
3. Gulf War Veterans and IAG.
Paul Shattock recognised that the constellation of symptoms associated with mood, cognition, memory and sleep disorder found in the GWVs was reminiscent of some of the common symptoms found in autism. He decided that it would be worthwhile to test the urine of GWVs for the presence of IAG- indolylacroylglycine.
The IAG test has been developed and validated in the field of autism spectrum disorders, ASD, where high levels of IAG have been found in ~80% of children and young people, Shattock et al. 1997, 1998; Whiteley et al. 1999. Independent laboratories have obtained similar results, AAL, 2000.
Figure 1. GWVS: (A) with clear and (B) doubtful IAG peak
We have now tested some 40 GWVs and found in every case but one high levels of IAG present in their urine, Figure 1. A number of children of GWVs have also been found to have high levels of IAG, Figure 2 even when the father, Figure 1B, had no clear IAG peak. We do not yet have any evidence that the children of GWVs are more susceptible to autism spectrum disorders than children born to non-deployed troops or those born to civilian parents. However it is a disturbing thought that the kinds of exposures suffered in the Gulf might lead to autistic spectrum disorders in children. There may be a parallel with the unfolding story of vaccines and the newly identified autism-associated ileo-colonic lymphoid nodular hyperplasia, Wakefield et al, 1998. Such a possibility is consistent with the identification of IAG as a major peak in chromatograms obtained from urine samples of people with ME-CFS and MCS. Both these diagnoses have been made in regard to some GWVs. Chemical and viral triggers are known to play a role in other chronic disorders, Urnovitz, 1992.
Figure 2A. Children of GWV A Figure 2B. Children of GWV B
4. Origins and Actions of IAG.
IAG is probably a metabolite of indol-3-ylacrylic acid, IAcrA, which in turn is derived from tryptophan. IAcrA has been found in small quantities in pigs born and reared in an aseptic environment, Marklova, 1999. However it might also be a product of metabolism by microorganisms in the gut. The most reasonable biochemical pathway is via the lactate which is a minor tryptophan metabolite in man- the major metabolite is indoleacetic acid, IAA, with virtually no indolylethanol, I-ethanol. An alternative pathway might involve the dehydrogenation of the propionate which is also a minor human metabolite derived from anaerobic catabolism in the gut, Loo and Woolf, 1957; Shaw et al. 1960, Scheme 1.
A second metabolic pathway for the tryptophan involves opening of the indole ring by tryptophan and indole dioxygenases, TDO/IDO, and catabolism via the kynurenine pathway which leads to compounds with pro- and anti-convulsant properties, Munoz-Hoyos et al., 1997. This pathway is widely used to regulate the levels of free tryptophan which is the only essential amino acid with immunoregulatory properties. High levels of tryptophan are needed for T-cell cloning which is responsible for combating infection and destroying cancer cells. However, persistent and excessive stimulation of this pathway may be important in the development of autoimmune diseases. Similarly lack of free tryptophan can lead to increased susceptibility to infection and malignant diseases, Mellor and Munn, 1999. 5-Hydroxytryptophan, 5-HT, (serotonin) is the potent neurotransmitter molecule which is formed by the action of tryptophan hydroxylase, TrpOHase, on tryptophan. Although only about 1% of tryptophan is utilised in this pathway any disturbance of this enzyme would have major consequences for the brain, the gut and other key organs, Rang and Dale, 1991. 5-HT and drugs influencing its release have been studied in ASD with some limited success.
On theoretical grounds IAcrA would be expected to disrupt membrane structures; planar geometry would distort the regular arrangement of fatty acid residues in membranes. Preliminary studies have shown this is the case, Bell 1999. A further possibility is that IAcrA might also serve as an irreversible inhibitor of key enzymes such as 5-hydroxytryptophan hydroxylase. Molecular modelling provides some support for this, Anderson, 2000. Enzymes with an active serine or cysteine moiety in their active site might also be inhibited by IAcrA, eg. chymotrypsin and trypsin major digestive enzymes in the gut.
