Gulf War Illness: Background, History, Definitions, Exposures

This unit presents the background and history of Gulf War illness (GWI), as well as the definitions and exposures on site.

Background and History

The Gulf War occurred in two phases, Operation Desert Shield, from August 1990 to January 1991where troops were deployed to the Persian Gulf, and Desert Storm from January 1991 to February 1991, a 6-week air and naval bombardment followed by a brief ground assault. While Kuwait was liberated at the end of February, bombing continued for several weeks and explosives in hundreds of Kuwait’s oil wells produced gases and smoke for months.

Definitions

As the service members returned from their deployment, they noticed multiple problems including widespread pain, fatigue, respiratory problems, gastrointestinal issues, skin abnormalities, memory- and cognitive defects, as well as mood alterations. These symptoms could not be explained by established medical diagnoses or standard laboratory tests. During the next two decades and beyond, efforts were made to understand the nature of these health-related problems. Varying manifestations and constellations of symptoms frequently resulted in a lack of pathophysiological evidence and legitimacy. From 1997 to 1998, three large scale studies resulted in illness definitions. As per the CDC definition (Fukuda et al., 1998), veterans are diagnosed with GWI if they report one or more symptoms that last for 6 months or longer in two of three categories, fatigue, musculoskeletal pain, and mood/cognition. According to the Kansas definition (Steele, 2000) GWI is identified in those who report moderate levels of symptoms in three of these six categories in the year before the assessment: 1. Fatigue, 2. Pain, 3. Neurological/cognitive/mood issues, 4. Respiratory problems, 5. Gastrointestinal problems, and 6. Skin problems. The CDC definition is the most commonly used GWI case definition in epidemiologic research to date, however, both CDC and Kansas Definitions are officially recognized by the National Academy of Medicine. A working group was formed in 2018 by the Department of Veterans Affairs to review current literature, progress towards a single case definition, and address short- and long-term actions regarding GWI.

Exposures

Given varying locations of deployment and different countries of units with subsequent varying exposures, no single cause of GWI exists. Instead, it is generally assumed that individuals who meet criteria for GWI were likely exposed to multiple agents and/or combinations of agents and chemicals. Environmental and toxic exposures are known to cause an excess of free radicals in the body’s cells, otherwise known as oxidative stress. Excess oxidative stress can damage cells, proteins, and DNA, contributing to an early onset of aging-related ailments. Overall, a number of factors are believed to play a role in the pathogenesis of GWI. These include 1. Vaccinations (Anthrax and Botulinum Toxoid), 2. Pyridostigmine Bromide (PB) pills as prophylactic against the nerve agent soman, 3. Pesticides including the repellent DEET, pyrethroids, organophosphates, and organochlorines, 4. 65 widespread oil well fires that emitted dense clouds of soot, liquids, aerosols, and gases, 5. chemical and biological weapons including sarin- and cyclosarin nerve gas and possibly mustard gas and soman mixes, 6. Depleted uranium, and 7. Other exposures such as chemical-resistant coating paint and toxic embedded fragments.

References

Fukuda, K., Nisenbaum, R., & Stewart, G. (1998). Chronic multisymptom illness affecting Air Force veterans of the Gulf War. JAMA, 280, 981–988.

Steele, L. (2000). Prevalence and patterns of Gulf War illness in Kansas veterans: Association of symptoms with characteristics of person, place, and time of military service. Am. J. Epidemiol., 152, 992–1002.

Gulf War Illness Symptoms and Psychosocial and Physiological Impact including Differences in Gender, Age and Ethnicity

This unit discusses the definitions, descriptions and effects of Gulf War Illness (GWI).

According to VA, service members and veterans started to report symptoms after their return from service in the Persian Gulf War. The symptoms of GWI vary widely and this makes it challenging for healthcare providers to recognize and treat it. Because of this variability, VA prefers not to use the term “Gulf War Illness,” and instead provides disability compensation benefits to veterans who served in Southwest Asia for illnesses that fall into the following three categories:

1. Undiagnosed illnesses (established in 1994)
2. Medically unexplained chronic multisymptom illnesses (established in 2001)
3. Nine specific infectious diseases (established in 2010)

All three categories of Gulf War illnesses (undiagnosed illness, medically unexplained chronic multisymptom illness, and infectious diseases) are presumed to be related to a veteran’s service in the Gulf War.

The Institute of Medicine (now National Academy of Medicine) in 2013, defined CMI as the occurrence of a spectrum of chronic symptoms experienced for 6 months or longer in at least two of the following six categories- fatigue, mood and cognition, musculoskeletal, gastrointestinal, respiratory, and neurologic symptoms. Other psychological and physiological difficulties associated with Gulf War Illness include substance use, PTSD, insomnia, interpersonal difficulties, skin disorders, menstrual disorders, effects on autonomic and neuroendocrine systems, cognitive impairments amongst others. In Unit 2, we also summarize some recent research studies on adverse health consequences and diagnostic symptoms in gulf war veterans.

