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'{{POV|date=December 2009}} {{Infobox Disease |Name = Gulf War illness |Image = Pyridostigmine.svg |Caption = pyridostigmine, a nerve agent antidote <br /> 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) affects [[veterans]] and civilians who were near conflicts during or downwind of a [[chemical weapons]] depot demolition, after the 1991 [[Gulf War]].<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> A wide range of acute and chronic symptoms have included [[fatigue (physical)|fatigue]], loss of muscle control, [[headache]]s, dizziness and loss of balance, memory problems, muscle and [[Arthralgia|joint pain]], [[indigestion]], skin problems, [[immune system]] problems, and [[birth defects]].<ref>University of Virginia. [http://www.healthsystem.virginia.edu/uvahealth/adult_environ/gulf.cfm Gulf War Syndrome]</ref> Roughly one in four of the 697,000 veterans who served in the first Gulf War are afflicted with the controversial disorder, a condition with serious consequences.<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> Exposure to toxic chemicals is the cause of the illness. Several specific causes have been investigated, including [[pyridostigmine bromide]] nerve gas antidote, [[organophosphate]] pesticides, chemical weapons, and [[depleted uranium]]. 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]]. Antidote pills given to protect troops from [[nerve agents]] and insect repellents used during deployment were most closely linked. Exposure to the destruction of the [[Khamisiyah|Khamisiyah weapons depot]], where large quantities of the chemical weapon [[sarin]] was stored, is negatively correlated with motor speed.<ref name=Toomey>Toomey ''et al'' (2009) "Neuropsychological functioning of U.S. Gulf War veterans 10 years after the war" ''J Int Neuropsychol Soc'' PMID 19640317</ref> Epidemiological evidence is consistent with increased risk of birth defects in the offspring of persons exposed to depleted uranium.<ref name="Hindin">Hindin, R. ''et al.'' (2005) [http://www.ehjournal.net/content/4/1/17 "Teratogenicity of depleted uranium aerosols: A review from an epidemiological perspective,"] ''Environmental Health,'' vol. 4, pp. 17. [http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1242351 at PubMed]</ref> Methods of preventing or treating Gulf War syndrome vary. While the treatment of sarin exposure has been studied,<ref name=Schecter>Schecter, WP (2004) "Cholinergic symptoms due to nerve agent attack: a strategy for management." ''Anesthesiol Clin North America'' '''22'''(3):579-90. PMID 15325720</ref> other [[acetylcholinesterase inhibitor]]s such as pyridostigmine bromide and organophosphate insect repellents may or may not involve similar management. [[Uranium]] can be decontaminated from steel surfaces<ref name=Francis>Francis, A.J. (2005) "Decontamination of uranium-contaminated steel surfaces by hydroxycarboxylic acid with uranium recovery." ''Environ Sci Technol'' '''39'''(13):5015-21. PMID 16053105</ref> and aquifers.<ref name=Wu>Wu, W.M. ''et al'' (2006) "Pilot-scale in situ bioremedation of uranium in a highly contaminated aquifer. 2. Reduction of u(VI) and geochemical control of u(VI) bioavailability." ''Environ Sci Technol'' '''40'''(12):3986-95. PMID 16830572</ref> Diplomatic reconciliation is a means of prevention of some mental effects.<ref name=Curle>Curle, A. (1997) "Public mental health. III: Hatred and reconciliation." ''Med Confl Surviv'' '''13'''(1):37-47. PMID 9080785</ref><ref name=Jentleson>Jentleson, B.W. (1996) [http://www.escholarship.org/uc/item/2tp1m760 "Preventive Diplomacy and Ethnic Conflict: Possible, Difficult, Necessary"] UC Berkeley Policy Paper 27, ''Institute on Global Conflict and Cooperation''</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, 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|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. National Academy of Sciences, 250,000<ref>http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12835</ref> 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>http://books.nap.edu/openbook.php?record_id=12835&page=109</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. "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>http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12835</ref> 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>http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12835</ref> 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 persistant, 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>http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12835</ref> 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>http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12835</ref> 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>[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> . A 2001 study of 15,000 U.S. combat veterans of the 1991 [[Gulf War]] 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> {|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% |} [[Image: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://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>]] {|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% || || |} 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" /> 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="ReferenceA">Page 262 (PDF page 270) of the November, 2008 U.S. Veterans Administration report</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|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]](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 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/> ===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>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 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/> [[Image:Iraq-gwi-map.jpg|left]] ===Sarin nerve agent=== 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=== [[Image: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">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 | pmid = 15205046}}</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 |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>{{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>[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> Epidemiological evidence is consistent with increased risk of birth defects in the offspring of persons exposed to DU.