Scheme 1. IAG-ORIGINS?
5. IAG and Opioids.
The production of IAG in the gut leads to extensive disorder of gut structure and function. Digestive processes are reduced leading to incomplete breakdown of proteins in the food and the increase in biologically active peptides such as the casomorphins, derived from milk, and the gliadomorphins derived from gluten. The compromised gut wall is 'leaky' and allows the opioid peptides resulting in extensive modulation of peripheral and central opioid effects. The central effects include changes in behaviour, cognition, perception and mood via major effects on the higher executive functions. In autism there are also changes in pain levels and in gut function which are consistent with this hypothesis, eg. self harming behaviour and large stool formation. The opioid theory of autism was first proposed by Pansepp, 1979 and since then has been supported by the work of Reichelt, 1981 and Shattock and colleagues, 1997,1998, 1999, 2000. Recent research on dermorphins, possible products of microbial metabolism, Clostridia spp. are the most likely source in the gut, has added to this theory, Reference. Dermorphins are some 700-fold more potent than morphine and opioids, AAL, 2000. They contain D-amino acids which render them resistant to metabolic breakdown and therefore prolong their actions in the body.
6. Disordered Sulphate Metabolism.
Waring, 2000, has been responsible for systematic and extensive research in this area. She found that serum sulphate/cysteine ratios were very low in many autistic children who also had high IAG levels. Low sulphate levels would lead to a number of important effects that would disturb normal physiological and biochemical processes.
i. Sulphation of glycosylaminoglycans, GAGs, is crucial for the integrity of mucous membranes, Owens, 1998, such as those lining the gut.
ii. Secretory and anchored mucins all involve appropriate sulphation levels.
iii. Many key GAGs are involved in immune processes such as cytokine receptor binding, cell migration and blood coagulation processes- heparins have been used to treat ME-CFS, Berg et al., 1999; see also Hannan et al., 2000.
iv. The important peptide hormones, cholecystokinin, CCK, and gastrin exist in equilibrium with their sulphated molecules. Sulphated CCK has a different spectrum of activity from the unsulphated molecule, Noble et al., 1999. CCK is the most abundant neuropeptide in the central nervous system.
v. The important steroid hormone, dehydroepiandrostenone, DHEA, also exists in equilibrium with its sulphated compound and is the most abundant steroid in the body. It is linked to the production of all other steroids, Kroboth et al., 1999.
vi. Bile acids important in the elimination of fat soluble compounds also depend upon sulphation for their efficient functioning.
vii. Sulphation is a key process which facilitates the urinary excretion of xenobiotics containing phenolic and amino groups.
viii. Sulphite oxidase the terminal enzyme of the sulphate cycle contains molybdenum- supplementation with molybdenum has been shown to cause significant improvements in behaviour in ~36% of autistic children, Waring, 2000.
ix. The terminal sulphate cycle is intimately linked to the methionine/cysteine cycle which involves the production of methionine that plays a key role in the methylation of major membrane components, folic acids and nucleic acid precursors.
x. Glutathione a key controller of cellular redox potential is dependent on the availability of cysteine.
xi. Taurine an excitatory amino acid depends on the methionine/cysteine cycle.
xii. Homocysteine which has been linked brain damage associated with mental retardation and thromboembolic diseases is an important part of this cycle.
xiii. The vitamins B6 and B12 are crucial to the proper functioning of the methionine/cysteine cycle.
Urinary sulphite levels also serve to indicate disorders of sulphate metabolism and we have found high urinary sulphite levels in every GWV tested to date.
Taken together the IAG/Opioid paradigm and disordered sulphate/cysteine metabolism provide mechanisms, which may well be synergistic, for the extensive biochemical disturbances that underlie both ASDs and GWS/I. New ways of diagnosis and treatment are opened up by this work.
