Examine individual changes

'{{POV|date=June 2012}} {{Infobox disease |Name = Gulf War illness |Image = Pyridostigmine.svg |Caption = [[Pyridostigmine]], a nerve agent antidote and one of the implicated toxins |ICD9 = {{ICD9|V65.5}} (inconclusive) <br /> also nonstandard "DX111" |MeshID = D018923 }} '''Gulf War syndrome''' (GWS) or '''Gulf War illness''' (GWI) is a chronic multisymptom disorder affecting [[veterans]] and civilians after the 1991 [[Gulf War]].<ref name=veteranIllnesses/><ref>{{cite journal |author=Iversen A, Chalder T, Wessely S |title=Gulf War Illness: lessons from medically unexplained symptoms |journal=Clin Psychol Rev |volume=27 |issue=7 |pages=842–54 |year=2007 |month=October |pmid=17707114 |doi=10.1016/j.cpr.2007.07.006}}</ref><ref>{{cite journal |author=Gronseth GS |title=Gulf war syndrome: a toxic exposure? A systematic review |journal=Neurol Clin |volume=23 |issue=2 |pages=523–40 |year=2005 |month=May |pmid=15757795 |doi=10.1016/j.ncl.2004.12.011}}</ref> A wide range of acute and chronic symptoms have included [[fatigue (physical)|fatigue]], musculoskeletal pain, cognitive problems, skin rashes and diarrhea.<ref>{{cite web | publisher = [[University of Virginia]] | archiveurl = http://replay.waybackmachine.org/20081011144938/http://www.healthsystem.virginia.edu/UVAHealth/adult_environ/gulf.cfm | title = Gulf War Syndrome | url = http://www.healthsystem.virginia.edu/uvahealth/adult_environ/gulf.cfm | archivedate = 2008-10-11}}</ref> Approximately 250,000<ref name="www8.nationalacademies.org">{{cite web | url = http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12835 | title = Gulf War Service Linked to Post-Traumatic Stress Disorder, Multisymptom Illness, Other Health Problems, But Causes Are Unclear| accessdate = 2012-05-09 | publisher = [[National Academy of Sciences]] | date = 2010-04-09 | last = Stencel | first = C }}</ref> of the 697,000 veterans who served in the 1991 Gulf War are afflicted with enduring chronic multi-symptom illness, a condition with serious consequences.<ref name=FedReport>{{cite web | url = http://www.va.gov/gulfwaradvisorycommittee/docs/GWIandHealthofGWVeterans_RAC-GWVIReport_2008.pdf | format = pdf | title = Gulf War Illness and the Health of Gulf War Veterans: Scientific Findings and Recommendations | author = Research Advisory Committee on Gulf War Veterans’ Illnesses | accessdate = 2012-05-09 | date = 2008-11-01 | publisher = U.S. Department of Veterans Affairs }}</ref> From 1995 to 2005, the health of combat veterans worsened in comparison with nondeployed veterans, with the onset of more new chronic diseases, functional impairment, repeated clinic visits and hospitalizations, chronic fatigue syndrome-like illness, posttraumatic stress disorder, and greater persistence of adverse health incidents.<ref>{{cite pmid | 21795757}}</ref> Those who were near conflicts during or downwind of [[chemical weapons]] depot demolition, had exposure to toxic chemicals which are currently believed to be the cause of the illness. Several specific causes have been investigated, including [[pyridostigmine bromide]] (PB) nerve gas antidote (NAPP) pills, [[organophosphate]] military strength pesticides, chemical weapons, and [[depleted uranium]] (DU). Causes which have been ruled out include [[post traumatic stress disorder]], [[anthrax]] [[vaccinations]],<ref name=FedReport/> and smoke from [[Kuwaiti oil fires|oil well fires]], though these exposures may have led to various illnesses and symptoms in a limited number of Gulf War veterans. PB or NAPP antidote pills given to protect troops from [[nerve agents]] and military strength insecticides used during deployment have currently been most closely linked to Gulf War veterans' chronic multi-symptom illness. Exposure to the destruction of the [[Khamisiyah|Khamisiyah weapons depot]], where large quantities of Iraqi chemical munitions containing [[sarin]] and cyclosarin nerve agents was stored, is negatively correlated with motor speed.<ref name=Toomey>{{cite journal | pmid = 19640317 | author-separator =, | last1 = Toomey | first1 = R| doi=10.1017/S1355617709990294 | last2 = Alpern | first2 = R | last3 = Vasterling | first3 = JJ | last4 = Baker | first4 = DG | last5 = Reda | first5 = DJ | last6 = Lyons | first6 = MJ | last7 = Henderson | first7 = WG | last8 = Kang | first8 = HK | last9 = Eisen | first9 = SA | title = Neuropsychological functioning of U.S. Gulf War veterans 10 years after the war. | journal = Journal of the International Neuropsychological Society: JINS | volume=15 | issue=5 | year=2009 | month=September | pages=717–29}}</ref> Exposure to depleted uranium is unlikely to be a primary cause of Gulf War Illness,<ref name="FedReport"/> but questions have been raised concerning possible neurotoxic effects of DU in Gulf War veterans, of whom a small subpopulation show a decrease in neurocognitive behavior.<ref>Aschner, M. and Jiang, G.C. (2009) "Toxicity studies on depleted uranium in primary rat cortical neurons and in Caenorhabditis elegans: what have we learned?" ''Journal of Toxicology and Environmental Health, Part B: Critical Reviews'' '''12'''(7):525-39 PMID 20183532</ref> Kidney function has been affected recently in veterans exposed to DU.<ref>Arzuaga, X. ''et al.'' (2010) "Renal effects of exposure to natural and depleted uranium: a review of the epidemiologic and experimental data" '''Journal of Toxicology and Environmental Health, Part B: Critical Reviews'' '''13'''(7-8):527-45 PMID 21170808</ref> There were a steady increase in malignancies and newborn malformations after the Gulf War.<ref name="Shelleh2012review">Shelleh, H.H. (2012) [http://www.smj.org.sa/PDFFiles/May12/Uranium.pdf "Depleted Uranium: Is it potentially involved in the recent upsurge of malignancies in populations exposed to war dust?"] ''Saudi Medical Journal'' '''33'''(5):483-8 PMID 22588807</ref> Exposure to heavy metals, solvents, paints and pesticides was associated with poor sperm quality, spontaneous abortion, birth defects, and cancer in offspring. Depleted uranium may cause reproductive toxicity, and exposure to it should be followed for increased risk of fertility problems and reproductive cancers.<ref name="Abu-Musa2008">Abu-Musa (2008) [http://www.marciainhorn.com/olwp/wp-content/uploads/Effect-of-war-on-fertility-a-review-of-the-literature.pdf "Effect of war on fertility: a review of the literature"] ''Ethics, Bioscience, and Life'' '''3'''(2):43-53 PMID 18644222</ref> A 2006 review of studies of international coalition veterans' children found no strong or consistent evidence of an increase in birth defects.