Assailed by an old enemy

The first UK research into so-called Gulf war syndrome shows that symptoms have blighted many lives. But GWS does not exist as a unique condition. Simon Wessely reports

The Gulf war of 1991 seemed to be that elusive military phenomenon - a swift, successful and almost bloodless (for our side at least) victory. Before the war itself, Desert Storm, we were psychologically prepared for mass casualties among coalition forces. I can remember five wards of our inner-city teaching hospital being cleared to prepare for the expected influx of casualties - similar scenes were repeated in every large civilian hospital in the United Kingdom. The prognostications were grim, not least because of the fearsome chemical and biological weapons possessed by the Iraqi president, Saddam Hussein.

In the event it did not happen. The coalition forces swept to a remarkable victory. Saddam Hussein never deployed his chemical or biological weapons.

Not one casualty arrived in a civilian hospital. The troops returned heroes and the generals became stars on the US lecture circuit.

But then the script started to go wrong. About six months after the end of the war, a physician responsible for the health of a single American Air Force unit began to report strange symptoms among Gulf veterans. As the months progressed, more US veterans began to come forward with similar elusive symptoms. Rumours began to spread across newspapers and the internet. People remembered all the dangerous things that had happened in the Gulf. The first possible culprit was the smoke that spiralled into the air at the end of the war when the retreating Iraqis set fire to the Kuwait oil fields. Then people remembered the tablets they had taken to protect themselves against chemical attack, the injections to protect them against biological warfare, the pesticides to prevent diseaseI In this country we lagged about two years behind the Americans, both in our knowledge of, and response to, the possible effects of the Gulf war. The trigger here was probably the Newsnight programme broadcast on June 7 1993.

After that, fears similar to those of US soldiers gained increasing publicity. British veterans too came forward with accounts of mysterious symptoms, as well as concerns that men who had been to the Gulf were fathering children with congenital malformations. The media quickly seized upon the long list of possible causes, while the apparent unconcern and occasional incompetence of the government persuaded many that something sinister was being covered up.

It was at that time that I and colleagues at London's King's College Hospital became interested in the health of British Gulf war veterans. I had been fascinated for years by the problem of chronic fatigue syndrome, better known as ME. The reports coming from some Gulf veterans were startlingly similar to the stories I heard every week from my civilian ME patients.

There was no doubt that there were veterans who were well when they went to the Gulf and were now clearly sick. But was this sickness related to their Gulf service? There were 53,000 British servicemen and women in the Gulf, and some would be expected to get sick over time. Was there any pattern to these complaints, any unique illness?

The only way to answer these questions was to carry out an epidemiological study. Epidemiology is the study of populations, rather than individuals.

We could study a single sick soldier until we were blue in the face, but it would not enable us to answer any of those fundamental questions. Only after looking at the totality of illness across all those who went to the Gulf, and comparing that with appropriate controls, could we make progress.

We therefore designed a study in which we would compare the illnesses of a random sample of British servicemen who went to the Gulf with the illnesses of two other groups. The first group comprised troops sent on peacekeeping duties to Bosnia. The second (labelled Era), consisted of soldiers in the military at the time of the Gulf war, but who went on neither deployment. In all, 12,000 personnel were interviewed.

Such a study was expensive. Sadly, the British government did not share our view about the importance of the issue, but fortunately the American government did. Official attitudes have changed significantly since then: two other major studies are under way, both funded by the British government.

Our most significant finding was that Gulf veterans were about twice as likely to complain of symptoms such as fatigue, pain, poor sleep, headaches, memory problems, joint pains and so on as members of the control groups and twice as likely to complain of asthma, back pain, arthritis and ulcers. Those who had been to the Gulf were also between two and three times more likely to have significant symptoms of post-traumatic stress or general psychological distress. Going to the Gulf had definitely affected the health of many veterans.

But did this mean that there was a Gulf war syndrome, a collection of symptoms and/or signs unique to the servicemen who had gone to the Gulf in 1991? We found no evidence to support the existence of such a syndrome.

Identical symptoms were also found in those who had been to Bosnia, and even among the Era control group. I had already seen similar symptoms in our Camberwell ME clinic in people who had never left south London. There was nothing unique about the symptoms of Gulf veterans. They were certainly suffering, but this was not explained by a specific illness particular to them.