7. IAG, Peptide hormones and the Gut-Brain Axis.
The gut is sometimes referred to as the second brain because it shares with the brain many of the well-established neurotransmitters and the more recently discovered neuropeptides, Table 5. This bi-directional signalling system, Figure 3, allows changes in the gut to impact on brain chemistry and vice versa. Amine precursor, uptake and decarboxylation, APUD, cells are present in the gut and in key areas of the brain, particularly the hypothalamus which controls endocrine production, Mulvihill et al, 1997.
Figure 3. Bidirectional signalling between the Gut and the Brain.
[Figure not included in webpage version]
Table 5. The site of the first identification of Peptide Hormones Common to the Gut and the Brain
Sub P = Substance P; TRH = thyroid releasing hormone; ENK = enkephalins; CGRP = calcitonin gene-related peptide; CRH = corticotrophin-releasing hormone; CCK = cholecystokinin; VIP = vasoactive intestinal polypeptide; PHI = peptide histidine leucine; PYY = peptide YY; NPY = neuropeptide Y; GRH = gastrin-releasing hormone; PP = pancreatic polypeptide.
In addition the gut and brain both use the established chemical transmitters, acetylcholine, noradrenaline, dopamine, 5-HT (serotonin), and histamine. These shared neurotransmitters, endocrine, paracrine and autocrine hormones, particularly the peptides, affect perception, cognition, behaviour, mood, emotions and brain development. They also interact with the immune system, see below. Note the presence of secretin, a pancreatic hormone, in the brain. Although its function has not yet been identified it is noteworthy that injections of secretin have proved helpful in treating some ASDs. The most widely abundant peptide in the brain is CCK which acts differentially at two different receptors, CCK1 and CCK2. Low levels of this peptide are associated with anxiety, panic attacks and schizophrenia whilst high levels are associated with depression and attenuation of memory and learning, free recall, and attenuated recognition. Opioid peptides modulate the effects of CCK, Figure 4, Noble et al., 1999.
Figure 4. Modulation of CCK Activity by Opioids
8. The Gut and the Immune System.
The gut is the largest lymphoid organ in the body and throughout its length it is rich in specialised areas of lymphoid tissue known as Peyer's patches. The purpose of this extensive immunological barrier is to protect the body against toxins and microorganisms which enter in food. Many pathological viruses and bacteria are associated with the gut, eg. enteroviruses like polio, coxsackie, and bacteria such as E.coli, Clostridia etc. see below. There is considerable regional specialisation in the mucosal immune system, Brandtzaeg et al., 1999a, 1999b. Intestinal shape and integrity are changes and managed by T cells, MacDonald et al. 1999. Inflammatory bowel disease and ASDs can be provoked by infection as shown by the presence of lymphoid nodular hyperplasia in children given measles virus in the triple vaccine, MMR. ME-CFS is strongly associated with coxsachie B viral infection and post polio syndrome is another expression of the consequences of another enteroviral inffection. In 45 % of GWVs there is a positive test for Mycoplasma fermentans incognitus which has serious pathogenic properties, Nicolson, 1996,1997, 1998. The role of infection in chronic illnesses is becoming increasingly recognised. The major communicating molecules generated by the immune system are cytokines such as Interleukin 1, 2, IL-1, IL-2 etc. There are receptors on brains cells for these molecules and IL-1 sickness syndrome is well known. Cells of the immune system have receptors for the peptides and other neurotransmitters used in the gut and the brain. Hence it is now clear that there bidirectional signalling systems that allow cross-talk between the nervous system, the endocrine and immune systems. Both the gut and the brain are major organs affected by the signalling molecules that are involved. This is the basis of the neuroendocrineimmune, NEI, paradigm, Kavelaars et al. 2000, which is also known as psychoneuroimmunology, PNI, Ader et al., 1991, see below.
9. Natural Gut Microflora and Fauna.
The gut contents include a variety of micro-organisms particularly important are the aerobic and anaerobic bacteria that break down food components, especially carbohydrates and peptone-amino acids, in the diet and produce many small molecules of importance, eg short chain organic acids, Table 6. Many of them have complex nutritional requirements. The importance of these probiotic organisms is increasingly being recognised. They populate different areas in the gut from the lumen, through the mucus layer, to the epithelial surface and finally to the crypts at the base of the villi, Mackie and Gaskins, 1999.
