Prevalence of Gulf war veterans who believe they have Gulf war syndrome: questionnaire study
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7311.473 (Published 01 September 2001) Cite this as: BMJ 2001;323:473All rapid responses
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To the Editor
Chalder et al set out to determine how many British Gulf war veterans
believed they had Gulf war syndrome (GWS). The study had three aims: (a)
to determine how many British Gulf war veterans believe they have GWS; (b)
factors associated with this belief and (c) to compare health outcomes
between those who believe they have GWS and those who do not. We felt
that this large cross sectional study achieved the first aim. However, we
have some observations about the other aims.
The authors assessed demographic data, health status, details of the
number of vaccines received, military exposures, and knowledge of others
with GWS. The validity of the sociodemographic data has already been
commented on (1,2). We would like to highlight gaps in knowledge
involving military exposures and vaccines as well as the lack of comment
on some health data.
Differing military exposures were considered together so it is
difficult to pinpoint particular factors affecting risk and to analyse
exposures separately. In addition, the types of vaccines were not
specified. It may be difficult for veterans to recall the number of
vaccinations received six years previously leading to a recall bias. The
number of vaccines that veterans remember receiving may also be related to
their present health status. It would seem logical that servicemen and
women going to the same war zone with the expectation of exposure to the
same risks would receive the same vaccines. We would expect that this
data should have been checked against MoD records. We do however
recognise that there may be reasons for this information not being
available.
Ninety percent (462) of those who believe they have GWS fulfilled the
Centers for Disease Control and Prevention (CDCP) criteria for this.
However, according to the authors’ data, a further 1275 met the criteria
for GWS without believing they had the syndrome. This was not commented
on by the authors but raises the question as to why GWS was under-reported
by these 1275 respondents.
The authors conclude that biopsychosocial factors in those who
believe they have GWS “should be addressed in clinical practice”. We feel
that a case-control study using CDCP criteria for GWS for symptomatic,
disabled veterans is needed to investigate the associated factors and
allow them to be addressed in clinical practice.
Holmes G, Barker J, Bremner S, Davies H, Tatnall P
G.I.Holmes@ncl.ac.uk
Dept Epidemiology and Public Health,
Medical School,
University of Newcastle upon Tyne,
NE2 4HH
1. Bagnall G, A Study is no study without all the facts. BMJ
Electronic responses 1 September 2001
2. Garner P, Gulf veterans response. BMJ Electronic responses. 1
September 2001
Competing interests: No competing interests
Chalder et al found that veterans who had had most vaccines were most
likely to self-report having Gulf War Syndrome (GWS). However the
implications of this were diminished by the fact that knowing someone else
with GWS was considered an even more important factor in holding the
belief that they had GWS.
There is no indication that the authors considered that vaccination
per se could be a primary factor, yet there is persuasive evidence to
support this idea. In 1969, Poser (1) considered at some length the
neurologic and neuropathologic complications of vaccinations and
immunizations. In a survey of the literature up to that time he was able
to quote several workers who implicated disturbances of the blood supply
in post-vaccination complications. He noted (p39) "Most important, a
vasculopathy, which may be mild (a simple alteration of vessel wall
permeability without any anatomic disruption) or severe ( vessel wall
necrosis) is the first and probably also a requisite phenomenon which
initiates the reactions of the nervous tissue itself. This probably
occurs both in the central as well as the peripheral nervous system.
Although this has always been ascribed to the venules, it is apparent that
arterioles and capillaries may also participate in producing this
phenomenon. The immediate results of such involvement may include
vascular occlusions leading to either encephalomalacia or focal lesions
caused by venous stasis."
The full implications of this statement need to be considered from
the view point of blood rheology. For example, venous stasis could
involve 2 factors. Firstly, because of the thixtropic nature of blood,
the reduced rate of flow in venules would lead to thixotropic
amplification of blood viscosity and thus increase the resistance to
flow. Secondly, unless there is an increase in the rate of blood flow to
produce an adequate yield shear stress, the stasis will become permanent
as a vascular occlusion.
