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'{{POV}} [[Image:DesertStormDestroyedIraqiScud.jpg|thumb|right|Military personnel examine the remains of a Scud during the Gulf War.]] '''Gulf War syndrome''' (GWS) or '''Gulf War illness''' (GWI) describes a range of [[illness|illnesses]] reported by combat [[veterans]] of the February, 1991 [[Gulf War]] typified by a range of [[medically unexplained symptoms]].<ref>Iversen A, Chalder T, Wessely S. "Gulf War Illness: lessons from medically unexplained symptoms." Clin Psychol Rev. 2007 Oct;27(7):842-54.</ref><ref>Gronseth GS. "Gulf war syndrome: a toxic exposure? A systematic review." Neurol Clin. 2005 May;23(2):523-40.</ref> Symptoms attributed to this syndrome have been wide-ranging and include acute and chronic ailments. These include [[fatigue (physical)|fatigue]], loss of muscle control, [[headache]]s, dizziness and loss of balance, memory problems, muscle and [[Arthralgia|joint pain]], [[indigestion]], skin problems.<ref>University of Virginia. [http://www.healthsystem.virginia.edu/uvahealth/adult_environ/gulf.cfm Gulf War Syndrome]</ref> Since the end of the Gulf War, the [[United States Department of Veterans Affairs|U.S. Department of Veterans Affairs]] (VA) and the [[Ministry of Defence (United Kingdom)|British Ministry of Defence]] have conducted numerous studies on Gulf War Veterans. While the exact source of veteran health complaints remains unknown, several possible causes have been investigated, including [[pyridostigmine bromide]] nerve gas antidote, [[organophosphate]] [[pesticide]]s, [[chemical weapons]], and [[depleted uranium]]. Causes which have been ruled out include [[post traumatic stress disorder]], [[vaccinations]], and [[Kuwaiti oil fires|smoke from oil well fires]].<ref name=FedReport/> In the United States in 2008, the federally mandated Research Advisory Committee on Gulf War Veterans' Illnesses released a 452-page report indicating that roughly 1 in 4 of the 697,000 veterans who served in the first Gulf War are afflicted with the disorder. The report stated that "scientific evidence leaves no question that Gulf War illness is a real condition with real causes and serious consequences for affected veterans."<ref name=FedReport>[http://sph.bu.edu/insider/images/stories/resources/annual_reports/GWI%20and%20Health%20of%20GW%20Veterans_RAC-GWVI%20Report_2008.pdf Gulf War Illness and Health of Gulf War Veterans]</ref> The report implicated exposure to toxic chemicals as the cause of the illness, and concluded that use of pills given to protect troops from effects of nerve agents, and pesticide use during deployment were the two conditions most closely linked to illness.<ref name=FedReport/> Exposure to the destruction of the [[Khamisiyah|Khamisiyah weapons depot]], where large quantities of the neurotoxin [[sarin]] was stored, is negatively correlated with motor speed.<ref>Toomey ''et al' (2009) "Neuropsychological functioning of U.S. Gulf War veterans 10 years after the war" ''J Int Neuropsychol Soc'' PMID 19640317</ref> ==Classification== Medial ailments associated with Gulf War Syndrome has been recognized by both the US Department of Defense, Department of Veterans Affairs, and Veterans Administration.<ref>[http://www.publichealth.va.gov/exposures/gulfwar/associated_illnesses.asp Gulf War Veterans' Illnesses: Illnesses Associated with Gulf War Service]</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” was used, as well as ICD-9 code V65.5 <ref>Department of Veterans Affairs [http://www.hanford.gov/hanford/files/VA_GuidetoGulfWarVeteransHealth.pdf A Guide to Gulf War Veterans' Health]</ref> ==Signs and symptoms== [[Image:DesertStormMap v2.svg|thumb|right|Summary of the [[Operation Desert Storm]] offensive ground campaign, February 24-28, 1991, by nationality (click for detail).]] About one-fourth of the 697,000 U.S. servicemen and women in the first Gulf War have shown symptoms related to Gulf War Syndrome. U.S. and 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>[http://www1.va.gov/rac-gwvi/docs/Minutes_Dec2005.pdf Research Advisory Committee on Gulf War Veterans’ Illnesses] December 12-13, 2005 Committee Meeting Minutes (page 