Gulf war syndrome needs coordinated study

BMJ 1995; 310 doi: (Published 14 January 1995) Cite this as: BMJ 1995;310:77

The attempt to explain mysterious illnesses among American veterans of the Gulf war has produced a confusing array of disorganised studies, according to the United States Institute of Medicine, the group asked by Congress to report on the syndrome. Until now the studies have been too small or too poorly designed to test whether a single syndrome exists, says the report from the institute's committee, published last week. “The government must determine which research efforts should be dropped because their usefulness has ebbed and which study gaps persist,” said the chairman of the committee, John Bailar III, professor of epidemiology and biostatistics at McGill University in Montreal, Canada.

Of the 697000 American troops who served in the war in 1990–1, about 43000 have reported ailments, which in some cases afflict their families. Myalgias, memory loss, birth defects, cancer, and respiratory and heart problems have been reported. About 36000 of the patients have diseases that explain the symptoms. Although there is no concrete evidence of a single agent causing disease among the rest, the government plans to spend almost $21m(£14m) this year to try to discover if there is one syndrome.

Congress asked the institute to review the government's investigations, and its first report focuses on what has been done so far to define and trace the syndrome. The report recommends that the small studies that focus only on a certain military unit or veterans in a certain state should end. Such studies were carried out initially in Indiana, Mississippi, and North Carolina. Surveys provide skewed results and should not be relied on. The committee says that the government should initiate large scale epidemiological studies in a representative population and that it should focus investigation on two clues: lead poisoning and chemical interaction. Raised lead concentrations have been found among veterans, and there has also been concern about the use of pesticides and permethrin as well as pyridostigmine bromide tablets (used to protect against Iraqi nerve gas).

The committee also recommends an investigation into a possible connection with visceral leishmaniasis, which causes fever, chronic fatigue, cough, abdominal pain, weight loss, anaemia, and splenomegaly - all of which have been reported among veterans. At present no clinical tests for the disease are satisfactory.

The committee wants the government to require the army, navy, air force, and the Veterans Administration to cooperate to ensure that studies are well designed and do not duplicate each other. It suggests that the armed services and the Veterans Administration should create a single patient record to promote more efficient collection of data. The committee found no evidence that soldiers had been exposed to chemical warfare. Nor did it think that evidence supported any association with the vaccines that the veterans were given.

The institute will monitor the progress on its recommendations and report to Congress again at the end of 1996. In that report it will consider further mental health, women's health, multiple chemical sensitivity, toxicological exposures, and nutrition.—JOHN ROBERTS, North American editor, BMJ

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