<ref name="DoyleReview" /> Methods of preventing or treating Gulf War syndrome vary. While the treatment of sarin exposure has been studied,<ref name=Schecter>{{cite journal | last1 = Schecter | first1 = WP | year = 2004 | title = Cholinergic symptoms due to nerve agent attack: a strategy for management | journal = Anesthesiol Clin North America | volume = 22 | issue = 3| pages = 579–90 | pmid = 15325720 | doi=10.1016/j.atc.2004.04.005}}</ref> other [[acetylcholinesterase inhibitor]]s such as pyridostigmine bromide and organophosphate insecticides may or may not involve similar management. ==Classification== Medical ailments associated with Gulf War illnesses have been recognized by both the [[United States Department of Defense|Department of Defense]] and the [[United States Department of Veterans Affairs|Department of Veterans Affairs]].<ref name=veteranIllnesses>{{cite web | url = http://www.publichealth.va.gov/exposures/gulfwar/associated_illnesses.asp | title = Gulf War Veterans' Illnesses: Illnesses Associated with Gulf War Service | date = nd | accessdate = 2012-05-09 | publisher = United States Department of Veterans Affairs }}</ref> Since so little concrete information was known about this condition the Veterans administrations originally classified individuals with related ailments believed to be connected to their service in the Persian Gulf a special non-ICD-9 code DX111, as well as ICD-9 code V65.5.<ref>{{cite web| author=Department of Veterans Affairs Veterans Health Initiative | url = http://www.hanford.gov/hanford/files/VA_GuidetoGulfWarVeteransHealth.pdf|title= A Guide to Gulf War Veterans' Health | archiveurl = http://web.archive.org/web/20060926215559/http://www.hanford.gov/hanford/files/VA_GuidetoGulfWarVeteransHealth.pdf | archivedate = 2006-09-26 | year = 2002}}</ref> There is no formal definition of the term "Gulf War syndrome" or "Gulf War illnesses"<ref>Iversen, A. ''et al'' (2007) "Gulf War Illness: lessons from medically unexplained symptoms" ''Clinical Psychology Reviews'' '''27'''(7):842-54 PMID 17707114</ref> but recent [[fMRI]] literature studying neurology of GWI patients has used the term "Gulf War Syndrome" to refer to three specific patterns of central nervous system activation.<ref>Gopinath, K. ''et al'' (2012) "FMRI reveals abnormal central processing of sensory and pain stimuli in ill Gulf War veterans" ''Neurotoxicology'' '''33'''(3):261-71 PMID 22327017</ref><ref>Tillman, G.D. (2012) "Event-related potential patterns associated with hyperarousal in Gulf War illness syndrome groups" ''Neurotoxicology'' (in press) PMID 22691951</ref> ==Signs and symptoms== [[File:DesertStormMap v2.svg|thumb|right|350px|Summary of the [[Operation Desert Storm]] offensive ground campaign, February 24–28, 1991, by nationality (click for detail).]] According to an April 2010 U.S. Department of Veterans Affairs (VA) sponsored study conducted by the Institute of Medicine (IOM), part of the U.S. [[United States National Academy of Sciences|National Academy of Sciences]], 250,000<ref name="www8.nationalacademies.org"/> of the 696,842 U.S. servicemen and women in the 1991 Gulf War continue to suffer from chronic multi-symptom illness, popularly known as "Gulf War Illness" or "Gulf War Syndrome." The IOM found that the chronic multi-symptom illness continues to affect these veterans nearly 20 years after the war, and, "the excess of unexplained medical symptoms reported by deployed [1991] Gulf war veterans cannot be reliably ascribed to any known [[psychiatric disorder]]."<ref name="books.nap.edu">{{cite book | pages = [http://books.nap.edu/openbook.php?record_id=12835&page=109 109] | author = Committee on Gulf War and Health: Health Effects of Serving in the Gulf War | title = Gulf War and Health, Volume 8 - Update of Health Effects of Serving in the Gulf War | publisher = [[National Academies Press]] }}</ref> According to the IOM, "It is clear that a significant portion of the soldiers deployed to the Gulf War have experienced troubling constellations of symptoms that are difficult to categorize," said committee chair Stephen L. Hauser, professor and chair, department of neurology, [[University of California, San Francisco]] (UCSF). "Unfortunately, symptoms that cannot be easily quantified are sometimes incorrectly dismissed as insignificant and receive inadequate attention and funding by the medical and scientific establishment. Veterans who continue to suffer from these symptoms deserve the very best that modern science and medicine can offer to speed the development of effective treatments, cures, and—we hope—prevention. Our report suggests a path forward to accomplish this goal, and we believe that through a concerted national effort and rigorous scientific input, answers can be found."<ref name="www8.nationalacademies.org"/> With the issuance of this report, the IOM pointed the way forward. There is a pressing need to answer lingering questions, such as why some veterans suffer a range of symptoms whereas others experience specific, isolated health problems or no ill health, and why some veterans who were not on the ground during the conflict or who arrived after combat ended have multisymptom illness, while others who served on the ground during the height of the battle have experienced few or no symptoms. The dearth of data on veterans' pre-deployment and immediate post-deployment health status and lack of measurement and monitoring of the various substances to which veterans may have been exposed make it difficult—and in many cases impossible—to reconstruct what happened to service members during their deployments nearly 20 years after the fact, the committee noted.<ref name="www8.nationalacademies.org"/> The report calls for a substantial commitment to improve identification and treatment of multisymptom illness in Gulf War veterans. The path forward should include continued monitoring of Gulf War veterans and development of better medical care for those with persistent, unexplained symptoms. Researchers should undertake studies comparing genetic variations and other differences in veterans experiencing multisymptom illness and asymptomatic veterans. It is likely that multisymptom illness results from the interactions between environmental exposures and genes, and genetics may predispose some individuals to illness, the committee noted. There are sufficient numbers of veterans to conduct meaningful comparisons given that nearly 700,000 U.S. personnel were deployed to the region and more than 250,000 of them suffer from persistent, unexplained symptoms. A consortium involving the U.S. Department of Veterans Affairs, U.S. Department of Defense, and National Institutes of Health could coordinate this effort and contribute the necessary resources.<ref name="www8.nationalacademies.org"/> The IOM also found that service in the 1991 Gulf War is a cause of post-traumatic stress disorder (PTSD) in some veterans and is also associated with gastrointestinal disorders such as irritable bowel syndrome; substance abuse, particularly alcoholism; and psychiatric problems such as anxiety disorder. And, IOM's report shows there is some evidence that service during the 1991 Gulf War is linked to fibromyalgia and chronic widespread pain, amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig's disease), sexual difficulties, and death due to causes such as car accidents in the early years after deployment, but the data are limited, said the committee that wrote the report.