<ref name="Hindin" /> 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 |pmc=1332661}}</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 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 name="autogenerated3" /> 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> Depleted uranium may have been standard ordnance in the arsenals of both sides during the [[2008 South Ossetia war]]. [[Image:Scud downed by Patriot missiles.JPEG|thumb|left|350px|Military personnel examine the remains of a Scud during 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> ====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/> ====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 [[Veterans Administration]] review committee. ====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> ==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> Management of potentially comorbid toxic exposures requires awareness of the toxins involved.<ref name=Schecter /> Exposure to the destruction of the [[Khamisiyah|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" /> and uranium exposure has also been associated with increased cancer rates.<ref name="ajph.org">[http://www.ajph.org/cgi/content/full/92/9/1410 The History of Uranium Mining and the Navajo People]</ref><ref>[http://www.ehponline.org/members/2001/109p305-309mulloy/mulloy-full.html Lung Cancer in a Nonsmoking Underground Uranium Miner]</ref><ref>[http://content.nejm.org/cgi/content/abstract/310/23/1481 Uranium mining and lung cancer in Navajo men]</ref><ref> [http://sfaa.metapress.com/app/home/contribution.asp?referrer=parent&backto=issue,8,11;journal,65,231;linkingpublicationresults,1:113218,1 Navajo Uranium Workers and the Effects of Occupational Illnesses: A Case Study]</ref><ref> [http://www.joem.org/pt/re/joem/abstract.00043764-200003000-00008.htm Uranium Mining and Lung Cancer Among Navajo Men in New Mexico and Arizona, 1969 to 1993]</ref><ref>[http://www.chestjournal.org/content/81/4/449.abstract Lung cancer among Navajo uranium miners.]</ref> {{Expand section|date=January 2010}} ==Management== Diplomatic reconciliation is one means of prevention,<ref name=Curle /><ref name=Jentleson /> beyond battlefield air quality management, which often conflicts with established tactical policy. For example, most organized armies practice "secure and hold" tactics which require occupation of areas before they can be decontaminated. ===Acetylcholinesterase inhibitors=== ====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=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) {{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 exposure=== [[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>Spagnul, A ''et al'' (2009) "Calixarene-entrapped nanoemulsion for uranium extraction from contaminated solutions." ''J Pharm Sci'' PMID 19780139</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 /> and aquifers.<ref name=Wu /> ==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 2008 U.S. 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> 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="ReferenceA"/> No studies that have evaluated birth outcomes and birth defects among Gulf War veterans and their children have assessed whether there is any connection between reproductive outcomes and uranium exposure in the Gulf War.<ref>Page 96 (PDF page 105) of the November, 2008 U.S. Veterans Administration report</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>Page 45 (PDF page 55) of the November, 2008 U.S. Veterans Administration report</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 Gulf War veterans.<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= 10.3201/eid0402.980208|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== [http://91outcomes.com 91outcomes.com] The leading Gulf War health and news site for Gulf War veterans, their advocates and their loved ones. *[[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://cdmrp.army.mil/gwirp/default.shtml/ U.S. Department of Defense-CDMRP-Gulf War Illness Research Program] A Congressionally mandated health research program focused on finding and funding the best science to improve the health and lives of veterans suffereing from Gulf War Illness. Consumer representatives suffering from Gulf War Illness serve on the program's scientific merit and overall program integration panels. ; Advocacy * [http://91outcomes.com/ 91outcomes.com] The leading health and news website for Gulf War veterans, their advocates, and their loved ones. * [http://www.ngwrc.org/ National Gulf War Resource Center] * [http://www.vmwusa.org/ Veterans of Modern Warfare] * [http://www.veteransforcommonsense.org/ Veterans for Common Sense] ; Membership Associations * [http://www.ngwrc.org/ National Gulf War Resource Center] * [http://www.vmwusa.org/ Veterans of Modern Warfare] ; Health Information * [http://91outcomes.com/ 91outcomes.com] The leading health and news website for Gulf War veterans, their advocates, and their loved ones. ; Other Information * [http://91outcomes.com/ 91outcomes.com] The leading health and news website for Gulf War veterans, their advocates, and their loved ones. * [http://www.gulflink.org/ Desert Storm Battle Registry] ; Video * ''Conspiracy Test: Gulf War Illness'' investigative report by the [[Discovery Channel]] - [http://www.youtube.com/watch?v=jhvdkdMFVJQ part 1], [http://www.youtube.com/watch?v=uErdz5NYmI4 part 2], [http://www.youtube.com/watch?v=PD_hR__sHzk part 3], [http://www.youtube.com/watch?v=eBZ-ZpCExi8 part 4], [http://www.youtube.com/watch?v=OwFQJj8Zbdg part 5] {{Gulf War}} {{DEFAULTSORT:Gulf War Syndrome}} [[Category:Gulf War syndrome| ]] [[Category:Genetic disorders]] [[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]]'