78)</ref> French troops also served to the North and West of all other combat troops, away and upwind of major combat engagements<ref>[http://www1.va.gov/rac-gwvi/docs/Minutes_Dec2005.pdf Research Advisory Committee on Gulf War Veterans’ Illnesses] December 12-13, 2005 Committee Meeting Minutes (page 68)</ref> . {|class="wikitable sortable" style="font-size:97%; text-align:right;" |+Excess prevalence of general [[symptom]]s<ref>[http://www1.va.gov/rac-gwvi/docs/Minutes_Dec2005.pdf Research Advisory Committee on Gulf War Veterans’ Illnesses] December 12-13, 2005 Committee Meeting Minutes (page 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>[http://www1.va.gov/rac-gwvi/docs/Minutes_Dec2005.pdf Research Advisory Committee on Gulf War Veterans’ Illnesses] December 12-13, 2005 Committee Meeting Minutes (page 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% || || |} ==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|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>[http://www1.va.gov/rac-gwvi/docs/ReportandRecommendations_2004.pdf Research Advisory Committee on Gulf War Veterans’ Illnesses 2004 Report]</ref> ===Pyridostigmine bromide nerve gas antidote=== The US military issued [[pyridostigmine bromide]] pills, PB, to protect against exposure to nerve gas agents such as [[sarin]] and [[soman]]. PB was used to pretreat nerve agent poisoning and 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 dosed 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 has recently been approved.<ref>PBS Frontline. [http://www.pbs.org/wgbh/pages/frontline/shows/syndrome/analysis/pyribrom.html 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. 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/> ===Pesticides=== The use of [[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>U.S. Department of Defense, Office of the Special Assistant to the Undersecretary of Defense (Personnel and Readiness) for Gulf War Illnesses Medical Readiness and Military Deployments. Environmental Exposure Report: Pesticides Final Report. Washington, D.C. April 17, 2003.</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>Krengel M, Sullivan K. Neuropsychological Functioning in Gulf War Veterans Exposed to Pesticides and Pyridostigmine Bromide. Fort Detrick, MD: U.S. Army Medical Research and Materiel Command; August, 2008. 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 follownf 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/> ===Chemical weapons=== [[Image:Iraq-gwi-map.jpg|right]] 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=0763731706 }}</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=0833026801 }}</ref> Gulf War veterans were exposed to a number of sources of these compounds, including [[nerve gas]] and [[pesticides]].<ref>{{cite web|url=http://news.scotsman.com/topics.cfm?tid=847&id=1311632004 |title=Campaigners hail 'nerve gas link' to Gulf War Syndrome - Scotsman.com News |publisher=News.scotsman.com |date= |accessdate=2009-11-24}}</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> [http://www.gulfweb.org/report/riegle1.html The Riegle Report]</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>[http://www.fas.org/irp/gulf/cia/970409/cia_wp.html ''Khamisiyah: A Historical Perspective on Related Intelligence'' by the Persian Gulf War Illnesses Task Force (9 April 1997)]</ref> Recent studies have confirmed earlier suspicions that exposure that 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>Beatrice Alexandra Golomb.[http://www.pnas.org/content/105/11/4295.short ''Acetylcholinesterase inhibitors and Gulf War illnesses'']</ref><ref>Navy Times. [http://www.navytimes.com/news/2008/03/military_gulfwar_illness_031108w/ Review says chemicals caused Gulf War illness]</ref> ===Depleted uranium=== {{POV-section}} [[Image:GWI DU map.gif|thumb|right|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">Global Security. ``[http://www.globalsecurity.org/military/systems/munitions/du.htm Depleted Uranium]``</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. The use of DU in [[munitions]] is controversial because of questions about potential long-term health effects.