Global Policy Forum

By Debora MacKenzie

Terence Walker is one of the lucky ones. On 19 January 1991 he was with 6000 British troops at Al Jubayl in Saudi Arabia, as the first Gulf war was beginning. At around 3am there were loud bangs and flashes, and troops scrambled into gas masks as chemical detector alarms sounded. Some detectors in the area registered the nerve gas sarin, but the UK's Ministry of Defence later said that these alerts were false alarms. Since Walker returned home he has suffered from chronic diarrhoea, sweating, insomnia, muscle and stomach pain, fatigue, loss of memory and arthritis. That does not sound so lucky. But in 1997, after five years of trying, he won a full military pension on the basis of some of those symptoms. Many similarly afflicted Gulf veterans have failed.

Military pensions are awarded when someone's disability or death can be proved to have been caused by service in the armed forces. Veterans of the first Gulf conflict say that the illnesses many of them now suffer follow a characteristic pattern and have a specific cause related to what happened to them in the area, and should therefore be classified as a specific disease: Gulf war syndrome. But for more than a decade, the UK, US, Australian and Canadian governments have disputed this, claiming that their symptoms are hard to attribute and often psychological in origin.

Leaked report

Now the US authorities have changed their stance, prompted by recent American research which suggests there is a disease with a physical basis linked to chemical exposure in the Gulf. The UK government still insists there is no link. But American researchers claim the studies the British are relying on were not designed in a way that would uncover the syndrome. According to leaks of a report, which is due to be released next week by the US Department of Veterans Affairs' Research Advisory Committee on Gulf War Veterans' Illnesses, "a substantial proportion of Gulf war veterans are ill with multisystem conditions not explained by wartime stress or psychiatric illness".

Some 30% of Gulf veterans suffer from various combinations of fatigue, muscle and joint pains, headache, and gut and cognitive problems - over and above non-Gulf veterans, the report says. It blames damage caused by nerve gas and its antidotes, and organophosphate insecticides (OPs), which all block the enzyme that normally destroys acetylcholine, an important neural signalling chemical.

Sprayed soldiers

In the UK, an independent inquiry, funded anonymously and headed by Lord Lloyd of Berwick, is investigating the illness. Testimony to the inquiry reviewed by New Scientist shows that British troops were exposed to the same chemicals as the Americans. Soldiers' tents were sprayed with locally bought insecticides to ward off disease-carrying sandflies and mosquitoes, and Walker testified that some soldiers were even sprayed directly.

Like most troops, Walker also took pyridostigmine, a drug meant to block effects of nerve gas but which can also cause some of the same effects. And evidence is mounting that at Al Jubayl or elsewhere in the battle zone he could have been exposed to sarin. On its website, the UK's Ministry of Defence admits that Gulf veterans "have more symptoms and are suffering more severely from them". But it states "the consensus of the international medical and scientific community is that there is insufficient evidence to enable this ill health to be characterised as a unique illness or syndrome".

Large cheques

Psychiatrist Simon Wessely of King's College London, who heads much of the UK's research efforts into illnesses suffered by Gulf war veterans, told the Lloyd inquiry: "What is important is that there is a Gulf war health effect. The Gulf war syndrome debate is really just of academic importance." Wessely says the veterans get the same symptoms as similar groups who did not go to the Gulf, "just more of them".

But as British and US witnesses told the Lloyd inquiry, if there were recognised definitions for a service-induced syndrome, many Gulf veterans - some 60,000 in the US, and several thousand in the UK - would be able to claim pensions more easily. Clearly, admitting the existence of a syndrome will cost money. Nicholas Soames, an opposition MP, who was Armed Forces Minister from 1994 to 1997 when the UK's investigations of Gulf war illnesses began, told Lloyd: "The government of course are very reluctant to admit responsibility for something which is going to involve them in writing large cheques, and nowhere more so than the Ministry of Defence because there are so many potential claimants."

False positives

Epidemiologist Robert Haley of the University of Texas in Dallas blames the US government's past denial of a syndrome on a "10-year misadventure". Expecting many cases of post-traumatic stress disorder (PTSD) the US authorities tested large groups of veterans, using questionnaires designed to screen for PTSD. Some 20% tested positive. Roughly the same percentage were reporting ill health, so the authorities blamed the mysterious illnesses on stress, Haley says.

However, the tests they used were designed to pick out possible cases for psychiatric evaluation, not to give a definitive diagnosis, and normally give a false positive rate around 20%. Follow-up investigations in the US and UK later showed only some 3% really had PTSD, not nearly enough to account for the sick veterans. Yet the conviction that Gulf illness is somehow caused by stress has persisted. "What we should have done was what we do for every new disease: establish a case definition," Haley says. This means finding out what unusual symptoms people are reporting, then looking for those symptoms in larger groups to see if they are widespread, associated with particular histories, or if they occur in characteristic clusters.

