Report to the Canadian Dept. of National Defense, Ottawa, May 14, 2001.

SUMMARY OF VETERANS’ CHRONIC ILLNESSES FROM SERVICE IN THE MIDDLE EAST

Prof. Garth Nicolson
The Institute for Molecular Medicine
Huntington Beach, California USA

At least 16% (>150,000) of the veterans of the first Persian Gulf War slowly developed a variety of complex chronic signs and symptoms (usually 6-18 months or more after the conflict) characterized by disabling fatigue, intermittent fevers, night sweats, painful joints and muscles, impairments in short-term memory, headaches, skin rashes, diarrhea and other gastrointestinal problems, respiratory complaints, light sensitivity and other visual disturbances, confusion, irritability, depression and other signs and symptoms.  These illnesses have been called Gulf War Syndrome or Gulf War Illnesses (GWI), and they have until recently defied appropriate diagnoses and treatments.

When we started our studies on 650 veterans two years after the first Gulf War, we found that almost all loosely fell into the category of fatiguing illnesses.   The problem at the time was that physical examinations and routine laboratory tests were not consistent with a single, specific diagnosis, and veterans often did not receive a diagnosis for their condition (“illness of unknown origin”), or more commonly they received a diagnosis of a stress-related disorder, such as Post-Traumatic Stress Disorder (PTSD).  Often the diagnoses assigned to patients reflected only one or a small group of their overall signs and symptoms, and diagnoses such as PTSD were probably given out of convenience.  GWI has been reported by various nations that deployed forces to the Gulf War in 1991, and in 2003 approximately 6,000 servicemen and servicewomen deployed to the Middle East and Afghanistan have reported similar signs and symptoms to the veterans of the first Gulf War.

The illnesses collectively called GWI are usually not fatal; however, thousands of veterans have died since the first Gulf War.  Estimates of between 15,000 and 25,000 or more deceased U.S. veterans have been advanced from the first Gulf War, but the exact figures are classified.  Therefore, it is difficult to determine if veterans are at higher risk of death than non-deployed personnel. Three groups have shown, however, that Gulf War veterans do have increased rates of accidental deaths compared to non-veterans.  It has been postulated but not proven that this is often due to neurologic impairments affecting the operation of motor vehicles and machinery.

Different Types of Exposures Result in Different Illnesses

It is likely that the overlapping chronic signs and symptoms found in GWI patients could be caused by quite different types of exposures.  GWI patients from the first Gulf War were exposed to chemical, radiological and/or biological agents, and most have reported combinations of such exposures.  Accurate diagnosis and successful treatment of GWI subsets for the first Gulf War and present Gulf War conflict will depend on identifying the illness-provoking exposures, because the different exposures require different methods for amelioration.

Gulf War veterans from the first Gulf War were exposed to a variety of chemicals, fumes and smoke from burning oil wells, anti-nerve agents, solvents used to clean equipment and a variety of other chemicals, including in some cases, possible exposures to low levels of Chemical Warfare (CW) agents.  Some CW exposure may have occurred because of destruction of CW stores in factories and storage bunkers during and after the war as well as possible offensive use of CW agents.  Some feel that there was no credible evidence for CW exposure; however, many veterans have been notified by the Department of Defense of possible CW exposures, and the signs and symptoms of some veterans are typical of low-level CW exposure.

Multiple Chemical Sensitivity Syndrome (MCS) has been proposed to result from multiple low level chemical exposures.  These syndromes can present with many of the signs and symptoms found in GWI patients, and many GWI cases may eventually be explained by complex chemical exposures.  In chemically exposed GWI patients, memory loss, headaches, cognitive problems, severe depression, loss of concentration, vision and balance problems and chemical sensitivities, among others, typify the types of signs and symptoms characteristic of organophosphate chemical exposures.  Arguments have been advanced that such exposures do not explain GWI, or that they may only be useful for a small subset of GWI patients.  These arguments for the most part are based on the medical literature where researchers studied the effects of single agent exposures, not the multiple, complex exposures that were encountered by Gulf War veterans. 

Iraqi Armed Forces were known to have extensive stores of CW, and intelligence reports indicated that orders to use offensive CW agents were given.  In testimony to the U. S. Congress, Army officers indicated that over 14,000 CW alarms sounded during but not before or after the air/ground offensive, and some soldiers were given medals for identifying the types of CW that were released.  Extensive stockpiles of CW agents were present in the region, and an unknown quantity of these weapons were released into the atmosphere during the air campaign and by the destruction of Iraqi storage bunkers after the conflict.