<ref name="www8.nationalacademies.org"/> Older research shows that the U.S. and the UK, with the highest rates of excess illness, are distinguished from the other nations by higher rates of [[pesticide]] use, use of anthrax [[vaccine]], and somewhat higher rates of exposures to oil fire [[smoke]] and reported chemical alerts. France, with possibly the lowest illness rates, had lower rates of pesticide use, and no use of anthrax vaccine.<ref>{{harvnb|RAC-GWVI Minutes|2005|p=78}}</ref> French troops also served to the North and West of all other combat troops, away and upwind of major combat engagements.<ref>{{harvnb|RAC-GWVI Minutes|2005|p=68}}</ref> {|class="wikitable sortable" style="font-size:97%; text-align:right;" |+Excess prevalence of general [[symptom]]s<ref>{{harvnb|RAC-GWVI Minutes|2005|p=70}}, ''This table applies only to coalition forces involved in [[combat]].''</ref>'''*''' !width="200px"| Symptom !width="50px"| U.S. !width="50px"| UK !width="75px"| Australia !width="75px"| Denmark |- |align="left"|Fatigue||23%||23%||10%||16% |- |align="left"|Headache||17%||18%||7%||13% |- |align="left"|Memory problems||32%||28%||12%||23% |- |align="left"|Muscle/joint pain||18%||17%||5%||2% (<2%) |- |align="left"|Diarrhea||16%|| ||9%||13% |- |align="left"|Dyspepsia/indigestion||12%|| ||5%||9% |- |align="left"|Neurological problems||16%|| ||8%||12% |- |align="left"|Terminal tumors||33%|| ||9%||11% |} {|class="wikitable sortable" style="font-size:97%; text-align:right;" |+Excess prevalence of recognized medical conditions<ref>{{harvnb|RAC-GWVI Minutes|2005|p=71}}</ref> !width="200px"| Condition !width="50px"| U.S. !width="50px"| UK !width="75px"| Canada !width="75px"| Australia |- |align="left"|Skin conditions |{{sort|20|20–21%}} ||21% ||{{sort|04|4–7%}} ||4% |- |align="left"|Arthritis/joint problems |{{sort|06|6–11%}} ||10% ||{{sort|0|(-1)–3%}} ||2% |- |align="left"|Gastro-intestinal (GI) problems |{{sort|15|15%}} || ||{{sort|05|5–7%}} ||1% |- |align="left"|Respiratory problem |{{sort|04|4–7%}} ||2% ||{{sort|02|2–5%}} ||1% |- |align="left"|Chronic fatigue syndrome |{{sort|01|1–4%}} ||3% || ||0% |- |align="left"|Post-traumatic stress disorder |{{sort|02|2–6%}} ||9% ||{{sort|06|6%}} ||3% |- |align="left"|Chronic multi-symptom illness |{{sort|13|13–25%}} ||26% || || |} Although Gulf War illness is the most prominent condition affecting Gulf War veterans, it is just one health issue to be addressed in the larger context of the health of Gulf War veterans. Other Gulf War-related health issues of importance include rates of diagnosable medical conditions and post-war mortality among Gulf War veterans, and questions related to the risk of birth defects and other health problems in veterans’ family members. Results from two studies, using different methods in different groups of symptomatic veterans, indicate that Gulf War illness is associated with a low-level, persistent immune activation, reflected in elevated levels of the cytokines IL-2, IFN-γ and IL-10. In addition, several studies have reported that NK cell numbers and/or cytotoxic activity are significantly reduced in veterans with Gulf War illness.<ref name=GWVI_08_p262>{{harvnb|RAC-GWVI Report|2008|p=262 (PDF p. 270)}}</ref> ===Birth defects=== [[File:Basrah birth defects.svg|thumb|250px|right|Graph showing the rate per 1,000 births of congenital malformations observed at Basra University Hospital, Iraq<ref>I. Al-Sadoon, ''et al.,'' writing in the Medical Journal of Basrah University, [http://web.archive.org/web/20110716160809/http://www.irak.be/ned/archief/Depleted%20Uranium_bestanden/DEPLETED%20URANIUM-2-%20INCIDENCE.htm (see Table 1 here)]. This version from data by same author(s) in Wilcock, A.R., ed. (2004) "Uranium in the Wind" (Ontario: Pandora Press) ISBN 0-9736153-2-X</ref>]] There were a steady increase in malignancies and newborn malformations after the Gulf War.<ref name="Shelleh2012review" /> Exposure to heavy metals, solvents, paints and pesticides was associated with poor sperm quality, spontaneous abortion, birth defects, and cancer in offspring. Depleted uranium may cause reproductive toxicity, and exposure to it should be followed for increased risk of fertility problems and reproductive cancers.<ref name="Abu-Musa2008" /> A 2006 review of several studies of international coalition veterans' children found no strong or consistent evidence of an increase in birth defects, calling the increase "modest."<ref name="DoyleReview">{{cite pmid|16687262}}</ref> ==Causes== The [[United States Congress]] mandated the [[National Academies of Science]] [[Institute of Medicine]] to provide nine reports on Gulf War Syndrome since 1998.<ref>[http://www.publichealth.va.gov/exposures/gulfwar/announcement.asp VA Press Release]</ref> Aside from the many physical and psychological issues involving any war zone deployment, Gulf War veterans were exposed to a unique mix of hazards not previously experienced during wartime. These included [[pyridostigmine bromide]] pills given to protect troops from the effects of nerve agents, depleted uranium munitions, and [[anthrax vaccine|anthrax]] and [[botulinum]] vaccines. The oil and smoke that spewed for months from hundreds of burning oil wells presented another exposure hazard not previously encountered in a warzone. Military personnel also had to cope with swarms of insects, requiring the widespread use of pesticides. United States Veterans Affairs Secretary [[Anthony Principi]]'s panel found that pre-2005 studies suggested the veterans' illnesses are neurological and apparently are linked to exposure to [[neurotoxins]], such as the nerve gas sarin, the anti-nerve gas drug [[pyridostigmine bromide]], and [[pesticide]]s that affect the nervous system. The review committee concluded that "Research studies conducted since the war have consistently indicated that psychiatric illness, combat experience or other deployment-related stressors do not explain Gulf War veterans illnesses in the large majority of ill veterans," the review committee said.<ref>{{cite web | url = http://www.va.gov/RAC-GWVI/docs/Committee_Documents/ReportandRecommendations_ScientificProgressinUnderstandingGWVI_2004.pdf | title = Research Advisory Committee on Gulf War Veterans’ Illnesses 2004 Report | format = pdf | date = 2004-09-01 | Scientific Progress in Understanding Gulf War Veterans’ Illnesses: Report and Recommendations | author = Research Advisory Committee on Gulf War Veterans’ Illnesses | publisher = United States Department of Veterans Affairs | accessdate = 2012-05-09 }}</ref> ===Pyridostigmine bromide nerve gas antidote=== The US military issued [[pyridostigmine bromide]] (PB) pills to protect against exposure to nerve gas agents such as sarin and [[soman]]. PB was used to pretreat nerve agent poisoning; it is not a vaccine however. Taken before exposure to nerve agents, PB was thought to increase the efficacy of nerve agent antidotes. PB had been used since 1955 for patients suffering from [[myasthenia gravis]] with doses up to 1,500&nbsp;mg a day, far in excess of the 90&nbsp;mg given to soldiers, and was considered safe by the FDA at either level for indefinite use and its use to pretreat nerve agent exposure had recently been approved.