With funding from billionaire businessman and one-time independent presidential candidate Ross Perot, Haley did just that. "When we talked to the veterans, certain symptoms really stood out," he says. He then constructed a questionnaire to find out if two separate groups of veterans had similar symptoms. Asking specific questions was crucial. "If you ask people, do you have aches and pains, people will say yes. But if you ask, do you have severe joint pains that keep you awake and last all day and for months, healthy people don't. Gulf veterans do."

Multisystem condition

Haley's studies revealed three clusters of symptoms (see table), which he thinks are variants of the same disease (New Scientist print edition, 29 March 2003). His findings have been verified by other labs. Han Kang at the Department of Veterans Affairs (VA) in Washington DC found the same clusters when he compared 10,000 Gulf to 9000 non-Gulf veterans. All were more frequent in Gulf veterans, and the most severe syndrome did not appear in non-Gulf veterans. Similar studies by Keiji Fukuda and colleagues at the Centers for Disease Control in Atlanta concluded "a chronic multisystem condition was significantly associated with deployment to the Gulf".

Studies of British veterans by Nicola Cherry, now in Canada at the University of Alberta in Edmonton, found a neurological syndrome significantly associated with the direct handling of OPs very much like Haley's syndrome 2; she did not ask about nerve gas. Another cluster with numbness, tingling and widespread pain seemed to correlate with heavy use of DEET insect repellent and bad reactions to anti-chemical weapons tablets, like Haley's syndrome 3. Wessely's group uncovered clusters of symptoms but concluded that they did not qualify as unique syndromes. Haley says this was because the study did not ask about 12 of the 23 symptoms he found were crucial, and did include five others that he says obscured the pattern.

No single cause

Other researchers who found no such clusters asked less specific questions. A study of reproductive health of 42,818 male Gulf veterans by Rebecca Simmons and colleagues at the London School of Hygiene and Tropical Medicine also asked them to write down their other symptoms. It was published in July, the week the Lloyd inquiry began, accompanied by a press release stating it had found no syndrome. But Simmons told New Scientist that it was not designed to find unusual clusters of symptoms. Wessely told New Scientist: "There is not one single cause for the ill health," adding that he believes we may never fully know what happened to the people who became ill.

Wessely asked both Gulf and non-Gulf veterans about 50 standard symptoms. "Gulf veterans reported every symptom twice as often," he told the Lloyd inquiry. If there were a unique Gulf syndrome, some would be relatively more frequent in the Gulf group. "But they are just experiencing more ill health. There is no unique syndrome here."

Wessely favours psychological explanations for Gulf war illnesses. The only thing that could have affected so many different people, he says, was stress, especially anxiety about chemical weapons, misinformation about Gulf war syndrome afterwards, and the many vaccinations Gulf troops received. His team found the more vaccine Gulf, but not non-Gulf veterans, received the more likely they are to be ill. Haley says the questions in Wessely's study were too vague to distinguish between a real syndrome and people who have, say, occasional dizziness or joint pain. He says this will confound efforts to uncover a meaningful pattern behind the veterans' symptoms.

Nerve gas link

Wessely counters that Haley's case definitions were not derived from large comparisons of Gulf to non-Gulf veterans. Haley says, without a precise case definition, such comparisons will only uncover non-specific increases in symptoms and do little to suggest causes. Haley's work has allowed precisely that exploration. Syndrome 2, the worst of the three, correlates strongly with exposure to OPs and suspected exposure to the nerve gas sarin.

Furthermore, Haley's team and two other groups have independently found specific neural damage that could explain some of the veterans' symptoms. These veterans also had lower levels of the variant of an enzyme, paraoxonase, which breaks down sarin-like compounds. The nerve gas link is crucial to the change of heart in the US. British and US authorities have denied there was any damage to troops as no soldiers showed the classic symptoms of acute exposure. But it now appears that very small, repeated exposure can also harm. Experiments on animals have shown that exposure to doses of sarin too low to cause observable immediate effects causes delayed, long-term nerve and brain damage similar to that seen in veterans.

"False" alarms

It now appears there was plenty of sarin about. The US Department of Defense told a Senate investigation in 1994 that each of the 14,000 chemical weapons alarms around the troops went off on average two or three times a day during allied aerial bombardment of Iraq - a total of between 1 and 2 million alarms. "All alarms were said to be false," James Tuite, a consultant to the investigation, told the Lloyd inquiry. But UN inspectors later found Iraqi chemical weapons dumps damaged by bombing, upwind of the Kuwait-Saudi border - where troops were most likely to later become ill (see map).

In particular, the blowing up of a large chemical weapons dump at Khamisiyah in March 1991 - after the fighting was over and chemical weapons detectors had been removed - created a plume of gas, which would have contained sarin and which could have affected at least 100,000 Allied soldiers, possibly far more. A Congressional study released in June this year found that the plume was "significantly higher" (taller) than the DoD claimed in its analysis in 2000, so the chemicals in it could have drifted over a wider area. Meanwhile, it found that two epidemiological surveys based on that analysis, which found no ill health linked to sarin exposure, were fundamentally flawed. The VA agreed. The UK's prime minister, Tony Blair, has stated that there is no use holding an official government inquiry - which Lloyd's was not - until all the research is in. Gulf war veterans say that now may be time.

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