Source: Office of the Special Assistant for Gulf War Illnesses
Diverse factors related to the Gulf War experience have been postulated as causes of chronic health problems.27 Potential health hazards include:
Infectious diseases were one of the first health threats confronted by Coalition troops deployed to the Arabian desert in August 1990. Based on experiences in WW II, the major endemic infectious disease risks were thought to be sandfly fever, cutaneous leishmaniasis, diarrheal disease, and malaria.28 However, only acute diarrheal disease and mild upper respiratory infections were a common problem for deployed Gulf War troops.
One unique infectious disease has been linked to the Gulf War deployment: viscerotrophic leishmaniasis.29 This infectious disease has been found in 12 U.S. veterans but none of the other Coalition military personnel.8 There have been no new cases of this infectious disease during the last nine years. Viscerotrophic leishmaniasis is a relatively mild form of systemic leishmanial infection caused by Leishmania tropica -- a single-celled parasite that typically causes skin disease. Prior to the deployment of U.S. troops, viscerotrophic leishmaniasis had not been identified in Saudi Arabia, Kuwait, or Iraq among local populations or foreign guest workers.
Biological warfare (BW)
Exposure to BW agents during the Gulf War has been hypothesized.30 However, there has been no confirmation that a biological warfare agent affected the health of Gulf War troops. In addition, most BW agents, like anthrax spores and botulinum toxin, are designed to be deadly in minute quantities, but there were no fatalities during the Gulf War consistent with exposure to highly lethal biological or chemical weapons.
Chemical warfare (CW)
Although there is no indication that CW agents were used offensively by Iraq during the Gulf War,1 exposure of veterans to low levels of CW agents has been a concern. Two possible sources of low level exposure have been evaluated: 1) bombing of Iraqi CW production and storage facilities during the air and ground war, and 2) the destruction shortly after the war of an ammunition storage facility at Khamisiyah, southern Iraq, where munitions containing sarin and cyclosarin were identified eight months later by a United Nations inspection team. The possibility that Coalition troops were harmed by CW agents is the focus of substantial government- funded research.31 Thorough investigations of possible CW and BW exposures also have been conducted by several U.S. government panels32, 33 and DoD’s Special Assistant for Gulf War Illnesses, Medical Readiness, and Military Deployments.34-76
Pesticides and insect repellents
Gulf War troops were primarily exposed to DEET, organophosphate pesticides, and permethrin.12 These chemical compounds are routinely used during deployments of U.S. military personnel to developing and tropical regions to prevent infectious disease transmission and also are commonly used in agriculture and for individual projection in the general population. Pesticides and repellents have been hypothesized to cause both unexplained symptoms and neurological disease among veterans, either by acting alone or in combination with other chemical substances and stress.77-81
Pyridostigmine bromide (PB)
PB pills were provided to some Coalition military personnel for self-administration as pretreatment against chemical warfare nerve agents. U.S. Troops were given twenty-one 30 mg PB tablets and instructed to take one tablet every eight hours whenever the threat of a CW attack was considered high during the air and ground war. DoD estimates that approximately 250,000 U.S. Military personnel took at least one 30 mg tablet of PB. PB has been postulated to cause long-term health problems by directly acting on the central nervous system and by synergistic toxicity from interactions with CW agents, pesticides, and stress.27,78,82 Since the mid 1950’s, PB has been used in very high doses over prolonged periods of time to treat myasthenia gravis without apparent long-term health effects. PB also has been used in general surgery to treat patients without myasthenia gravis.83
Oil well fire smoke
In February 1991, the retreating Iraqi army ignited over 600 oil wells, which burned until November 1991, producing massive clouds of smoke. Environmental monitoring conducted after the war indicated that exposure to airborne pollutants had not been great for Coalition troops and that long-term health effects were unlikely.84, 85 Measured levels of pollutant gases and polycyclic aromatic hydrocarbons (PAHs) were comparable to concentrations in large, urban U.S. cities. Nevertheless, smoke clouds sometimes drifted to ground level, which increased exposure for combat troops. On the basis of self-completed questionnaires, U.S. Troops deployed to Kuwait reported a higher incidence of eye and upper respiratory tract irritation, shortness of breath, cough, rashes, and fatigue than unexposed troops.86
Anthrax and botulinum vaccinations
Two non- live vaccines given to U.S. Troops during this deployment have been hypothesized to cause long-term health effects: About 150,000 U.S. Troops received one to two doses of an FDA-approved anthrax vaccine and 8000 troops (1.1% of deployed U.S. forces) received an investigational botulinum vaccine.12 These vaccines had been used for several decades, alone and in combination, without apparent long-term health effects.87 Other vaccinations were administered during the Gulf deployment, for example, influenza vaccine and routine booster doses of standard vaccines, like typhoid and tetanus.
The British also gave their troops varied vaccines, including a novel pertussis adjuvant for vaccination of troops against anthrax. The possibility has been raised that combinations of these vaccines -- given over a short period of time during a stressful deployment -- may be responsible for long-term health problems.88-91 However, in an epidemiological study conducted after the war, no difference was found in the prevalence of post-deployment health complaints among groups of Canadian veterans who received the same vaccinations as British personnel compared to Canadians who received different combinations of vaccines.17 In another post-war study, the anthrax vaccine given to U.S. Forces was found not to be contaminated with bacteria, as had been hypothesized.92 Lastly, the Institute of Medicine evaluated the current anthrax vaccine and concluded that it is safe.93
Depleted uranium (DU)
In this war, U.S. Military forces used DU for both armor on tanks and for munitions (kinetic penetrators) because of DU’s enhanced armor-piercing capability.27 Due to its biological effects as a heavy metal and as a source of radiation, DU presents a potential health risk when it enters the body as shrapnel or is inhaled following aerosolization from impact and combustion. In the VA Depleted Uranium Follow-up Program at the Baltimore, Maryland, VA Medical Center, 60 U.S. Veterans who may retain DU shrapnel from friendly- fire incidents are being evaluated. To date, these veterans have not experienced health problems that can be related to the effects of radiation exposure or heavy metal intoxication.94-97
Physical and psychological stress
Stress has been hypothesized to be a cause of chronic symptoms and illnesses among some Gulf War veterans. As true of all wars, the Gulf War deployment was associated with extreme physical and psychological stress from life-threatening combat, harsh living conditions, loss of privacy, and separation from family. Stress can lead to psychological illnesses, which manifest with physical symptoms and has been theorized to play a substantive role in the development of organic disease.98,99 Numerous studies have shown increased levels of stress-related symptomatology among Gulf War veterans.100-104
Sand and less common exposures
Some troops may have been exposed to a number of other potential health hazards,105-109 including:
a. Airborne sand, allergens, and irritants;
c. Chemical agent-resistant coating (CARC) paint fumes containing isocyanate;
d. Various petroleum products, like leaded gasoline, diesel fumes, and JP4 fuel used in tent heaters and on the ground to keep sand from blowing; and;
e. Decontamination solution 2, which contains propylene glycol, monomethyl ether, and ethylene glycol.
Combinations of exposures
As noted, combinations of diverse environmental exposures, along with physical and psychological stress, have been hypothesized to cause both well-recognized illnesses and unexplained symptoms among Gulf War veterans.27 For example, an initial study indicated that stress might increase the effects of pyridostigmine bromide in the central nervous system,110 but several follow-up studies did not confirm this finding.111-114
As this list of potential health risks demonstrates, Gulf War veterans were subjected to complex environmental and psychological exposures. Like prior military conflicts, veterans had to contend with a multitude of health hazards due to the chaotic, life-threatening nature of warfare.11