<ref>{{cite news | publisher = PBS Frontline | accessdate = 2012-05-09 | date = 1996-12-01 | url = http://www.pbs.org/wgbh/pages/frontline/shows/syndrome/analysis/pyribrom.html | title = Pyridostigmine bromide use in the First Gulf War }}</ref> About half of U.S. Gulf War veterans report using PB during deployment, with greatest use among Army personnel. Concerns have been raised about the possibility of increased health problems from PB when it is combined with other risk factors.{{Citation needed|date=May 2012}} Given both the large body of epidemiological data on myasthenia gravis patients and follow up studies done on veterans it was concluded that while it was unlikely that health effects reported today by Gulf War veterans are the result of exposure solely to PB, use of PB was [[Causality|causally associated]] with illness.<ref name=FedReport/> ===Organophosphate pesticides=== The use of [[organophosphate]] [[pesticides]] and [[DEET|insect repellants]] during the first Gulf War is credited with keeping rates of pest-borne diseases low. Pesticide use is one of only two exposures consistently identified by Gulf War epidemiologic studies to be significantly associated with Gulf War illness.<ref>{{cite book | publisher = [[United States Department of Defense]] | author = Office of the Special Assistant to the Undersecretary of Defense (Personnel and Readiness) for Gulf War Illnesses Medical Readiness and Military Deployments | title = Environmental Exposure Report: Pesticides Final Report | location = Washington, D.C. | date = 2003-04-17 }}</ref> Multisymptom illness profiles similar to Gulf War illness have been associated with low-level pesticide exposures in other human populations. In addition, Gulf War studies have identified dose-response effects, indicating that greater pesticide use is more strongly associated with Gulf War illness than more limited use.<ref>{{cite book | last = Krengel | first = M | coauthors = Sullivan K | title = Neuropsychological Functioning in Gulf War Veterans Exposed to Pesticides and Pyridostigmine Bromide | location = Fort Detrick, MD | publisher = U.S. Army Medical Research and Materiel Command | date = 2008-08-01 | url = http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA491742 | accessdate = 2012-05-09 }} W81XWH-04-1-0118</ref> Pesticide use during the Gulf War has also been associated with [[neurocognitive]] deficits and [[neuroendocrine]] alterations in Gulf War veterans in clinical studies conducted following the end of the war. The 2008 report concluded that “all available sources of evidence combine to support a consistent and compelling case that pesticide use during the Gulf War is causally associated with Gulf War illness.”<ref name=FedReport/> ===Sarin nerve agent=== [[File:Iraq-gwi-map.jpg|left]] Many of the symptoms of Gulf War syndrome are similar to the symptoms of organophosphate, [[mustard gas]], and [[nerve gas]] poisoning.<ref name=Friis>{{cite book |title=Epidemiology for Public Health Practice |last=Friis |first=Robert H. |coauthors=Thomas A. Sellers |year=2004 |publisher=Jones & Bartlett Publishers |isbn=0-7637-3170-6 }}</ref><ref>{{cite book |title=A Review of the Scientific Literature as it Pertains to Gulf War Illnesses |last=Spektor |first=Dalia M. |coauthors=Richard A. Rettig, Lee H. Hilborne, Beatrice Alexandra Golomb, Grant N. Marshall, L. M. Davis, Cathy Donald Sherbourne, Naomi H. Harley, William S. Augerson, Gary Cecchine, United States Dept. of Defense |year=1998 |publisher = [[RAND Corporation]] |isbn=0-8330-2680-1 }}</ref> Gulf War veterans were exposed to a number of sources of these compounds, including nerve gas and [[pesticides]].<ref>{{cite news | url = http://www.scotsman.com/news/uk/campaigners_hail_nerve_gas_link_to_gulf_war_syndrome_1_1046500 | title = Campaigners hail 'nerve gas link' to Gulf War Syndrome |publisher=News.scotsman.com |accessdate=November 24, 2009 |location=Edinburgh |date=November 13, 2004}}</ref> Chemical detection units from the Czech Republic, France, and Britain confirmed chemical agents. French detection units detected chemical agents. Both Czech and French forces reported detections immediately to U.S. forces. U.S. forces detected, confirmed, and reported chemical agents; and U.S. soldiers were awarded medals for detecting chemical agents. The [[Riegle Report]] said that chemical alarms went off 18,000 times during the Gulf War. After the air war started on January 16, 1991, coalition forces were chronically exposed to low but nonlethal levels of chemical and biological agents released primarily by direct Iraqi attack via [[missile]]s, [[rocket]]s, [[artillery]], or aircraft [[munitions]] and by [[Nuclear fallout|fallout]] from allied bombings of Iraqi chemical warfare munitions facilities.<ref>{{citation | title = U.S. Chemical and Biological Warfare-Related Dual Use Exports to Iraq and their Possible Impact on the Health Consequences of the Gulf War | date = 1994-02-09 | accessdate = 2012-05-09 | last = Riegle | first = DW | authorlink = Donald W. Riegle, Jr. | url = http://en.wikisource.org/wiki/Riegle_Report | publisher = [[Wikisource]] }}</ref> In 1997, the US Government released an unclassified report that stated, ''"The US Intelligence Community (IC) has assessed that Iraq did not use chemical weapons during the Gulf War. However, based on a comprehensive review of intelligence information and relevant information made available by the United Nations Special Commission (UNSCOM), we conclude that chemical warfare (CW) agent was released as a result of US postwar demolition of rockets with chemical warheads at several sites including Khamisiyah"''. Over 125,000 U.S. troops and 9,000 UK troops were exposed to nerve gas and [[mustard gas]] when the Iraqi depot in Khamisiyah was destroyed.<ref>{{cite web | url = http://www.fas.org/irp/gulf/cia/970409/cia_wp.html | title = Khamisiyah: A Historical Perspective on Related Intelligence | author = Persian Gulf War Illnesses Task Force | date = 1997-04-09 | accessdate = 2012-05-09 | publisher = [[Federation of American Scientists]] }}</ref> Recent studies have confirmed earlier suspicions that exposure to sarin, in combination with other contaminants such as pesticides and PB were related to reports of veteran illness. Estimates range from 100,000 to 300,000 individuals exposed to nerve agents<ref name=Golomb08>{{cite journal |author=Golomb BA |title=Acetylcholinesterase inhibitors and Gulf War illnesses |journal=Proc. Natl. Acad. Sci. U.S.A. |volume=105 |issue=11 |pages=4295–300 |year=2008 |month=March |pmid=18332428 |pmc=2393741 |doi=10.1073/pnas.0711986105}}</ref> ===Depleted uranium=== [[File:GWI DU map.gif|thumb|right|350px|Major Gulf War engagements in which DU rounds were used.]] [[Depleted uranium]] (DU) was widely used in tank [[kinetic energy penetrator]] and [[autocannon]] [[Shell (projectile)|rounds]] for the first time in the Gulf War. DU is a dense, weakly radioactive metal. Munitions made from it often burn when they impact a hard target, producing toxic [[combustion]] products. Roughly 320 tons of DU were used during the February, 1991 conflict.