Thus, the link between vaccinations and the blood flow problems
reported by Poser probably lies in the field of blood rheology. In some
subjects vaccinations/immunizations produce a short term change in the
red cell shape populations, while in others the change persists for a long
time and may be associated with a variety of symptoms due to dysfunction
of the central nervous system and muscles. Both tissues involved are avid
users of oxygen. In 1992, consideration was given to the reasons why some
individuals infected with the same virus recovered within a week or two
while others remained unwell for long periods (2) It was concluded that
the key factor could be mean capillary diameter, as in accordance with the
Poiseuille formula, flow through narrow tubes was directly related to the
fourth power of tube radius. It was proposed that about 15 percent of the
population would fall into the bottom segment of a normal distribution of
mean capillary diameters. Such individuals were considered to be at risk
of a variety of chronic disorders and would live normal lives until
becoming exposed to some agent which altered red cell shape populations,
and then they would become symptomatic. It could be of significance that
Chalder et al record that 17.3% of their sample considered that they
suffered from GWS
The concept was based upon the observation that in healthy
individuals red blood cells could be classified into 6 different shape
classes (3). Various factors, both physiological or pathological which
changed the environment of the red cells would initiate a change in the
red cell shape populations. The most frequent abnormality is an increase
in flat cells and these have been observed in small numbers of blood
samples from sick GWS vets living in England, Australia, Canada and the
USA. Similar changed red cell shape populations occur in other chronic
disorders which show a considerable symptom overlap with those of GWS.
Such conditions include ME, CFS, fibromyalgia and multiple chemical
sensitivity. Because flat cells are poorly deformable they reduce the
rate of blood flow in capillaries. For that reason tissues may not
receive the oxygen and nutrient substrate they need at a rate sufficient
to sustain normal tissue function and they will become dysfunctional.
Tissues worst affected will be those which normally have a high rate of
utilisation of oxygen and nutrient substrates such as muscles, central
nervous system and secreting glands. It is not surprising that such
tissues are those most commonly involved with symptoms.
There is evidence that the anthrax vaccine contained squalene as an
adjuvant and anti-squalene antibodies have been identified in those with
GWS, even though squalene has not been approved for this purpose by the
FDA. It seems that the same vaccine was used in England, Canada,
Australia and the USA. GWS has been reported in service personnel from
all of these countries, but the French armed forces which were not
vaccinated do not have GWS in their personnel.
On the basis of a small number of samples it is postulated that GWS
is a consequence of an idiosyncratic response to one or more vaccines,
which changed red cell shape populations, in service men/women who by
chance shared the anatomical feature of smaller than usual capillaries.
An
application to explore this possibility in blinded blood samples from sick
vets and healthy service personnel, was made to the US Army Medical
Research Acquisition Activity. While "The proposed effort is relevant to
the Command research mission," no funds were available.
In conclusion it should be noted that after the expenditure of many
millions of dollars in a variety of fields of research, those with GWS
continue to be symptomatic. Because any tissue with an inadequate rate of
blood flow may become dysfunctional, it would be surprising if behavioural
disorders were not identified as a consequence of CNS dysfunction. But if
altered blood rheology can be demonstrated by red cell shape analysis or
other haemorheological techniques such as viscometry or red cell
filtrability, then it might be possible to provide relief for sick
veterans by using haemorheologic agents which could increase the rate of
capillary blood flow by improving red cell deformability.
References.
1 Poser CM. Disseminated vasculomyelinopathy. A review of the clinical
and pathologic reactions of the nervous system in hyperergic diseases.
Acta Neurol Scand 1969;15 (suppl 37):7-43.
2. Simpson LO. Chronic tiredness and idiopathic chronic fatigue - a
connection ? NJ Med 1992;89:211-216.
3. Simpson LO. Blood from healthy animals and humans contains
nondiscocytic erythrocytes. Br J Haematol 1989;73:561-564.
Competing interests: No competing interests
The occupational health data set has not been established. Therefore,
the persistence of vaccination and combination exposures has little
bearing on the percieved present psychological state of the veteran. Just
the anger level.
In chinese terms that would equate to brain, creation of disease,
immune suppression=disease. However, not one country has done the most
essential correlation of exposure, job function, and air samples. They
just weren't taken.It was CNN show and tell.
However, if You read US Deployment Quaterly (USSG), You will find in
the rear the teratogenic, mutagenic reproductive evidence effects or nexus
cause of exposures in black and white at a rate of 1 per 100. Not 1 per
100,000. 1 per 100. Basic medical statistics. Just expendable human
beings. Just ask me I had over nine injections.
Competing interests: No competing interests
Editors
I welcome this paper as yet another piece of evidence supporting the
facts that many gulf veterans are ill after service in the gulf conflict.
This paper raises some important issues surrounding the investigation of
military health research :-
1) Sample was taken from information supplied by the Ministry of
Defence - how do we know this information to be accurate ? (None of the
Gulf veterans groups trust the M.O.D. anymore)
2) The structure of the Armed Forces means that Junior Ranks will
greatly outnumber those of Officers.
3) The educational levels of Junior Ranks will obviously (in the
majority of cases) be below that of Officer ranks.
4) Members of the Armed Forces still serving will be less likely to
report ill health due to compromising thier careers and promotion
prospects.