Table 6. Predominant Bacteria of the Intestinal Microflora.
It is important to recognise that other micro-organisms play a part in the normal functioning of the gut and some of these can give rise to serious disease, eg E. coli and Candida spp. The bacterial population can be considerably influenced by food and the following chart summarises an in vitro study which shows the varying proportion of different bacteria at different levels in the gut and how they change with the introduction of different carbohydrate sources, Table 7. Of particular note is the considerable increase in the proportion of lactobacilli and decrease in clostridia spp. when rice is the carbohydrate source rather than wheat or oats.
Table 7. Variations in Percentage of Gut Bacteria Populations with Different Food Sources.
These figures are from a model of one particular part of the bowel. Somewhat different figures have been obtained for conditions modelled for other parts of the bowel, Anon 2000. Note the dramatic changes in the lactobacillus levels when the diet is changed from wheat to rice. A gluten free diet would lead to increases in the lactobacillus population and a reduction in the clostridia population.
The Neuroendocrineimmune Paradigm.
The bidirectional signalling is summarised in Figure 5 and shown in more detail in Figure 6. Opioid peptides are key signalling molecules between the endocrine, immune, brain nerve tissues, and the pineal complex . the latter is particularly associated with circadian rhythms.
Figure 5. Bidirectional signalling between the Nerve Tissue, N, the immune system, I, and the Endocrine System
Figure 6. Challenge and Homeostasis in the NeuroendocrineImmune systems.
OPs = Opioid Peptide transmitter molecules.
A new and important region of challenge is by odours which are transported intraneuronally within the olfactory tract which enter the limbic system of the brain directly since the tract penetrates the blood-brain barrier. This mechanism is of great importance in MCS, Ashford and Miller, 1998.
11. Multiple Overlapping Syndromes.
From the above it is clear that a number of little understood chronic conditions appear to share a common set of biochemical markers indicative of extensive disturbance and dysfunction of tryptophan, opioid, and suphur metabolism. These shared characteristics are part of common mechanisms of pathology associated with a number of overlapping syndromes, Hooper, 2000b, Figure 7. A further common characteristic has been identified by Simpson, 1989a, 1989b; Spurgin, 1995. He has found a high proportion of red blood cells, RBCs, with a flattened discoid shape. These non-discocytic cells are associated with loss of fluidity and flexibility of the membranes of RBCs with subsequent inability to pass readily down small capillary blood vessels. The outcome is reduced carriage of oxygen and reduced removal of waste products, carbon dioxide and lactic acid especially, via RBCs. This gives rise to fatigue and the inability to recover from exercise- fatiguability- so characteristic of all these syndromes. An alternative measure of lipid membrane structure are the direct tests for lipids used by laboratories such as Biolab Medical.
Figure 7. Overlapping Syndromes with Common Biochemical Disturbances.
Key -see main text OCs, organochlorine pesticides; ??? other related conditions; OPs = organophosphate pesticides; GWS = Gulf War Syndrome; FMS = Fibromyalgia syndrome; ME-CFS = Myalgic encephalomyelitis; MCS = Multiple Chemical Sensitivity; HPA = hypothalamic-pituitary-adrenal stress axis.
If IAG, Sulpite, or sulphate/cysteine ratios, and RBC shape and lipid structure form a common core of shared biochemistry it is important that more specific tests associated with the individual syndromes are identified. In the case of pesticide poisoning specific identification of the pesticide will characterise the syndrome/illness. Fibromyalgia and ME-CFS commonly exist together, White et al, 2000, but there are well established clinical tests that are used to diagnose fibromyalgia. Very recently a specific test for ME-CFS has been reported that distinguishes ME-CFS from fibromyalgia, Spence et al, 2000. MCS is generally characterised by sensitivities to a wide group of chemicals at very low concentrations, Ashford and Miller, 1998. Richardson, 2000, has described the use of choline citrate and ascorbic acid to effectively treat organochlorine poisoning in patients presenting with a diagnosis of ME-CFS.