Depleted uranium (DU) was used extensively in the Gulf War, and it remains an important radioactive contaminant of the battlefield.  DU, a by-product of uranium processing, is used in armor-penetrating ammunition and in protective armor on tanks and other vehicles. When a DU penetrator hits an armored target, it ignites, forming uranium oxide particles.  The particles that form are usually small and due to their high density settle quickly onto vehicles, bunkers and the surrounding sand, where they can be easily inhaled, ingested or re-aerosolized. Following contamination, the organs where DU can be found include the lungs and regional lymph nodes, kidney and bone. It is therefore possible that the immune-compromising effects of DU or other exposures have led to the high rates of cancer found in Gulf War veterans.  Studies on DU should be initiated to determine the prevalence of contamination, and extent of body stores of uranium and other radioactive heavy metals. Such DU exposure, however, is unlikely to explain the most common signs and symptoms of GWI patients.

Bacterial infections have been found in many GWI patients and in some cases their immediate family members. The veterans' immediate family members appear to develop similar signs and symptoms after the return of veterans to the family, and we have documented the same bacterial infections in family members as found in the veterans.   One estimate derived from U.S. Senate inquiries of over 1,200 GWI families indicated that approximately 77% of spouses and 65% of children born to affected veterans after the war now have the signs and symptoms of GWI.  Our published studies identified the likely infections involved in transmission to family members.

We have found that most of the signs and symptoms in a large subset of GWI patients can be explained by chronic pathogenic bacterial infections, such as mycoplasmal infections. In studies of over 2,000 U.S. and British veterans with GWI, approximately 40% of GWI patients have such infections, compared to a few percent in the non-deployed, healthy population.  This has been confirmed in a large study of 1,600 veterans at over 30 VA and DoD medical facilities. When compared with civilian patients with Chronic Fatigue Syndrome or Fibromyalgia Syndrome, the civilian counterparts of GWI, about 50% of these civilian patients were positive for mycoplasmal infections, indicating another link between these disorders.  In contrast to GWI, however, several species of mycoplasmas were found in civilian patients, but the Gulf War patients (and their ill immediate family members) principally had only one type of infection.

Since it is unlikely that one or even a few exposures will explain all the signs and symptoms found in GWI patients, seeking subsets or clusters of exposed patients may be important.   It could eventually allow practitioners to use unique combinations of treatments based on individual exposures of each veteran.

Development of New Treatments for Veterans’ Illnesses

Treatment of veterans’ illnesses should follow from knowledge of the types of exposures encountered by veterans.  For example, the treatment of chemically sensitive patients involves removal of offending chemicals from the patients’ environment, and may also include methods to remove chemicals from the patients’ body storage sites where they accumulate, and other treatments.  Chemically exposed patients can be extremely sensitive to a variety of commonly encountered chemicals, including perfumes and air fresheners, petrochemical fumes, chlorine, cleaning solutions and solvents.  They may also be very sensitive to certain foods, and special diets can be necessary.  In some cases, skin contact with certain substances can cause strong reactions.
 
We have found that GWI patients with chemical exposures benefit from dry saunas, as well as magnesium sulfate-hydrogen peroxide baths. Toxic substances may also be removed through a program of heat treatment, physical therapy, nutritional supplementation, and in some cases other therapies, such as hyperbaric oxygen therapy (oxygen under pressure).  In addition to heat, exercise and diet, a variety of medications may alleviate some symptoms in GWI patients.  Few patients have benefited from anti-anxiety, anti-depressant and anti-inflammatory drugs extensively used by the VA and DoD, and this approach may not be beneficial for most GWI patients, especially those with chronic infections or with MCS.

Reduction of DU in exposed patients depends on reducing the body burden of heavy metals by chelation, and surgical removal of shrapnel, combined with nutritional strategies.  Although the actual composition of DU and the extent of its toxicity and troop exposure remain to be determined, removal of DU is likely important.  We have proposed the use of chelation therapy for DU contamination, and studies should be initiated to determine its effectiveness.

Chronic bacterial infections can be diagnosed with our advanced molecular biological diagnostics and can be treated with the appropriate antibiotics and other treatments, such as hyperbaric oxygen treatment.  Treatment with antibiotics can result in improvement and even recovery in GWI patients made ill by bacteria or mycoplasmas.  The recommended treatments for systemic infections require long-term antibiotic therapy, because few patients recover after only a few weeks or months of treatment. Unfortunately, most physicians are reluctant to treat for the necessary time to allow full recovery. Interestingly, if such patients had illnesses that were caused by stress or solely by chemical exposures, they would not respond to the recommended antibiotics and slowly recover as we have seen in our published studies. 