The author`s state (in the discussion section) "The odds ratio was
not affected by distress or disability, states that could have existed
prior to, or resulted from, service in the gulf" - Due to the nature of
the Armed forces no soldiers would have been sent to the gulf had they
been disabled, if a soldier was suffering from stress reaction, likewise
they would not have been sent to the gulf conflict - any soldier showing
stress reaction in the gulf was immediately returned to the U.K.
The author`s also state "It is possible that the 17% of veterans who
believed they had the syndrome had a unique adverse exposure - not
experienced by the 83% who did not - What unique adverse exposure? Did we
not serve in the same conflict ? were we not vaccinated with exactly the
same vaccines? the respondents of the study should have come from
different regions of the gulf conflict therefore it would be safe to
assume the 17% who have the syndrome should be from scattered units and
therefore not have a unique adverse exposure.
The majority of the veterans who have attended the Medical Assessment
Programme have commented on the way they have been treated whilst at the
M.A.P. - this has led to a deep mistrust in the Medical Assessment
Programme and veterans have no faith in this service - now seeing it as a
method for the M.O.D. to try to put the "stress" excuse as the cause of
the veterans health problems, therefore I am not surprised to see that the
number of veterans attending the M.A.P. is falling at an alarming rate -
THEY DO NOT GET TAKEN SERIOUSLY - We are the people who suffer these
health problems every day of our lives, some like myself are medically
qualified, some of my problems are / maybe stress related but not the
majority - they are physical health problems and I do not believe for one
minute they have anything to do with a "stress response / reaction".
Competing interests: No competing interests
As human beings, we often reject that which we have never experienced
and therefore do not understand. This trait in a lay person may or may
not impact adversely upon someone else, but in members of the medical
profession, it all too frequently leads to iatrogenisis.
When testifying before a Congressional Committee on the Gulf War
Syndrome, Daniel Clauw put it this way: "It is arrogant of us as
scientists, to feel that because we cannot precisely define a problem,
that it doesn't exist." Certainly it is arrogant, but it is unfortunately
a traditional arrogance. It was not unusual for the distressed asthmatic
to receive a slap in the face and be told to "Stop that nonsense!" some
decades ago. Polio, tetanus, epilepsy, gastric ulcers, MS were all at one
time labelled as hysteria and I am sure, if pressed to do so, the authors
of the paper entitled "Prevalence of Gulf war veterans who believe they
have the Gulf War Syndrome", could come up with a few more.
As I read the paper, I was reminded of an incident which occurred a
few years ago in New Zealand. A farmer had sprayed his pastures with a
substance that was guaranteed to promote lush growth. It lived up to
expectations but his cows became seriously ill, and the manufacturer had
little option but to admit that the product was not as safe as the
advertisements claimed. He would have looked very foolish if he had called
in psychiatric experts to testify that it was simply a case of mass
hysteria, which happens all too often when people are adversely affected.
This study into the prevalence of the Gulf War Syndrome, revolved
around rank, level of education, the "perceptions" and the "beliefs"
sufferers held about their health, and the influence exerted by their
peers who were similarly affected. The impression I received was that
the authors regard GWS sufferers with contempt. Discomfort generated by
the collective power rather than the preferred individual vulnerability,
seems a logical explanation for the patronizing and demeaning contention
that the peer support system is for the purpose of encouraging people to
persuade each other that they are sick.
The authors commented that, "Those who believed they had Gulf War
Syndrome were more likely to be of lower rank...and were less well
educated." The fact that they were also more likely to have had greater
exposure to a variety of toxins was skimmed over. "We adjusted for
confounding factors that had the potential to distort results - such as
education, rank..." The army does not accept illiterates into its ranks
so how should that be interpretted? I take from this statement that the
factors were distorted to justify the end result, and since the authors
chose to make the distinction, I make the point that the broken leg of the
moron is every bit as broken as the broken leg of the genius.
Multi-symptoms were vaguely referred to, but not specified, and no
mention was made at all of abnormal (generally non-routine) test results.
In November 2000, the professor visited New Zealand to address an
international meeting on integrating psychology and medicine. One cannot
help but wonder if the day will come when the diabetic or the person with
meningitis will be prescribed prozac, CBT, graded exercise and/or ECT
along with their insulin and antibiotics. Or, as is clearly the case with
GWS and ME, skip the niceties and get straight down to the psychiatric
"goodies".
Gurli Bagnall,
Patients' Rights Campaigner,
New Zealand.