12. Treatment and the Sunderland Protocol [View ' The Sunderland Protocol' here].
The Sunderland Protocol, Figure10, provides a structured programme of treatment for all the overlapping syndromes are listed in the protocol and can be justified from a consideration of the opioid theory of autism, disordered sulphate, lipid and energy metabolism.
1. Remove the 'bullets'. These are the opioid peptides routinely available in the diet. Essentially this means removing milk and then gluten sources from the diet. The effects of removing milk are most rapidly seen, usually within 3 weeks. If no advantage is gained then it can be restored to the diet. Next take out the gluten- the response here is much slower and takes up to 3 months to become apparent. Children may respond more quickly. Almost always the effect is to make the patient feel worse, at first. A useful analogy is with opiate withdrawal symptoms.
TEST FOR PESTICIDES IN BLOOD/BODY FAT.
2. Restore sulphate levels and the sulphur cycle (this also includes the methionine cycle). Sulphate can be provided by Epsom salt baths or with small oral doses. Other sulphur supplements are MSM (methylsulphonylmethane). Garlic and onions are good sources of sulphur compounds. Vitamin B6 and B12 are essential in the methionine cycle. Assess Glutathione levels and glutathione sulphur transferase function and activity.
3. Look at antioxidant status, Vitamin C, E, selenium and zinc and possibly copper and iron.
4. Look at lipid metabolism and the use of essential fatty acids of the n-3 and n-6 classes- fish oils and evening primrose oils etc.
5. Look at energy metabolism, succinate, NADH, Enzyme Co-Q, etc.
6. Take steps to restore gut function with probiotics, glutamine, enzyme supplements such as papain, 'Seren-aid', etc.
Re-testing can be done to measure changes in the different marker molecules and improvement assessed by clinical tests.
The stepwise approach offers a helpful way of identifying those things that are effective in ameliorating the syndrome/illness and avoids the confusion and expense that is commonplace when people who are desperately ill try almost anything in a random fashion.
Figure 10 The Sunderland Protocol-Slightly modified to cover all Overlapping Syndromes.
[Figure not included in webpage version but see 'The Sunderland Protocol']
It is becoming increasingly clear that additives, sweeteners, colouring agents and other ingredients in 'junk' foods which form an growing part of the diet of many people, particularly the young, can have destructive social and behavioural effects on children especially, Winder, 2000, Lewis, 1998; Werbach, 2000; Anthony et al.,1997. Very significant improvements in behaviour and educational achievements followed the strict withdrawal of such components from the diet of school children, Winder 2000.
Also of concern are the growing amounts of pesticides and preservatives that are routinely consumed in food. The more complete the food the greater the quantities of such materials that are consumed. For example, eating whole meal bread will ensure the intake of essential vitamins and roughage but will at the same time increase the intake of pesticides and preservatives many of which are known to have adverse effects on many systems in the body, eg. organophosphates which are present in flour damage the nervous system, are mutagenic and carcinogenic, induce asthmatic reactions, and slow heart rate sometimes initiating a rebound tachycardia and hypertension. There is growing concern about these components in all our foods. the association of these toxins with the increasing numbers of ASDs, ME-CFS, asthma cases, etc., requires much more investigation. The increased emissions from road traffic, especially the particulates in the PM range of <2.5 microns, are thought to play an important part in the massive increase in childhood asthma.
Nevertheless, at the present time our growing understanding of chronic overlapping syndromes offers new ways of understanding and ameliorating the common symptoms of many of these disorders. The suffering and struggle of those involved with these syndromes is beginning to bear healing in this neglected and controversial area of sickness. The Sunderland Protocol is part of this hopeful development. I thank all who have borne the problems, difficulties and joys of ASDs for this gift to Gulf War Veterans, OP poisoned farmers, and others who share this disordered biochemistry.