<ref name=MillerMcClain>{{cite journal | author = Miller AC, McClain D. | title = A review of depleted uranium biological effects: in vitro and in vivo studies | journal = ''Rev Environ Health'' | year = 2007 Jan-Mar | volume = 22 | issue = 1 | pages = 75–89 | 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 journal | title = Depleted and natural uranium: chemistry and toxicological effects | author = E. S. Craft, A. W. Abu-Qare, M. M. Flaherty, M. C. Garofolo, H. L. Rincavage, M. B. Abou-Donia | journal = ''Journal of Toxicology and Environmental Health Part B: Critical Reviews'' | year = 2004 | volume = 7 | issue = 4 | pages = 297–317 | doi = 10.1080/10937400490452714}}</ref> 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= |page=17 |year= 2005|pmid=16124873 |doi=10.1186/1476-069X-4-17}}</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> and potentially [[carcinogen]]ic<ref>[http://www.gulflink.osd.mil/medsearch/Cancer/DOD122.shtml]{{Dead link|date=April 2008}}</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>[http://www.deploymentlink.osd.mil/du_library/du_ii/du_ii_tabl1.htm ]{{dead link|date=November 2009}}</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>{{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}}</ref> A 2001 study of 15,000 February 1991 U.S. [[Gulf War]] combat veterans and 15,000 control veterans found that the Gulf War veterans were 1.8 (fathers) to 2.8 (mothers) times more likely to have children with birth defects.<ref>{{cite journal | author = Kang, H., ''et al.' | year = 2001 | url = http://www.annalsofepidemiology.org/article/PIIS1047279701002459/abstract | title = Pregnancy Outcomes Among U.S. Gulf War Veterans: A Population-Based Survey of 30,000 Veterans | journal = ''Annals of Epidemiology'' | volume = 11 | issue = 7 | pages = 504–511 | pmid = 11557183 | doi = 10.1016/S1047-2797(01)00245-9 }}</ref> After examination of children's medical records two years later, the birth defect rate increased by more than 20%: <blockquote>"Dr. Kang found that male Gulf War veterans reported having infants with likely birth defects at twice the rate of non-veterans. Furthermore, female Gulf War veterans were almost three times more likely to report children with birth defects than their non-Gulf counterparts. The numbers changed somewhat with medical records verification. However, Dr. Kang and his colleagues concluded that the risk of birth defects in children of deployed male veterans still was about 2.2 times that of non-deployed veterans."<ref>Department of Veterans Affairs (2003) [http://web.archive.org/web/20060929095251/http://www1.va.gov/gulfwar/docs/GulfWarNov03.pdfwww1.va.gov/gulfwar/docs/GulfWarNov03.pdf "Q's & A's - New Information Regarding Birth Defects,"] ''Gulf War Review'' '''12'''(1), p. 10.</ref></blockquote> In a study of U.K. troops, "Overall, the risk of any malformation among pregnancies reported by men was 50% higher in Gulf War Veterans (GWV) compared with Non-GWVs."<ref>Doyle, P., ''et al.'' (2004) [http://ije.oupjournals.org/cgi/content/full/33/1/74 "Miscarriage, stillbirth and congenital malformation in the offspring of UK veterans of the first Gulf war,"] ''International Journal of Epidemiology,'' '''33'''(1), pp. 74-86; PMID 15075150.</ref> 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 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 name="autogenerated3" /> [[Image:Basrah birth defects.svg|thumb|right|250px|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://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 097361532X</ref>]] 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. The three studies most representative of Gulf War era veterans in the U.S. and U.K. have all indicated significant excess rates of birth defects in children of Gulf War veterans. News articles have reported that rates of cancer and birth defects in Iraq increased dramatically during the 1990s, specifically in regions where the greatest quantity of [[depleted uranium]] was used in the Gulf War. Conference reports describing an increased incidence of congenital anomalies in Basrah and increased numbers of cancer cases, both in Iraqi military personnel who served in the war and in four Iraqi hospitals, lend some support to these contentions.