Introduction. The health of Gulf War veterans

Iraq invaded Kuwait on 2 August 1990. Shortly after Coalition forces, led by the United States, began a military deployment known as Operation Desert Shield. On 17 January 1991, an active air campaign began against Iraq and on 24 February, a ground war began, lasting only four days. It was a resounding military success. Iraqi forces were beaten in the field and expelled from Kuwait. The main contributor to the Coalition was the United States, with 697 000 personnel. Substantial contributions also came from the United Kingdom (53 000), Australia, Saudi Arabia, Egypt, Oman, France, Syria, Kuwait, Pakistan, Canada, Bahrain, Morocco and Qatar. Twenty-five other countries also contributed smaller numbers.

Not only was the campaign a military success, it was also a medical success. It is only during the modern era that deaths from battle injuries have exceeded deaths from disease for most armies. Traditionally, fighting in hostile environments, such as the desert, has been associated with morbidity and mortality, often substantial, from causes not related to enemy action, such as heat stroke, dehydration and infectious disease. Yet during the Gulf campaign there were few deaths from those sources among American or British personnel (Hyams et al. 1995). Hence, the military medical authorities must have ended the campaign relieved not to have had to deal with large-scale casualties and delighted with the success of their preventive measures.

Now over a decade later all that sounds a little hollow. Military success was not accompanied by regime change, which would require a second war. Few will remember the genuine medical achievements of the campaign and instead most people when asked about the Gulf War and health, will answer ‘ah yes, that's where Gulf War Syndrome began’.

It was shortly after the cessation of hostilities that reports started to emerge from the United States of clusters of unusual illnesses occurring among Gulf War veterans. Claims were made that previously fit veterans had developed unusual diseases, illnesses and symptoms. Reports emerged also of children with birth defects being born to Gulf War veterans.

These reports were anecdotal and impressionistic. Details remain obscure—when many of these clusters were formally investigated there was no objective evidence of any new illness or alternatively it could not be shown that these represented anything other than normally occurring conditions. Belatedly, formal clinical and epidemiological research was at last commissioned, but by the time these studies had started to report, Gulf War Syndrome had captured the public imagination.

Long before the machinery of scientific research had rolled into action, Gulf War Syndrome had been the focus of a remarkable barrage of publicity and media attention. By the mid-1990s Gulf War Syndrome became a media cause celebre on both sides of the Atlantic.

Since then the subject of ill health among Gulf War veterans has been the subject of a growing number of research papers and reviews, and of reports produced by scholarly institutions and committees, including a report from the Royal Society addressing the health risks of depleted uranium. However, what has been lacking has been a broad-based multi-author overview of the subject. This issue is an attempt to fill that gap.

In putting together this issue, I have been guided by the principle that there is no definitive analysis of the Gulf health issue. To date, no single discipline has produced a solution to the Gulf health enigma—no toxicologist, no immunologist, no neurologist and no psychiatrist. Many have tried, one or two have even claimed to have succeeded, but have failed to convince the scientific and medical community that they have stumbled across the cause of this problem.

I make no apology then for the broad scope of this issue. When I ask informed but non-expert colleagues and friends what they know about the aetiology of Gulf War health problems, the usual response involves some mention of various hazards encountered by members of the Armed Forces who took part in the campaign, such as the pollution from the oil well fires lit by retreating Iraqi forces. Others wonder about the various medical counter measures instituted to protect against the threat from chemical and biological weapons. So readers will not be surprised that I have turned to experts in the field of toxicology, immunology, neurology and other medical sciences. However, as our contributors and the expert review bodies have shown, a careful look at the literature fails to implicate any of these and other hazards, either singularly or in combination, as the definitive cause of ill health. Fifteen years following the Gulf war and after an enormous and costly research effort, and after tens of thousands of clinical examinations of Gulf War veterans in over 20 countries, we now have to ask ourselves how likely it is that we will eventually uncover a unique ‘Gulf War Syndrome’.

