Gulf War syndrome (GWS) also known as Gulf War illness or chronic multi-symptom Illness, is a chronic and multi-symptomatic disorder affecting military veterans of the Gulf War (1990–1991). A wide range of acute and chronic symptoms have been linked to the illness, including fatigue, muscle pain, cognitive problems, insomnia, rashes and diarrhea. Approximately 250,000 of the 697,000 U.S. veterans who served in the Gulf War have an enduring chronic multi-symptom illness. From 1995 to 2005, the health of combat veterans worsened in comparison with nondeployed veterans, with the onset of more new chronic diseases, functional impairment, repeated clinic visits and hospitalizations, myalgic encephalomyelitis/chronic fatigue syndrome-like illness, post-traumatic stress disorder, and greater persistence of adverse health incidents.
Since 2022, Gulf War syndrome has been primarily linked to exposure to sub-lethal amounts of organophosphate nerve agents, particularly sarin and cyclosarin, released atmospherically during Coalition attacks on Iraqi chemical weapons facilities. Susceptibility was influenced by an allele in the PON1 gene. Exposure to pesticides containing other organophosphates and exposure to pills containing pyridostigmine bromide, also referred to as nerve agent pre-treatment sets (NAPS) tablets, used as a pre-treatment to protect against nerve agent effects, has been found to be associated with the neurological effects seen in Gulf War syndrome. Other potential causes that have been investigated are mustard gas and emissions from oil well fires, but their relationships to the illness are not as clear. Gulf War illness is not the result of combat or other stressors, and Gulf War veterans have lower rates of post-traumatic stress disorder (PTSD) than veterans of other wars.
The Royal British Legion said research suggested up to 33,000 UK Gulf War veterans could be living with Gulf War illness, with 1,300 claiming a war pension for conditions connected to their service. In 2007 the Royal British Legion produced a comprehensive report entitled Legacy of Suspicion, which made recommendations about necessary research and compensation. The Royal British Legion is still campaigning for the UK government to properly address symptoms experienced by veterans of the Gulf War.
According to a 2013 report by the Iraq and Afghanistan Veterans of America, veterans of the U.S. wars in Iraq and Afghanistan may also have Gulf War illness, though later findings identified causes that would not have been present in those wars.
Signs and symptoms According to the Institute of Medicine (IOM), part of the U.S. National Academy of Sciences, 250,000 of the 696,842 U.S. servicemen and women in the 1991 Gulf War continue to be affected by chronic multi-symptom illness, which the IOM refers to as Gulf War illness. The IOM found that it continued to affect these veterans 20 years after the war.
Veterans showed medically unexplained symptoms. Many of the biological pathways affected by illness are unclear, such as why symptoms are diverse in some and specific in others. A lack 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 to reconstruct what happened to service members during their deployments. The IOM report called for a substantial commitment to improving identification and treatment of multi-symptom illness in Gulf War veterans focussing on continued monitoring of Gulf War veterans, improved medical care, examination of genetic differences between symptomatic and asymptomatic groups and studies of environment-gene interactions.
A variety of signs and symptoms have been associated with GWI: +Excess prevalence of general symptoms * Symptom U.S. UK Australia DenmarkFatigue23%23%10%16%Headache17%18%7%13%Memory problems32%28%12%23%Muscle/joint pain18%17%5%2% (<2%)Diarrhea16% 9%13%Dyspepsia/indigestion12% 5%9%Neurological problems16% 8%12%Terminal tumors33% 9%11% * This table applies only to coalition forces involved in combat.
+Excess prevalence of recognized medical conditions Condition U.S. UK Canada AustraliaSkin conditions 21% 4%Arthritis/joint problems 10% 2%Gastro-intestinal (GI) problems 1%Respiratory problem 2% 1%Chronic fatigue syndrome 3% 0%Post-traumatic stress disorder 9% 3%Chronic multi-symptom illness 26%
Birth defects have been suggested as a consequence of Gulf War deployment. However, a 2006 review of several studies of international coalition veterans' children found no strong or consistent evidence of an increase in birth defects, finding a modest increase in birth defects that was within the range of the general population, in addition to being unable to exclude recall bias as an explanation for the results. A 2008 report stated that "it is difficult to draw firm conclusions related to birth defects and pregnancy outcomes in Gulf War veterans", observing that while there have been "significant, but modest, excess rates of birth defects in children of Gulf War veterans", the "overall rates are still within the normal range found in the general population". The same report called for more research on the issue.
Comorbid illnesses Persian Gulf War veterans have an increased risk of multiple sclerosis.