<ref name="FedReport" /> ===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>[http://www1.va.gov/rac-gwvi/docs/Minutes_Dec2005.pdf Research Advisory Committee on Gulf War Veterans’ Illnesses] December 12-13, 2005 Committee Meeting Minutes (pages 148, 154, 156)</ref> ===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 these munitions were deployed to four locations in Iraq.<ref> Anthony H. Cordesman. Iraq and the War of Sanctions: Conventional Threats and Weapons of Mass Destruction</ref> During Operation Desert Storm, 41% of U.S. combat soldiers and 75% of UK combat soldiers were vaccinated against [[anthrax]].<ref>[http://www1.va.gov/rac-gwvi/docs/Minutes_Dec2005.pdf Research Advisory Committee on Gulf War Veterans’ Illnesses] December 12-13, 2005 Committee Meeting Minutes (page 73.)</ref> Like all vaccines, the early 1990s version of the [[anthrax vaccine]] was a source of several [[adverse drug reaction|side effect]]s. Reactions included local skin irritation, some lasting for weeks or months.<ref>[http://www.gao.gov/new.items/d0192t.pdf GAO-01-92T Anthrax Vaccine: Preliminary Results of GAO's Survey of Guard/Reserve Pilots and Aircrew Members<!-- Bot generated title -->]</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>[http://orig.clarionledger.com/news/0105/16/m11.html The Clarion-Ledger: Mississippi's News Source<!-- Bot generated title -->]</ref> While recent studies have demonstrated the vaccine’s is highly reactogenic <ref> Pharmacoepidemiology and Drug Safety.Short-term reactogenicity and gender effect of anthrax vaccine: analysis of a 1967-1972 study and review of the 1955-2005 medical literature</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/> ==Diagnosis== 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>Kelsall ''et al'' (2009) "Physical, psychological, and functional comorbidities of multisymptom illness in Australian male veterans of the 1991 Gulf War," ''Am J Epidemiol'' '''170'''(8):1048-56. PMID 19762370</ref> {{Expand|date=December 2009}} ==Management== Management of the toxic exposures requires awareness of their constituent parts. Diplomatic reconciliation is the primary means of prevention.<ref>Curle, A. (1997) "Public mental health. III: Hatred and reconciliation." ''Med Confl Surviv'' '''13'''(1):37-47</ref> ===Nerve agent antidotes and insect repellents=== 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=Golomb>Golomb, B. (2008) [http://www.pnas.org/content/105/11/4295.abstract "Acetylcholinesterase inhibitors and Gulf War illnesses"] ''Proc Natl Acad Sci''; [http://www.reuters.com/article/latestCrisis/idUSN10593482 Reuters]; [http://www.medpagetoday.com/PublicHealthPolicy/MilitaryMedicine/tb/8671 ''MedPageToday.com'']</ref> A federal report released in November, 2008, agreed, stating that exposure to two substances "are causally associated with Gulf War illness":<ref>[http://www.cnn.com/2008/HEALTH/11/17/gulf.war.illness.study/index.html "Gulf War illness is real, new federal report says" on CNN]</ref> *[[pyridostigmine bromide]], an [[acetylcholinesterase inhibitor]] intended to protect against nerve agents.<ref>[http://www1.va.gov/rac-gwvi/docs/Minutes_Dec2005.pdf Research Advisory Committee on Gulf War Veterans’ Illnesses] December 12-13, 2005 Committee Meeting Minutes</ref>, and *[[pesticide]]s and [[insect repellent]]s (often acetylcholinesterase inhibitors) ===Nerve gas=== Exposure to [[nerve gas]] is a possible comorbidity. Chemical weapons classified as [[nerve gases]] are also strong acetylcholinesterase inhibitors. ===Depleted uranium=== The use of [[depleted uranium]] in [[munitions]] is controversial because of questions about potential long-term health effects.<ref name=MillerMcClain /> 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 /> It is weakly radioactive and remains so because of its long [[half-life]]. 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">Mitsakou C, Eleftheriadis K, Housiadas C, Lazaridis M [http://www.ncbi.nlm.nih.gov/pubmed/12705453 Modeling of the dispersion of depleted uranium aerosol.] 