<ref name="autogenerated6">{{cite web | title = Depleted Uranium | publisher = [[GlobalSecurity.org]] | url = http://www.globalsecurity.org/military/systems/munitions/du.htm | date = nd | accessdate = 2012-05-09 }}</ref> After military personnel began reporting unexplained health problems in the aftermath of the Gulf War, questions were raised about the health effect of exposure to depleted uranium.<ref>Friedl, K.E., ''et al'' (2009) "Neuropsychological issues in military deployments: lessons observed in the DoD Gulf War Illnesses Research Program" ''Military Medicine'' '''174'''(4):335-46 PMID 19485101</ref> The use of DU in [[munitions]] is controversial because of questions about potential long-term health effects.<ref name=MillerMcClain>{{cite pmid | 17508699 }}</ref> Normal functioning of the [[kidney]], [[brain]], [[liver]], [[heart]], and numerous other systems can be affected by uranium exposure, because in addition to being weakly radioactive, uranium is a [[toxic metal]].<ref name=Craft04>{{cite pmid | 15205046}}</ref> Epidemiological evidence is consistent with increased risk of birth defects in the offspring of persons exposed to depleted uranium.<ref name="Hindin" /><ref name="Shelleh2012review" /> Exposure to heavy metals, solvents, paints and pesticides was associated with poor sperm quality, spontaneous abortion, birth defects, and cancer in offspring.<ref name="Abu-Musa2008" /> Because uranium is a heavy metal and chemical toxicant with nephrotoxic (kidney-damaging),<ref>[http://hps.org/publicinformation/ate/q754.html Health effects of uranium<!-- Bot generated title -->]</ref> [[Teratogenesis|teratogenic]] (birth defect-causing),<ref>{{cite journal |author=Hindin R, Brugge D, Panikkar B |title=Teratogenicity of depleted uranium aerosols: a review from an epidemiological perspective |journal=Environ Health |volume=4 |issue= 1|page=17 |year= 2005|pmid=16124873 |doi=10.1186/1476-069X-4-17 |pmc=1242351}}</ref><ref>{{cite journal |author=Arfsten D, Still K, Ritchie G |title=A review of the effects of uranium and depleted uranium exposure on reproduction and fetal development |journal=Toxicol Ind Health |volume=17 |issue=5–10 |pages=180–91 |year=2001 |pmid=12539863 | doi = 10.1191/0748233701th111oa}}</ref> [[immunotoxin|immunotoxic]],<ref name="Wan2006">{{cite journal | author = Wan B, Fleming J, Schultz T, Sayler G | title = In vitro immune toxicity of depleted uranium: effects on murine macrophages, CD4+ T cells, and gene expression profiles | journal = Environ Health Perspect | volume = 114 | issue = 1 | pages = 85–91 | year = 2006 | pmid = 16393663 | pmc = 1332661}}</ref> and potentially [[carcinogen]]ic<ref>{{cite web|url=http://www.gulflink.osd.mil/medsearch/Cancer/DoD122.shtml|title=Carcinogenic Potential of Depleted Uranium and Tungsten Alloys|author=Miller, Alexandra C|publisher=U.S. Department of Defense}}</ref> properties, uranium exposure is associated with a variety of illnesses.<ref>[http://www.atsdr.cdc.gov/toxprofiles/tp150.html ATSDR — Toxicological Profile: Uranium<!-- Bot generated title -->]</ref> The chemical toxicological hazard posed by uranium dwarfs its radiological hazard because it is only weakly radioactive, and depleted uranium even less so. DU has recently been recognized as a [[neurotoxin]].<ref name="autogenerated3">{{cite journal |author=Jiang G, Aschner M |title=Neurotoxicity of depleted uranium: reasons for increased concern |journal=Biol Trace Elem Res |volume=110 |issue=1 |pages=1–17 |year=2006 |pmid=16679544 | doi = 10.1385/BTER:110:1:1}}</ref> In 2005, depleted uranium was shown to be a neurotoxin in rats.<ref>{{cite journal |author=Anandan N, Shetty S, Patil K, Ibrahim A |title=Acute urinary retention caused by anterior urethral polyp |journal=Br J Urol |volume=69 |issue=3 |pages=321–2 |year=1992 |pmid=1568112 |doi=10.1111/j.1464-410X.1992.tb15541.x}}</ref> Early studies of depleted uranium [[aerosol]] exposure assumed that uranium combustion product particles would quickly settle out of the air<ref>{{cite web|url=http://www.deploymentlink.osd.mil/du_library/du_ii/du_ii_tabl1.htm|title=Depleted Uranium in the Gulf (II) TAB L - Research Report Summaries | archiveurl = http://web.archive.org/web/20070110044534/http://www.deploymentlink.osd.mil/du_library/du_ii/du_ii_tabl1.htm|archivedate=10 January 2007}}</ref> and thus could not affect populations more than a few kilometers from target areas,<ref>{{cite journal |author=Mitsakou C, Eleftheriadis K, Housiadas C, Lazaridis M |title=Modeling of the dispersion of depleted uranium aerosol |journal=Health Phys |volume=84 |issue=4 |pages=538–44 |year=2003 |pmid=12705453 |doi=10.1097/00004032-200304000-00014}}</ref> and that such particles, if inhaled, would remain undissolved in the lung for a great length of time and thus could be detected in urine.<ref>{{cite journal |author=Horan P, Dietz L, Durakovic A |title=The quantitative analysis of depleted uranium isotopes in British, Canadian, and U.S. Gulf War veterans |journal=Mil Med |volume=167 |issue=8 |pages=620–7 |year=2002 |pmid=12188230}}</ref> [[Uranyl]] ion contamination has been found on and around depleted uranium targets.<ref>{{cite journal |author=Salbu B, Janssens K, Lind O, Proost K, Gijsels L, Danesi P |title=Oxidation states of uranium in depleted uranium particles from Kuwait |journal=J Environ Radioact |volume=78 |issue=2 |pages=125–35 |year=2005 |pmid=15511555 |doi=10.1016/j.jenvrad.2004.04.001}}</ref> In 2001, a study was published in Military Medicine that found DU in the urine of Gulf War veterans.<ref>{{cite journal |author=Hodge S, Ejnik J, Squibb K, McDiarmid M, Morris E, Landauer M, McClain D |title=Detection of depleted uranium in biological samples from Gulf War veterans |journal=Mil Med |volume=166 |issue=12 Suppl |pages=69–70 |year=2001 |pmid=11778443}}</ref> Another study, published by [[Health Physics]] in 2004, also showed DU in the urine of Gulf War veterans.<ref>{{cite journal |author=Gwiazda R, Squibb K, McDiarmid M, Smith D |title=Detection of depleted uranium in urine of veterans from the 1991 Gulf War |journal=Health Phys |volume=86 |issue=1 |pages=12–8 |year=2004 |pmid=14695004 |doi=10.1097/00004032-200401000-00004}}</ref> A study of UK veterans who thought they might have been exposed to DU showed aberrations in their [[white blood cell]] [[chromosome]]s.<ref name="Schröder2003">{{cite pmid|12678382}}</ref> Mice immune cells exposed to uranium exhibit abnormalities.