So were their symptoms linked to their time in the Gulf? We asked members of all three groups about a range of possible dangers they might have encountered. But no specific pattern linking any particular exposure to any particular outcome emerged. Seventy per cent of the Gulf group reported using personal pesticides, but so did 49 per cent of the Bosnia veterans, and 38 per cent of the Era servicemen and women. There was nothing to suggest any particular health problem unique to pesticide use.

But there were four hazards that stood out among the experiences of the Gulf group. These were: witnessing the burning oil wells in Kuwait after the war; taking nerve agent protective pills (Naps); being involved in chemical alerts; and wearing nuclear-biological-chemical suits to protect against chemical and/or biological warfare. Eighty per cent of those who went to the Gulf wore NBC suits at some time, 80 per cent used the Naps tablets (to protect against chemical attack), 70 per cent were involved in chemical alerts and 9 per cent believed they were exposed to actual chemical attack. Our conclusion is that the worse health of the Gulf servicemen may be partly because they experienced or remembered more hazards than did the soldiers in the control groups, rather than because they were victims of any one particular hazard.

There is one further possible culprit. All the servicemen were offered vaccinations before Desert Storm. These were partly booster jabs against the infections any traveller would be protected against and partly against two particularly awful diseases - plague and anthrax - that formed part of Saddam Hussein's biological weapons.

We found there was an increase in ill health in those who received vaccines against biological warfare (plague, anthrax), together with pertussis, the latter given to speed up the immunological response to anthrax. This was not a large effect, but it was significant. Receiving multiple vaccinations was also associated with a modest, but significant, increase in ill health, but only in the Gulf group and not in Bosnia veterans.

We do not know why. Last year Graham Rook, an immunologist at University College London, suggested that the effects of giving lots of vaccinations in a short space of time in a high-stress situation, coupled with giving pertussis vaccine to speed things up, might trigger an immunological reaction. We are now following this line of enquiry.

So is Gulf war syndrome a new phenomenon? One could be forgiven for thinking so. Many of the hazards facing the soldiers in the Gulf were new - modern troops are now exposed to risks unknown to a previous generation.

But the symptoms the soldiers complain of are not so unique. Going back in history we can find moving descriptions of identical symptoms and disability in veterans returning from the first world war. In those days doctors coined terms such as shell shock and effort syndrome to describe illnesses that sound indistinguishable from the complaints of Gulf war veterans. We have certainly found some new villains, but those of us who have never been to war must never forget the awful nature of all conflict.

With the benefit of hindsight we know that being a British soldier in the Gulf was less dangerous than being one in Belfast, and that our casualties were miraculously light - but those who fought in the Gulf did not know that at the time. Instead they knew that Saddam Hussein possessed chemical and biological weapons, which he had already used on his own people and was unlikely to be deterred by any moral scruples from using again. Active service is always stressful, always carries risk of death and injury - the Gulf was no exception. Some Gulf war illness is what happens whenever you send young men to war.

So what should we do next? We have shown for the first time that going to the Gulf has affected the health of some of those who served there. We now want to understand how and why. Over the next 18 months we will be carrying out intensive studies of both sick and well veterans. These will involve studies of respiratory, immunological and neuropsychological function, as well as neurological tests for evidence of nerve damage, possibly from exposure to organophosphate pesticides.

The task for the military is less straightforward. We must never forget that in previous wars infection routinely killed more soldiers than combat - the medical measures taken during the Gulf war were extraordinarily successful in preventing any deaths from disease and should not be changed without a great deal of thought. We must also remember that in the next war, soldiers, sailors and airmen may all encounter biological warfare agents such as anthrax. These are deadly. Thus our results must be seen in the context of why troops receive vaccinations. We may be asking troops to choose between a small risk of long term symptoms set against a high risk of death if they encounter the real thing.

There is only one way to prevent this happening again. Do not send young men and women to war. If we do, we should not be surprised when some come back sick.

Simon Wessely of the Gulf illness research unit, Guy's, King's and St Thomas's Medical School, is the principal author of the first British study into the so-called Gulf war syndrome, published in today's Lancet.