2003 Apr, Retrieved January 15, 2009</ref> During a three week period of conflict in 2003 [[Iraq]], 1,000 to 2,000 tonnes of DU munitions were used, mostly in cities.<ref name="gaurdian2003">Paul Brown, [http://www.guardian.co.uk/uk/2003/apr/25/internationaleducationnews.armstrade Gulf troops face tests for cancer] ''guardian.co.uk'' 25 April 2003, Retrieved February 3, 2009</ref> The actual acute and chronic toxicity of DU is also a point of medical controversy. Multiple studies using cultured cells and laboratory rodents suggest the possibility of [[leukemia|leukemogenic]], [[gene]]tic, [[reproduction|reproductive]], and [[neurological]] effects from chronic exposure.<ref name=MillerMcClain /> A 2005 [[epidemiology]] review concluded: "In aggregate the human epidemiological evidence is consistent with increased risk of birth defects in offspring of persons exposed to DU."<ref name="Hindin" /> The [[World Health Organization]] states that no consistent risk of reproductive, developmental, or carcinogenic effects have been reported in humans.<ref>{{cite web |url= http://www.who.int/mediacentre/factsheets/fs257/en/ |title= Depleted uranium |author= World Health Organization }}</ref><ref>{{cite web |url= http://www.who.int/ionizing_radiation/env/du/en/index.html |title= Depleted uranium |author= World Health Organization }}</ref> However, the objectivity of this report has been called into question.<ref>{{cite web |url= http://www.bbc.co.uk/radio4/today/reports/international/uranium_20061101.shtml |title= Depleted Uranium Weapons |author= Angus Stickler, BBC }}</ref> ==Epidemiology== Epidemiologic studies have been performed evaluating many suspected 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 Veterans Administration report.<ref>[http://sph.bu.edu/insider/images/stories/resources/annual_reports/GWI%20and%20Health%20of%20GW%20Veterans_RAC-GWVI%20Report_2008.pdf Gulf War Illness and Health of Gulf War Veterans] (page 220-221)</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>[http://sph.bu.edu/insider/images/stories/resources/annual_reports/GWI%20and%20Health%20of%20GW%20Veterans_RAC-GWVI%20Report_2008.pdf Gulf War Illness and Health of Gulf War Veterans] (page 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 Persian Gulf vets vs. non-Persian Gulf vets.<ref> New England Journal of Medicine. Disease and Suspicion after the Persian Gulf War. Volume 335:1525-1527, November 14, 1996</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= |url= http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2640148/pdf/9621191.pdf}}</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>News Services, "Gulf War Syndrome Is Real, Panel Concludes", ''[[Washington Post]]'', November 18, 2008, p. 14.</ref> 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>[http://record.wustl.edu/news/page/normal/6377.html Record: Study finds multisymptom condition is more prevalent among Persian Gulf vets<!-- Bot generated title -->]</ref> ==See also== *''[[Beyond Treason]]'' an 89-minute 2005 documentary that covers the Gulf War syndrome. *[[Environmental issues with war]] ==References== {{Reflist|2}} ==External links== ; Research * [http://www1.va.gov/rac-gwvi/ Research Advisory Committee on Gulf War Veterans' Illnesses], publishers of the 2008 ''[http://www1.va.gov/rac-gwvi/docs/GWIandHealthofGWVeterans_RAC-GWVIReport_2008.pdf Gulf War Illness and the Health of Gulf War Veterans: Scientific Findings and Recommendations]'' (7.4 MB PDF) * [http://www.unep.org/pdf/iraq_ds_lowres.pdf Post Conflict Assessment Iraq] by the [[United Nations Environment Programme]] (2003 PDF; undergoing revision[http://www.bandepleteduranium.org/en/docs/77.pdf][http://www.un.org/News/Press/docs/2008/ga10792.doc.htm]) ;Associations * [http://www.gulfwarvets.com/ American Gulf War Veterans Association] * [http://www.ngwrc.org/ National Gulf War Resource Center] * [http://www.vmwusa.org/ Veterans of Modern Warfare] {{DEFAULTSORT:Gulf War Syndrome}} [[Category:Gulf War syndrome| ]] [[Category:Immune system disorders]] [[Category:Military personnel]] [[Category:Neurological disorders]] [[Category:Syndromes]] [[Category:Gulf War]] [[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 syndrooma]] [[sv:Gulfkrigssyndromet]]'