If then direct exposure to toxic hazards or inadvertent side effects from medical counter measures, are not the sole answer, it seems appropriate to consider another constant risk of warfare—the role of psychological stress and injury. As with most issues around Gulf health problems, there are those who feel that psychiatry is definitely the answer to the problem, and those who feel that it is an insult to even ask the question. However, there are some similarities between the conclusions reached by those who have reviewed the psychiatric data on Gulf Veterans' health, and those who have reviewed the medical data. There is no denying that exposure to organophosphate pesticides, smoke pollution, depleted uranium and the like can be damaging to health. And there is no denying that war is a stressful business. Since the beginning of the last century we have known that if men are exposed to the conditions of modern industrial warfare for long enough, many will become acute psychiatric casualties. It had been assumed that most of these illnesses would be short-lived, or if not, then more related to pre-disposing factors than the war itself, but even this view started to change as a result of the aftermath of the Vietnam conflict, and by the start of the Gulf War, it was conventional wisdom that a ‘bad’ war would cause as much in the way of long-term psychiatric casualties as it would physical casualties—indeed, the two were intimately related (Jones & Wessely 2001).

As Robert Gifford and colleagues show, the Gulf War was indeed stressful for many, especially in the period preceding the ground war. Some psychiatric casualties were observed, but nothing on the scale seen after the Vietnam War, let alone the long campaigns of the First or Second World Wars. The Gulf War was not the Pacific War, nor the campaign waged by the British and American air forces over the skies of Germany. So there was an increase in long-term psychiatric ill health, but this is also inadequate to explain all the observed health changes that have been found in Gulf veterans.

That would be reason enough to have turned to the final set of contributions, which come from the broadly defined humanities. Like all military conflicts, the Gulf War had elements of both old and new, and hence a historian's perspective is invaluable in setting the context of post-conflict syndromes, if only to show that the Gulf War Syndrome is not the first time that we have had to confront some of these enigmas. The Gulf War Syndrome saga also took place in a political and social arena—not only because of the frequent claims of political mismanagement that surfaced on both sides of the Atlantic, but also because, as Durodie shows, it is a mistake to consider the questions that were asked about the health of service personnel, and the questions that they asked themselves, without reference to the wider context of social and cultural health concerns. Finally, Gulf veterans are neither a uniform nor a homogenous group. Careful ethnographic study can also add to our understanding of the Gulf War Syndrome story. Whether we like it or not, illness is influenced by culture—both military culture and civilian health cultures, and no account of the Gulf War illness story is complete without some reflection on these issues.

When I mention to friends and colleagues that for some years my main research activity has been to study the health of Gulf War veterans, I am invariably asked ‘so what is the cause of Gulf War Syndrome then?’ I preface my answer with some discourse on why Gulf War Syndrome is a misnomer, and that Gulf War illness or even illnesses is preferable, but I am only buying time. Does this volume provide an answer?

The answer is no. True, we have learned a great deal about the health of Gulf War veterans. Nevertheless, none of the contributions to this themed issue possess the definitive solution to the Gulf War illness question. Nor do those who have not contributed. There is as yet no single, definitive, explanation for what has been observed. It is my opinion that this is unlikely to change with the passage of time, and that the delay in commencing serious scientific study of the problem has meant that any chances that once existed of providing better answers on aetiology have probably vanished. Unlike many health problems, the window of opportunity to properly investigate post-deployment health problems is brief (Hotopf & Wessely 2005). Perhaps time will prove this pessimistic prediction wrong, and there is no denying that we have learned much about post-deployment physical and psychological health problems and their management. But in the meantime, I think that those who are not seeking simplistic answers, but an intelligent exposition of the facts and discussion of the possibilities, will find reading this issue worthwhile.

My gratitude then goes to all the contributors, who have responded to the call with such scholarship and skill, and I am pleased to say, alacrity. It would be insidious to single out any one person from the list of expert authors, but one in particular deserves special mention. In May 2005 I asked Jennifer Vasterling who works for the Veteran's Administration in New Orleans to co-author the section on neuropsychological disorders. Just as she was putting together her chapter, Hurricane Katrina struck her hometown. Jennifer was relocated to Houston, but at the time of writing has still to gain access to either her home or office. Despite that, her and Doug Bremner's contribution arrived on time. My thanks to her, and to everyone who has contributed to what I believe to be the most comprehensive analysis of the Gulf War illness issue to date.