We have also found abnormal levels of certain substances (thyroid hormone, aldosterone, cortisol, vitamin B12) in some Gulf War patients, possibly due to autoimmune attack on endocrine tissues caused by chronic infections.  In our studies we found it important to use dietary supplements and other more natural means along with the more conventional allopathic approaches to help restore health. Our Institute has run clinical trials and published the benefits of using certain nutraceutical products that build the immune system of patients, such as GWI veterans whose immune systems have been compromised.  These would be made available at the proposed facility.

Need for a Comprehensive Program of Diagnosis and Treatment

The approach used currently for analysis and treatment of Gulf War veterans and other veterans is to place them into strict diagnosis categories so that they can receive narrow treatments on the basis of their limited diagnoses.  Although convenient and commonly used for civilians, this may not be the best approach for military patients with complex, chronic illnesses, which tend to have multiple causes and require complex therapeutic approaches.

Recent attention to the role of chemical and radiological exposures, hormonal deficiencies, and infections with microorganisms (some possibly originating from the vaccines used by the military), in patient subsets, has allowed us to successfully diagnose and treat GWI cases.  Because this approach has not been widely used, we hope to develop facilities to extensively evaluate and successfully treat ill veterans and their ill family members, who are at present usually denied appropriate care and treatment for their illnesses.

Finally, we have a vast network of informed physicians that we work with and these physicians need to educate other physicians and allied health practitioners.  Our Institute has run a few seminars with continuing medical education credits, including seminars for physicians and allied health professionals. This type of educational program needs to be expanded and should be implemented for veterans, their families, and health care professionals.  

Some Recent References

Nicolson GL, Nasralla M, Franco AR, De Meirlier K, Nicolson NL, Ngwenya R, Haier J. Mycoplasmal infections in fatigue illnesses: Chronic Fatigue and Fibromyalgia Syndromes, Gulf War Illness and Rheumatoid Arthritis.  J Chronic Fatigue Syndr 2000; 6(3/4):23-39.

Nicolson GL, Nass M, Nicolson NL. Anthrax vaccine: controversy over safety and efficacy. Antimicrob Infect Dis Newsl 2000; 18(1):1-6.

Nicolson GL, Nass M, Nicolson NL. The anthrax vaccine controversy. Questions about its efficacy, safety and strategy. Med  Sentinel 2000; 5:97-101.

Nicolson GL, Nasralla M, Franco AR et al. Diagnosis and Integrative Treatment of Intracellular Bacterial Infections in Chronic Fatigue and Fibromyalgia Syndromes, Gulf War Illness, Rheumatoid Arthritis and other Chronic Illnesses. Clin Pract Alt Med 2000; 1(2):92-102.

Nicolson GL, Nasralla M, Haier J, Nicolson NL. Gulf War Illnesses: Role of chemical, radiological and biological exposures. In: War or Health, H. Tapanainen, Ed., 431-446, Zed Press, Helinsiki, 2001.

Nicolson GL, Nass M, Nicolson NL. Safety and efficacy problems with the anthrax vaccine.  Why we must not use this vaccine for military personnel. J Degenerative Disease  2000; 2(1):5-11.

Nicolson GL.  Gulf War Illnesses—their causes and treatment. Armed Forces Med. Dev. 2001; 2:41-44.

Nicolson GL, Berns P, Nasralla M, Haier J, Nicolson NL, Nass M. Gulf War Illnesses: chemical, radiological and biological exposures resulting in chronic fatiguing illnesses can be identified and treated. J Chronic Fatigue Syndr 2003; 11(1):135-154.

Nicolson GL, Berns P, Nasralla M, Haier J, Pomfret J. High Frequency of Systemic Mycoplasmal Infections in Gulf War Veterans and Civilians with Amyotrophic Lateral Sclerosis (ALS). J Clin Neurosci 2002; 9:525-529.

Nicolson GL, Nasralla M, Nicolson NL, Haier J. High Prevalence of Mycoplasmal Infections in Symptomatic (Chronic Fatigue Syndrome) Family Members of Mycoplasma-Positive Gulf War Illness Patients. J Chronic Fatigue Syndr 2003; 11(2):21-36.

Nass M, Nicolson GL. Anthrax vaccine: historical perspective and current controversy.  J Nut Environ Med 2002; 14:277-286.