Competing interests: No competing interests
To the Editors of the BMJ,
I am an unlikely party to be commenting upon the article recently
published in your journal, "Prevalence of Gulf war veterans who believe
they have Gulf war syndrome: questionnaire study" by Chalder, et. al. The
conclusions and indeed, the premises upon which this study is based, is
indicative of a basic error in logic which has led to much suffering every
time a puzzling medical phenomena is found. You see, I believe I may
have Gulf War Syndrome but am a civilian who has never served in the armed
forces of any country.
Does my current belief that I have something similar to this pattern
mean that I do have GWS? No, it means that after I became disabled with a
multi-system ailment which included brain damage and chemical
intolerances, my only hope for an explanation of what had befallen me
required I look for similar symptomatology among other patients. This is
not a search for support for a nebulous belief system but a fact finding
mission. Only through finding persons with commonalities of experience and
comparing test results could I hope to provide my puzzled doctors with a
map for further inquiries. This is the emerging procedure for those who
have yet to be diagnosed by a medical model that insists "stress" is the
appropriate ICD 9 code for any ailment that cannot be rapidly assessed and
medicated to everyone's satisfaction. It is also an answer for ailments
that government agencies might find themselves responsible for
compensating or those associated with the manufacturing of profitable
items linked to signs of toxicity in humans.
Little wonder that persons who are inquiring as to their status as
possible GWS are those who would end up "knowing" someone with the same
problems. Perhaps this is an "effect" of having this illness rather than
a part of the cause for it. One does not tell members of a cancer support
group that knowing other cancer victims resulted in their having this
disease. They sought one another out after the fact. Such a search for
other victims of a disease process is often less of a need for emotional
support than it is a way to confirm that one's information and medical
consultants are most likely to result in a positive outcome for the
patient. LIfe disrupting and life threatening illnesses do not inspire
most of us to trust in the words of a single medical advisor who may or
may not have expertise in the ailment under scrutiny. Emotional support
is a secondary benefit of these encounters.
Official agencies should start to wonder how a sixth or seventh of
our fighting GULF WAR forces (American incidence statistics resemble those
of British forces) can all have similar stories about their illnesses
which are strikingly different from ailments in other wars, pre-Agent
Orange. No one can deny that stress has been the hallmark of military
service throughout the millenia. It is only in recent generations with
the proliferation of chemical weapons and "defenses" such as
experimental vaccinations and multiple forms of pesticides (untested in
those combinations) that these novel patterns of illnesses are observed.
Novel circumstances require new problem solving strategies rather than
denial of the experiences of so many of our healthiest citizens. Or are
they the healthiest?
That leads us to question the other assumption of this article: that
all GW veterans started out as identical in physiological terms. Only
when one comes to reject such a hypotheses can we proceed with truly
objective investigation. None of the references cited in this article
mentions why this population might be different from other servicemen and
women. I looked further into the matter and found later studies by Dr.
Haley (cited in this study), research by Dr. Abou-Donia of Duke University
and a body of work by Dr. Furlong at the University of Washington at
Seattle. These articles centered around pesticide exposures similar to
those I have had in residential and occupational settings. Persons with
such exposures and certain symptom constellations affecting multiple
systems, also appeared to have deficiencies in an enzyme known as
paroxonase or PON 1. I contacted Dr. Furlong and he graciously permitted
me to be tested for this substance which is a test not yet commercially
available in this country. Lo and behold, I was similar to sub groups of
GWS veterans in my low concentrations of this substance known to aid in
the detoxification of organophosphate pesticides and the nerve agent,
sarin. Might it be more productive to look into these genetic
differences rather than denying the common experiences being reported by
veterans and civilians in various degrees of severity?
Facts will always remain in short supply when men and women of
science are told to "believe" that what patients EXPERIENCE must always be
an unreliable basis for research. Perhaps it should be suggested that this
is particularly true when the funding for such inquiries might paint an
unprofitable portrait for ailments associated with profitable industries
such as pharmaceuticals and pesticide manufacturers. We have only to look
at recent and upcoming EPA cancellations of pesticide registrations of
organophosphates requiring mediation by the PON 1 system for further clues
into this "mystery".
I am just a recently disabled, middle aged woman without a strong
background in medicine. However, I shall have to continue to guide the
process of my own diagnosis and treatment until patients are regarded as
sentient human beings with a certain set of experiences. We may present
clinical problems which require treating physicians to seek out
researchers looking into illnesses related to our modern technological
"advances". We must not remain a group of "acceptable risks" sacrificed
to current medical-industrial denials of ailments associated with
possible cases of chemical injury.
Barbara Rubin
Agasaya@webtv.net
Competing interests: No competing interests
Once again another report about how patients think about their illnesses by a psychiatrically based team...