<ref name="Wan2006" /> In the [[Balkans]] war zone where depleted uranium was also used, an absence of problems is seen by some as evidence of DU munitions' safety. "Independent investigations by the World Health Organization, European Commission, European Parliament, United Nations Environment Programme, United Kingdom Royal Society, and the Health Council of the Netherlands all discounted any association between depleted uranium and leukemia or other medical problems."<ref name="autogenerated6" /> In Italy, controversy over the health risks associated with the use of DU continues, with a Senate investigation committee was due to release its report into 'Balkan Syndrome' by the end of 2007.<ref>{{cite web |author=Anes Alic|url=http://www.isn.ethz.ch/news/sw/details.cfm?id=18290|title=Depleted uranium, depleted health concerns|publisher=ISN Security Watch|date=October 29, 2007}}</ref> Since then, there has been a resurgence of interest in the health effects of depleted uranium, especially since it has recently been linked with neurotoxicity.<ref>{{cite pmid | 16679544 }}</ref> The aerosol produced during impact and combustion of depleted uranium munitions can potentially contaminate wide areas around the impact sites or can be inhaled by civilians and military personnel.<ref name="ncbi.nlm.nih.gov">{{cite pmid | 12705453}}</ref> A 2008 review by the U.S. Department of Veterans Affairs found that while low-level exposure to DU was widespread during the Gulf War, the persistent effects of low-dose exposures have only been minimally assessed. They found no association between DU exposure and multisymptom illness, concluding that "exposure to DU munitions is not likely a primary cause of Gulf War illness". However questions remain about the long-term effects of higher-dose exposure to DU.<ref name="FedReport"/> [[File:Scud downed by Patriot missiles.JPEG|thumb|left|350px|Military personnel examine the remains of a Scud during the Gulf War. The health affects of Scud missile fuel have been ruled out as causing illnesses associated with the Gulf War]] ===Ruled out=== Several potential causes beyond vaccinations, stress, and oil well fires—explained in more detail below—have been ruled out. Other ruled-out potential causes include [[Scud]] missile fuel and infectious diseases. Limited evidence from several sources suggests that an association with the combined effects of multiple neurotoxicant exposures and receipt of multiple vaccines can not be ruled out.<ref>Veterans Administration (November, 2009) p. 11 (PDF page 21)</ref>{{full}} ====Anthrax vaccine==== Iraq had loaded anthrax, [[botulinum|botulinum toxin]], and [[aflatoxin]] into [[scud|missiles]] and artillery shells in preparing for the Gulf War and that{{Clarify|date=January 2011}}{{Vague|date=January 2011}} these munitions were deployed to four locations in Iraq.<ref>{{cite book | first = AH | last = Cordesman | title = Iraq and the War of Sanctions: Conventional Threats and Weapons of Mass Destruction | url = http://books.google.com/books?id=qFCkQRQApSwC | year = 1999 | publisher = [[Greenwood Publishing Group]] | isbn = 978-0-275-96528-0}}</ref> During Operation Desert Storm, 41% of U.S. combat soldiers and 75% of UK combat soldiers were vaccinated against anthrax.<ref>{{harvnb|RAC-GWVI Minutes|2005|p=73}}</ref> Reactions included local skin irritation, some lasting for weeks or months.<ref>{{cite web | url = http://www.gao.gov/new.items/d0192t.pdf | last = Chan | first = KC | date = 2000-10-11 | accessdate = 2012-05-09 | format = pdf | title = GAO-01-92T Anthrax Vaccine: Preliminary Results of GAO's Survey of Guard/Reserve Pilots and Aircrew Members | publisher = [[Government Accountability Office]] }}</ref> While the [[Food and Drug Administration]] (FDA) approved the vaccine, it never went through large scale clinical trials, unlike most other vaccines in the United States.<ref>{{cite news | url = http://orig.clarionledger.com/news/0105/16/m11.html | date = 2001-05-16 | title = Expert: Anthrax vaccine not proven| last = Burdeau | first = C | work = [[The Clarion-Ledger]] }}</ref> While recent studies have demonstrated the vaccine’s is highly reactogenic,<ref>{{cite journal |author=McNeil MM, Chiang IS, Wheeling JT, Zhang Y |title=Short-term reactogenicity and gender effect of anthrax vaccine: analysis of a 1967–1972 study and review of the 1955–2005 medical literature |journal=Pharmacoepidemiol Drug Saf |volume=16 |issue=3 |pages=259–74 |year=2007 |month=March |pmid=17245803 |doi=10.1002/pds.1359 }}</ref> there is no clear evidence or epidemiological studies on Gulf War veterans linking the vaccine to Gulf War Syndrome. Combining this with the lack of symptoms from current deployments of individuals who have received the vaccine led the Committee on Gulf War Veterans’ Illnesses to conclude that the vaccine is not a likely cause of Gulf War illness for most ill veterans.<ref name=FedReport/> ====Combat stress==== Research studies conducted since the war have consistently indicated that psychiatric illness, combat experience or other deployment-related stressors do not explain Gulf War veterans illnesses in the large majority of ill veterans, according to a [[U.S. Department of Veterans Affairs]] (VA) review committee. An April 2010 Institute of Medicine review found, "the excess of unexplained medical symptoms reported by deployed [1991] Gulf war veterans cannot be reliably ascribed to any known psychiatric disorder."<ref name="books.nap.edu"/> ====Oil well fires==== During the war, many [[Kuwaiti oil fires|oil wells were set on fire in Kuwait]] by the retreating Iraqi army, and the smoke from those fires was inhaled by large numbers of soldiers, many of whom suffered acute [[pulmonary]] and other chronic effects, including [[asthma]] and [[bronchitis]]. However, firefighters who were assigned to the oil well fires and encountered the smoke, but who did not take part in combat, have not had GWI symptoms.<ref>{{harvnb|RAC-GWVI Minutes|2005|pp=148,154,156}}</ref> ==Diagnosis== {{Expand section|date=January 2010}} Multisymptom illness is more prevalent in Gulf War I veterans than veterans of previous conflicts, but the pattern of comorbidities is similar for actively deployed and nondeployed military personnel.<ref>{{cite journal | last1 = Kelsall | first1 = H. L.| author-separator =, | last2 = McKenzie | year = 2009 | first2 = DP | last3 = Sim | first3 = MR | last4 = Leder | first4 = K | last5 = Forbes | first5 = AB | last6 = Dwyer | first6 = T | title = Physical, psychological, and functional comorbidities of multisymptom illness in Australian male veterans of the 1991 Gulf War | journal = Am J Epidemiol | volume = 170 | issue = 8| pages = 1048–56 | pmid = 19762370 | doi=10.1093/aje/kwp238}}</ref> Management of potentially comorbid toxic exposures requires awareness of the toxins involved.<ref name=Schecter /> Exposure to the destruction of the Khamisiyah weapons depot, where large quantities of the chemical weapon [[sarin]] was stored, is negatively correlated with motor speed.