A 2017 study by the U.S. Department of Veterans Affairs found that veterans possibly exposed to chemical warfare agents at Khamisiyah experienced different patterns of brain cancer mortality risk compared to the other groups, with veterans possibly exposed having a higher risk of brain cancer in the time period immediately following the Gulf War.
Iraqi veterans Opposing Iraqi veterans of the Iraqi Army in the Gulf War also experienced acute and chronic symptoms associated with Gulf War syndrome, although this group is understudied compared to U.S. veterans. A 2011 study in the U.S. Army Medical Department Journal reported Iraqi veterans of the Gulf War had a higher prevalence of somatic disorders as compared to Iraqi civilians, with risk greater in troops stationed in Kuwait.
In comparison to Allied troops, health symptoms were similar amongst Iraqi veterans: +Risk of health symptoms Symptom Odds ratios (95% CI) - Zone 1 vs Zone 3 Headaches 3.65 (2.51–5.31) Respiratory disorder 4.09 (2.60–6.43) Genitourinary disorder 4.06 (2.65–6.21) Musculoskeletal disorder 4.33 (2.96–6.33) Chronic fatigue 126.3 (29.9–532.8) Skin disorders 1.89 (1.24–2.87) Miscellaneous disorders 4.43 (2.44–8.05) * Zone 1 = In Kuwait, Zone 3 = 360 km from Kuwait.
Causes Many of the symptoms of Gulf War illness are similar to the symptoms of organophosphate, mustard gas, and nerve gas poisoning. Gulf War veterans were exposed to a number of sources of these compounds, including nerve gas and pesticides. In 2022, researchers led by Robert Haley, MD at University of Texas Southwestern Medical Center found that exposure to sarin nerve gas in soldiers who had a particular genetic mutation that prevented them from breaking down the nerve gas is likely to be responsible for the syndrome. The findings and an editorial by two leading epidemiologists were published in Environmental Health Perspectives.
The United States Congress mandated the U.S. Department of Veterans Affairs' contract with the National Academy of Sciences (NAS) to provide reports on Gulf War illnesses. Between 1998 and 2009, the NAS's Institute of Medicine (IOM) authored ten such reports. In addition to the many physical and psychological issues involved in 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 munitions, and multiple simultaneous vaccinations including anthrax and botulinum toxin vaccines. The oil and smoke that spewed for months from hundreds of burning oil wells presented another exposure hazard not previously encountered in a war zone. Military personnel also had to cope with swarms of insects, requiring the widespread use of pesticides. High-powered microwaves were used to disrupt Iraqi communications, and though it is unknown whether this might have contributed to the syndrome, research has suggested that safety limits for electromagnetic radiation are too lenient., Testimony to the Senate Veterans Affairs Committee by Meryl Nass, MD on September 25, 2007
The Research Advisory Committee on Gulf War Veterans' Illnesses (RAC), a VA federal advisory committee mandated by Congress in legislation enacted in 1998, 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 pesticides that affect the nervous system. The RAC concluded in 2004 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 RAC concluded that "exposure to pesticides and/or to PB [pyridostigmine bromide nerve agent protective pills] are causally associated with GWI and the neurological dysfunction in GW veterans. Exposure to sarin and cyclosarin and to oil well fire emissions are also associated with neurologically based health effects. Gene-environment interactions are likely to have contributed to development of GWI in deployed veterans. The health consequences of chemical exposures in the GW and other conflicts have been called "toxic wounds" by veterans. This type of injury requires further study and concentrated treatment research efforts that may also benefit other occupational groups with similar exposure-related illnesses."
Sarin nerve agent
Low-level exposure to nerve agents has been suggested as the cause of GWI. In 1991, Chemical detection units from Czechoslovakia, 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. Initially, the report claimed that after the air war started on January 16, 1991, coalition forces were chronically exposed to low, nonlethal levels of chemical and biological agents released primarily by direct Iraqi attack via missiles, rockets, artillery, or aircraft munitions and by fallout from allied bombings of Iraqi chemical warfare munitions facilities.
However, in 1997, the US Government released an unclassified report that stated:
Over 125,000 U.S. troops and 9,000 U.K. troops were exposed to nerve gas and mustard gas when the Iraqi depot in Khamisiyah was destroyed. Studies have confirmed earlier suspicions that exposure to 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.
The 2014 report by the U.S. Department of Veterans Affairs (VA) Research Advisory Committee on Gulf War illnesses (RAC) concluded that, "exposure to the nerve gas agents sarin/cyclosarin has been linked in two more studies to changes in structural magnetic resonance imaging findings that are associated with cognitive decrements, further supporting the conclusion from evidence reviewed in the 2008 report that exposure to these agents is etiologically important to the central nervous system dysfunction that occurs in some subsets of Gulf War veterans."