Why is that studies of the GWS are not done by Physicians and Immunologists using the latest technology ( ie PCR vs serology)to assess whether the very real symptoms and incapacity can be explained by abnormalities in test results rather than telling us that people can be significantly emotionally affected by witnessing the atrocities of war. We all know that such experiences can affect behaviour.
The thing that psychiatrists often seem to forget is that ALL DISEASE must have a molecular basis. I grant that assessing the physiology behind purely psychiatric conditions - whatever they are ! - is very tricky given that most patients are unlikely to consent to brain biopsies BUT there are tests & assessments available that can address the theoretical abnormalities that are widely discussed in the community and also by G Nicolson in a number of papers.
I would like to see these people taken more seriously by clinicians keen to address the problems these patients have from a patho-physiological point of view and not just keep trotting out paper after paper effectively claiming that it is "all in their attitude" an approach that has also been used to account for CFS as well.
Many of my patients have clear cut evidence of intracellular infections and they also show significant beneficial repsonses to treatment.
yours
Philip Stowell
Competing interests: No competing interests
Gulf War veterans and post-conflict dysfunction ("Gulf War Syndrome")
Gulf War veterans and post-conflict dysfunction ("Gulf War Syndrome")
EDITOR - We have read the results of the latest questionnaire based study
from the Gulf War Research Unit at King's College.[1] The authors found
that 17% of 2961 Gulf War veterans believe themselves to be suffering from
"Gulf War Syndrome", although the group has found no evidence to support
such a syndrome.[2] The veterans' belief was reinforced if they knew
someone with similar symptoms. We believe that this represents post-
conflict dysfunction expressed according to health beliefs prevailing at
the time the questionnaire was administered.
Hyams et al[3] investigated the health of veterans without organic disease
from conflicts since the American Civil War disease ("Disordered action of
the heart"). He showed that veterans complained of a range of physical and
cognitive symptoms, the nature of which was independent of the conflict
and gained diagnoses based on the then current aetiological beliefs. The
Ministry of Defence's Gulf Veterans' Medical Assessment Programme (GVMAP)
now provides a robust clinical base.[4] Of the 3000 who have attended (6%
of the deployed force), we find 80% are well. The 20% who are ill account
for about 1 % of the deployed force. Unwin et al[5] showed that self-
reported physical functioning in Gulf veterans is broadly similar to that
in a control group of non-deployed forces and Bosnia veterans, but that
the perceived quality of their health is reduced. The difference between
the 17% of Chalder et al[1] and our clinical findings may be explained by
the disordered health perception and related behaviour. We suggest that
this, and the syndromes discussed by Hyams et al[3] constitute post-
conflict dysfunction.
The King's group speculate that social networks, usually protective of
health, worked perversely in the case of the Gulf War veterans. A major
omission in their discussion was lack of consideration of the rôle of the
media in reporting Gulf veterans' illnesses. Whilst not suggesting that
the media is solely the "infective agent", its function as 'the vector of
disease' of the nebulous "Gulf War Syndrome" deserves comment. Media
distortion and oversimplifications of the issues are the rule arid were
exemplified when the Daily Telegraph of 31 August 2001 commenting on the
King's paper, ran the headline "One in six veterans has Gulf War
Syndrome". We have taken histories from many veterans who attended the MAP
because of fears fanned by ill-informed and unbalanced media speculation.
Some of these men have post-conflict dysfunction, but none "Gulf War
Syndrome".
Roger Gabriel
Consultant Physician, GVMAP
Lt Col J P G Bolton
Medical Adviser, GVIU
Amanda J Bale
Database Manager, GVMAP
Professor Harry A Lee
Head of GVMAP
References:
1. Chalder T, Hotopf M, Unwin C et al. Prevalence of Gulf war veterans who
believe they have Gulf war syndrome: questionnaire study. BMJ 2000;323:473
-6.
2. Ismail K, Everitt B, Blatchley N et al. Is there a Gulf War Syndrome?
Lancet 1999;353:179-82.
3. Hyams K C, Wignall F S, Roswell R. War syndromes and their evaluation:
from the US Civil War to the Persian Gulf. Am Intern Med 1966;125:398-495.
4. Lee H A, Gabriel R, Bale A J, Bolton J P G, Blatchley N. Clinical
findings of the second 1000 UK Gulf War Veterans who attended the Ministry
of Defence's Medical Assessment Programme. JRAMC 2001;147:153-160.
5. Unwin C, Blatchley N, Coker W J, Ferry S, Hotopf M, Hull L et al. The
health of United Kingdom Servicemen who served in the Persian Gulf War.
Lancet 1999;353:169-78.
Competing interests: No competing interests