In terms of gender specific impact of Gulf War Illness, overall, there is a lack of studies for female gulf war veterans. Studies indicate higher rates of reproductive issues, miscarriages, and birth defects among veterans with GWI, and found that postwar conceptions were at increased risk for ectopic pregnancies and spontaneous abortions. Excess rates of women’s health problems in breast cysts, abnormal Pap smears, yeast infections, and bladder infections have been documented.

About 16 percent of the nearly 700,000 military personnel who served in the 1991 Gulf War were African American men and women. However, few studies have reported race-specific prevalence of Gulf War Illness and no studies have provided detailed race-specific information about symptoms.

The studies summarized in this unit demonstrate that more research needs to be conducted to fully grasp the multisymptomatic impact and mechanism of Gulf War Illness and how it affects specific gender and ethnic minorities similarly or differently.

Understanding the Illness Experiences: Health Care Provider Perspectives and Veteran Perspectives

This unit presents the findings of three studies about the health care provider perspectives and veteran perspectives regarding Gulf War Illness (GWI).

Study 1

In the first study, we interviewed 10 health care providers (7 females, 3 males; 8 white, 2 Asian; 3 physicians, 2 psychologists, 2 acupuncturists,1 social worker, 1 nurse, 1 medical sociologist, 1 pharmacologist) across the US about their experiences with veterans with GWI. We analyzed the data using a grounded theory method and created a grounded theory framework with four main categories: 1. Lack of knowledge of the multi-symptoms illness, 1. Lack of treatment options, 3. Personalized care limited to validation alone, 4. Systemic challenges.

Overall, the findings supported the notion that there are gaps in knowledge about GWI among healthcare providers, which leads to continued uncertainty about how to best treat GWI veterans. Given the challenges in care faced by veterans with GWI, further research including on systemic issues with lack of communication from the top down, and on difficulties in personalizing care is needed. The findings indicate that it is imperative that providers have access to educational materials on GWI.

Study 2

In another study, we examined veterans’ perspectives and lived experiences with GWI. Participants included 40 Gulf War veterans (32 males, 8 females, 28 white, 9 Black, 4 Latino, 3 American Indian, 1 Asian, and 1 multicultural) who were screened through CDC and Kansas Definitions of GWI. They were interviewed with a focus on the experience of their illness, healthcare received, supports and resources. At the end of the interview, they were given art materials to make an art collage response based on what was talked about and how they related to their GWI experience. We analyzed the data using a grounded theory method and created a grounded theory framework with five main categories: 1. Challenging symptoms affect all areas of life, 2. Persisting unknowns, 3. Varying treatment quality, 4. Coping with Gulf War Illness, and 5. Importance of acknowledgment.

Graphic Elicitations

In a third study, we compared the graphic elicitations of the veteran participants to the interview responses to learn what was specific about the art collage. Three main themes emerged that pinpointed what the art elicitation process could contribute: 1. Synthesis and confirmation of themes, 2. Salient aspects of living with GWI, and 3. Revealing previously unarticulated experiences.

The unique contributions of the collage process overall were to promote spontaneity and metaphorical thinking, uncover lived experiences, and allow for new affective responses.

Interventions and Treatments for Gulf War Illness

Research to test interventional approaches and identify standards of treatment for Gulf War Illness continues to remain in progress. Some of the resources that are available include:

• VA/DoD codified the best practices for the management of Gulf War Illness (GWI)
• War Related Illness and Injury Study Center (WRIISC), Department of Veteran Affairs has published a handout for healthcare providers for Gulf War Illness updated in 2018. This handout mentions pharmacological and non-pharmacological interventions such as CBT and exercise trials for active management of GWI symptoms.
• Other resources include systematic reviews and research published in special issues in journals on Gulf War Illness

In this unit, we summarize the intervention studies for Gulf War Illness that can largely be mapped on to categories of clinical and behavioral interventions, complementary and integrative treatments, diet and nutritional supplements, and other interventions and interventions including medications, simulations, etc.

One of the widely used Clinical and Behavioral Intervention include Cognitive behavioral therapy or CBT. Some researchers have examined the use of CBT for insomnia, problem-solving therapy, and telemedicine CBT with gulf war veterans. Mindfulness-based interventions have also been investigated as potential treatment methods for alleviating some of the symptoms associated with GWI. Complementary and integrative healthcare intervention continue to be utilized with US Gulf-War era veterans. Studies have examined the effect of exercise, acupuncture, acupressure, tai-chi, yoga, specific diets, herbal vitamins and nutritional supplements. Other interventions include the effect of CPAP - nasal continuous positive airway pressure, and studies including specific medications on the symptoms of Gulf War illness.

There is no one single treatment approach that is best and being used for veterans with Gulf War Illness. There is ongoing research about what might be helpful for the multisymptomatic illness with an increasing emphasis towards incorporating a multi-treatment approach.