<ref name=Toomey /> Epidemiological evidence is consistent with increased risk of birth defects in the offspring of persons exposed to depleted uranium.<ref name="Hindin">{{cite pmid | 16124873}}</ref> ==Management== ===Nerve agent antidote and insect repellent=== In 2008, a paper published in the ''[[Proceedings of the National Academy of Sciences]]'' suggested that excess illnesses in Gulf War veterans could be explained in part by their exposure to organophosphate and [[carbamate]] [[acetylcholinesterase inhibitor]]s.<ref name=Golomb08/> A federal report released in November, 2008, agreed, stating that exposure to two substances "are causally associated with Gulf War illness":<ref name = CNN>{{cite news | url = http://www.cnn.com/2008/HEALTH/11/17/gulf.war.illness.study/index.html | title = Gulf War illness is real, new federal report says | publisher = [[CNN]] | last = Silverleib | first = A | date = 2008-12-09 | accessdate = 2012-05-09 }}</ref> *[[pyridostigmine bromide]], an acetylcholinesterase inhibitor intended to protect against nerve agents,<ref>{{harvnb|RAC-GWVI Minutes|2005}}</ref> and *[[pesticide]]s and [[insect repellent]]s (often acetylcholinesterase inhibitors) {{Expand section|date=December 2009}} ===Sarin=== Exposure to sarin, a nerve gas, is a possible comorbidity. Chemical weapons classified as nerve agents are also strong [[acetylcholinesterase inhibitors]]. A 2004 review discusses symptoms, signs, and treatment of nerve agent exposure.<ref name=Schecter /> ===Uranium=== Uranium exposure should be followed for increased risk of fertility problems and reproductive cancers.<ref name="Abu-Musa2008" /> [[Genotoxicity|Genotoxic]] [[mutagen]]s such as uranium should be treated with [[chelation therapy]]<ref>{{cite journal|pmid=18313802|year=2008|last1=Sawicki|first1=M|last2=Lecerclé|first2=D|last3=Grillon|first3=G|last4=Le Gall|first4=B|last5=Sérandour|first5=AL|last6=Poncy|first6=JL|last7=Bailly|first7=T|last8=Burgada|first8=R|last9=Lecouvey|first9=M|title=Bisphosphonate sequestering agents. Synthesis and preliminary evaluation for in vitro and in vivo uranium(VI) chelation|volume=43|issue=12|pages=2768–77|doi=10.1016/j.ejmech.2008.01.018|journal=European journal of medicinal chemistry}}</ref> or other means shortly after exposure.<ref>{{cite journal | pmid = 19780139 | author-separator =, | last1 = Spagnul | first1 = A| doi=10.1002/jps.21932 | last2 = Bouvier-Capely | first2 = C | last3 = Phan | first3 = G | last4 = Rebière | first4 = F | last5 = Fattal | first5 = E | title = Calixarene-entrapped nanoemulsion for uranium extraction from contaminated solutions | journal = Journal of pharmaceutical sciences | volume=99 | issue=3 | year=2010 | month=March | pages=1375–83}}</ref> Incorporated uranium becomes uranyl ions, which accumulate in bone, liver, kidney, and reproductive tissues. Uranium can be decontaminated from steel surfaces<ref name=Francis>{{cite journal | doi = 10.1021/es048887c | last1 = Francis | first1 = A.J. | last2 = Dodge | year = 2005 | first2 = CJ | last3 = McDonald | first3 = JA | last4 = Halada | first4 = GP | title = Decontamination of uranium-contaminated steel surfaces by hydroxycarboxylic acid with uranium recovery | journal = Environ Sci Technol | volume = 39 | issue = 13| pages = 5015–21 | pmid = 16053105 }}</ref> and aquifers.<ref name=Wu>{{cite journal | doi = 10.1021/es051960u | last1 = Wu | first1 = W.M. | last2 = Carley | year = 2006 | first2 = J | last3 = Gentry | first3 = T | last4 = Ginder-Vogel | first4 = MA | last5 = Fienen | first5 = M | last6 = Mehlhorn | first6 = T | last7 = Yan | first7 = H | last8 = Caroll | first8 = S | last9 = Pace | first9 = MN | title = Pilot-scale in situ bioremedation of uranium in a highly contaminated aquifer. 2. Reduction of u(VI) and geochemical control of u(VI) bioavailability | journal = Environ Sci Technol | volume = 40 | issue = 12| pages = 3986–95 | pmid = 16830572 }}</ref> ==Epidemiologic research== Epidemiologic studies have been performed evaluating many suspected [[Etiology (medicine)|etiologic]] factors for Gulf War illness as seen in veteran populations. Below is a summary of epidemiologic studies of veterans displaying multisymptom illness and their exposure to suspect conditions from the 2008 U.S. Veterans Administration report.<ref>{{harvnb|RAC-GWVI Report|2008|pp=220–1}}</ref> A fuller understanding of immune function in ill Gulf War veterans is needed, particularly in veteran subgroups with different clinical characteristics and exposure histories. It is also important to determine the extent to which identified immune perturbations may be associated with altered neurological and endocrine processes that are associated with immune regulation.<ref name=GWVI_08_p262/> No study that have evaluated birth outcomes and birth defects among Gulf War veterans and their children has assessed whether there is any connection between reproductive outcomes and uranium exposure in the Gulf War.<ref>{{harvnb|RAC-GWVI Report|2008|p=96 (PDF p. 105)}}</ref> Very limited cancer data have been reported for U.S. Gulf War veterans in general, and no published research on cases occurring after 1999. Because of the extended latency periods associated with most cancers, it is important that cancer information be brought up to date and that cancer rates be assessed in Gulf War veterans on an ongoing basis. In addition, cancer rates should be evaluated in relation to identifiable exposure and location subgroups.<ref>{{harvnb|RAC-GWVI Report|2008|p=45 (PDF p. 55)}}</ref> {| class="wikitable" <!-- this table has not been peer reviewed --> |----- ! style="align: left;" colspan="8" | Epidemiologic Studies of Gulf War Veterans: Association of Deployment Exposures With Multisymptom Illness<ref>{{harvnb|RAC-GWVI Report|2008|p=222}}</ref> |----- ! style="align: left;" colspan="1" | ! style="align: left;" colspan="2" |Preliminary Analysis (no controls for exposure) ! style="align: left;" colspan="3" |Adjusted Analysis (controlling for effects of exposure) ! style="align: left;" colspan="2" |Clinical Evaluations |----- ! style="align: left;" colspan="1" | ! style="align: left;" colspan="1" |GWV population in which association was assessed ! style="align: left;" colspan="1" |GWV population in which association was statistically significant ! style="align: left;" colspan="1" |GWV population in which association was assessed ! style="align: left;" colspan="1" |GWV population in which association was statistically significant ! style="align: left;" colspan="1" |Dose response effect identified? ! style="align: left;" colspan="2" | |----- ! style="align: left;" colspan="1" |Pyridostigmine bromide ! style="align: left;" colspan="1" |10 ! style="align: left;" colspan="1" |9 ! style="align: left;" colspan="1" |6 ! style="align: left;" colspan="1" |6 ! style="align: left;" colspan="1" |{{unicode|✓}} ! style="align: left;" colspan="2" |<small>Associated with neurocognitive and HPA differences in GW vets</small> |----- ! style="align: left;" colspan="1" |Pesticides ! style="align: left;" colspan="1" |10 ! style="align: left;" colspan="1" |10 ! style="align: left;" colspan="1" |6 ! style="align: left;" colspan="1" |5 ! style="align: left;" colspan="1" |{{unicode|✓}} ! style="align: left;" colspan="2" |<small>Associated with neurocognitive and HPA differences in GW vets</small> |----- ! style="align: left;" colspan="1" |Physiological Stressors ! style="align: left;" colspan="1" |14 ! style="align: left;" colspan="1" |13 ! style="align: left;" colspan="1" |7 ! style="align: left;" colspan="1" |1 ! style="align: left;" colspan="1" | ! style="align: left;" colspan="2" | |----- ! style="align: left;" colspan="1" |Chemical Weapons ! style="align: left;" colspan="1" |16 ! style="align: left;" colspan="1" |13 ! style="align: left;" colspan="1" |5 ! style="align: left;" colspan="1" |3 ! style="align: left;" colspan="1" | ! style="align: left;" colspan="2" |<small>Associated with neurocognitive and HPA differences in GW vets</small> |----- ! style="align: left;" colspan="1" |Oil Well Fires ! style="align: left;" colspan="1" |9 ! style="align: left;" colspan="1" |8 ! style="align: left;" colspan="1" |4 ! style="align: left;" colspan="1" |2 ! style="align: left;" colspan="1" |{{unicode|✓}} ! style="align: left;" colspan="2" | |----- ! style="align: left;" colspan="1" |Number of Vaccines ! style="align: left;" colspan="1" |2 ! style="align: left;" colspan="1" |2 ! style="align: left;" colspan="1" |1 ! style="align: left;" colspan="1" |1 ! style="align: left;" colspan="1" |{{unicode|✓}} ! style="align: left;" colspan="2" | |----- ! style="align: left;" colspan="1" |Anthrax Vaccine ! style="align: left;" colspan="1" |5 ! style="align: left;" colspan="1" |5 ! style="align: left;" colspan="1" |2 ! style="align: left;" colspan="1" |1 ! style="align: left;" colspan="1" | ! style="align: left;" colspan="2" | |----- ! style="align: left;" colspan="1" |Tent Heater Exhaust ! style="align: left;" colspan="1" |5 ! style="align: left;" colspan="1" |4 ! style="align: left;" colspan="1" |2 ! style="align: left;" colspan="1" |1 ! style="align: left;" colspan="1" | ! style="align: left;" colspan="2" | |----- ! style="align: left;" colspan="1" |Sand/Particulates ! style="align: left;" colspan="1" |3 ! style="align: left;" colspan="1" |3 ! style="align: left;" colspan="1" |3 ! style="align: left;" colspan="1" |1 ! style="align: left;" colspan="1" | ! style="align: left;" colspan="2" | |----- ! style="align: left;" colspan="1" |Depleted Uranium ! style="align: left;" colspan="1" |5 ! style="align: left;" colspan="1" |3 ! style="align: left;" colspan="1" |1 ! style="align: left;" colspan="1" |0 ! style="align: left;" colspan="1" | ! style="align: left;" colspan="2" | |----- |} ==Controversy== Similar syndromes have been seen as an after effect of other conflicts &mdash; for example, '[[shell shock]]' after [[World War I]], and ''[[post-traumatic stress disorder]] (PTSD)'' after the [[Vietnam War]]. A review of the medical records of 15,000 [[American Civil War]] soldiers showed that "those who lost at least 5% of their company had a 51% increased risk of later development of cardiac, gastrointestinal, or nervous disease."<ref name="Enserink2001">{{cite doi|10.1126/science.291.5505.812}}</ref> A November 1996 article in the [[New England Journal of Medicine]] found no difference in death rates, hospitalization rates or self-reported symptoms between Persian Gulf veterans and non-Persian Gulf veterans. This article was a compilation of dozens of individual studies involving tens of thousands of veterans. The study did find a statistically significant elevation in the number of traffic accidents suffered by Gulf War veterans.<ref>{{cite journal |author=Campion EW |title=Disease and suspicion after the Persian Gulf War |journal=N. Engl. J. Med. |volume=335 |issue=20 |pages=1525–7 |year=1996 |month=November |pmid=8890106 |doi=10.1056/NEJM199611143352010}}</ref> An April, 1998 article in Emerging Infectious Diseases similarly found no increased rate of hospitalization and better health overall for veterans of the Persian Gulf War vs. Veterans who stayed home.<ref name=pmid_9621191>{{cite journal |author=Knoke JD, Gray GC |title=Hospitalizations for unexplained illnesses among U.S. veterans of the Persian Gulf War |journal=Emerging Infect. Dis. |volume=4 |issue=2 |pages=211–9 |year=1998 |pmid=9621191 |pmc=2640148 |doi= 10.3201/eid0402.980208}}</ref> Despite these studies, on November 17, 2008 a congressionally appointed committee called the Research Advisory Committee on Gulf War Veterans' Illnesses, staffed with independent scientists and veterans appointed by the Department of Veterans Affairs, announced that the syndrome is a distinct physical condition. The committee recommended that Congress increase funding for research on Gulf War veterans' health to at least $60 million per year.<ref name = CNN/> In January 2006, a study led by Melvin Blanchard and published by the ''[[Journal of Epidemiology]]'', part of the "National Health Survey of Gulf War-Era Veterans and Their Families", stated that veterans deployed in the Persian Gulf War had nearly twice the prevalence of chronic multisymptom illness, a cluster of symptoms similar to a set of conditions often called Gulf War Syndrome.<ref>{{cite web | url = http://record.wustl.edu/news/page/normal/6377.html | title = Study finds multisymptom condition is more prevalent among Persian Gulf vets | date = 2006-01-20 | last = Purdy | first = MC | accessdate = 2012-05-09 | publisher = [[Washington University in St. Louis]] }}</ref> ==See also== *[[Environmental issues with war]] ==References== {{Reflist|30em}} ==External links== * [http://www1.va.gov/rac-gwvi/ Research Advisory Committee on Gulf War Veterans' Illnesses] * [http://www.vmwusa.org/ Veterans of Modern Warfare] * [http://91outcomes.com/ 91 Outcomes.com] - News for Gulf War veterans * [http://www.ngwrc.org/ National Gulf War Resource Center] * [http://www.gulflink.org/ Desert Storm Battle Registry] * ''Conspiracy Test: Gulf War Illness'' investigative report - [http://www.youtube.com/watch?v=jhvdkdMFVJQ part 1], [http://www.youtube.com/watch?v=uErdz5NYmI4 2], [http://www.youtube.com/watch?v=PD_hR__sHzk 3], [http://www.youtube.com/watch?v=eBZ-ZpCExi8 4], [http://www.youtube.com/watch?v=OwFQJj8Zbdg 5] * {{dmoz|Society/Military/Veterans/Issues/Health/Gulf_War_Illness/}} {{Gulf War}} {{DEFAULTSORT:Gulf War Syndrome}} [[Category:Gulf War syndrome| ]] [[Category:Genetic disorders with no OMIM]] [[Category:Immune system disorders]] [[Category:Military personnel]] [[Category:Neurological disorders]] [[Category:Syndromes]] [[ar:مرض حرب الخليج]] [[de:Golfkriegssyndrom]] [[es:Síndrome del Golfo]] [[fr:Syndrome de la guerre du Golfe]] [[it:Sindrome della guerra del Golfo]] [[nl:Golfsyndroom]] [[ja:湾岸戦争症候群]] [[pt:Síndrome da Guerra do Golfo]] [[sl:Zalivski sindrom]] [[fi:Persianlahden oireyhtymä]] [[sv:Gulfkrigssyndromet]]'