Soldier of Fortune Magazine 2003

Return to the Gulf

Similar Types of Casualties are expected from Gulf War II

Prof. Garth L. Nicolson

The Institute for Molecular Medicine, Huntington Beach, CA (website: www.immed.org)

SSG Robert Jones remembers vividly from his service in Desert Storm coming across a large group of dead sheep and camels in Southern Iraq.   They looked as if they were sleeping on the ground, but upon closer examination the ubiquitous flies that constantly harassed anything alive or dead were nowhere in sight.  At the time SSG Jones didn’t think much of the incident, but it would come back to haunt him later as he watched his family slowly come down with an illness that slowly struck him after the war and left him unable to perform the most menial tasks.  Similar to many other Gulf War families, SSG Jones’ illness spread to his wife and children, and now he helplessly watches them slowly deteriorate.  His wife Deborah has been in and out of military and civilian hospitals over the last few years, and the war-related infection that was transmitted to Deborah and children has wracked the family.  Slowly the infection spread to the bones in her face and major organs and cannot be stopped, causing severe pain, headaches and suffering.  Instead of treating his family, the U.S. Army ordered Robert to undergo psychiatric evaluation, and he is now in the process of being medically discharged.  SSG Jones’ story is unfortunately not unique to veterans of the Gulf War.

Although the Persian Gulf War in 1991 was touted as one of the most successful conflicts in U.S. history in terms of mission objectives and few battlefield casualties, since the war between 150,000-200,000 veterans of the Gulf War have registered for war-related disabilities, making this one of the costliest wars U.S. Forces have ever fought.  Most of these veterans had chronic illnesses that slowly evolved after their deployments and some veterans’ illnesses progressed to life-threatening conditions that have spread to spouses and children.  Have we learned our lesions from Gulf War I and taken steps to reduce or eliminate the illnesses associated with Persian Gulf service?  Unfortunately, there is no easy answer to this question.

Some steps have been taken to better identify chronic casualties within the Department of Defense (DoD) and Veterans’ Administration (VA) health facilities. The illnesses collectively called Gulf War Illnesses or GWI are usually not fatal; however, thousands of veterans have died since the war, and we have no idea how many veterans’ family members have died when illnesses spread to family members.   Possible reasons why these deaths have not been evaluated in official studies may be the limited populations studied, and the lack of information on veterans who left the Armed Forces and died outside of military and VA hospitals and absence of information on immediate family members.  Estimates of between 15,000 and 25,000 or more deceased U.S. veterans have been advanced, but the exact figures are classified and may be much higher.  Therefore, it is difficult to determine if Gulf War veterans are at significantly higher risk of death than non-deployed personnel, although it appears that this is the case. Three research groups have shown that Gulf War veterans do have increased rates of accidental deaths compared to non-veterans.  It has been postulated that this is due to neurological impairments affecting the operation of machinery and motor vehicles.

Illnesses Associated with the Gulf War

The DoD has claimed that there were no unique illnesses associated with deployment to the Persian Gulf and that there is no such thing as Gulf War Syndrome.  I agree with this argument, and in fact we were among the first to name the non-specific conditions associated with the war Gulf War Illnesses (GWI).  Similar illness groups or clusters can be found in personnel (albeit at lower rates) deployed to Bosnia.  But epidemiologic analyses of GWI have been criticized on the basis of self-reporting and self-selection, and that the veterans under study may not have been representative of the larger population of veterans.   Those criticisms may be valid, but it remains important to characterize signs and symptoms and identify exposures, if possible, of Gulf War veterans in order to find effective treatments for individual GWI patients, and when necessary their immediate family members.  

Most current case definitions for GWI are symptom-based, that is they are based almost entirely on the mostly nonspecific signs and symptoms of the patient.  Thus they are not based on the usual laboratory tests and other criteria that should identify routine causes of illness.  Although repeatedly denied by the VA and DoD over the years, a consensus of different researchers has shown much higher prevalence or incidence rates of GWI in deployed than in nondeployed forces.  One case control study (comparison of two carefully matched groups) of Gulf War veterans showed higher symptom prevalence in the deployed groups than in personnel from the same units that were not deployed.  For certain signs and symptoms, this difference was dramatic.  For example, the rate of diarrhea in the deployed groups was over 13-times greater than in the non-deployed groups.  In three different studies deployed forces had excess rates of 26%, 30% and 32% of GWI symptoms over non-deployed forces, indicating that the illnesses were related to Persian Gulf deployment not to some other circumstance unrelated to deployment. 

Similarity of GWI to Civilian Chronic Illnesses 

The most commonly found signs and symptoms of GWI are shown in Chart 1.  Although it has been argued that the joint pain and stiffness, fatigue, memory loss, night sweats, skin rashes and diarrhea found in GWI patients are nonspecific and often lack a physical cause, this conclusion may simply be the result of inadequate workup and lack of availability of routine tests that could define the underlying causes for these conditions.

In most GWI patients the variable incubation time, ranging from months to years after presumed exposure, the cyclic nature of the relapsing fevers and the other chronic signs and symptoms and their subsequent appearance in immediate family members are consistent with an organic, likely infectious process, not a psychosomatic disease or post-traumatic stress disorder.  The civilian syndrome most similar to GWI is Chronic Fatigue Syndrome.  In fact, when we examined the signs and symptoms of 650 ill Gulf War veterans, we found that they were strikingly similar to the signs and symptoms found in civilians with Chronic Fatigue Syndrome (Figure 1).

Chronic Fatigue Syndrome is defined by persistent, debilitating fatigue for over six months in a person who has no previous history of similar symptoms.  Such fatigue does not resolve with rest, and is severe enough to reduce or impair average daily activity below 50% of the patient's pre-illness activity level.   Patients also report at least four of the following symptoms: fever, sore throat, joint pain and stiffness, muscle pain, headaches, painful lymph nodes, sleep difficulties, and neuropsychiatric complaints, such as memory loss, visual disturbances, confusion, irritability and depression.  These signs and symptoms closely parallel those found in most cases of GWI, as we published in 1996.  This also indicates that GWI is not a new syndrome, and it has close similarities to Chronic Fatigue Syndrome.  Recently the VA and DoD have begun to finally accept Chronic Fatigue Syndrome as a valid diagnosis for illness associated with the Gulf War.

There are some differences between GWI and Chronic Fatigue Syndrome that may be important.  Researchers at the University of Texas Southwestern Medical School found differences in brain scans in Gulf War veterans compared to normal subjects.  What they found supports the theory that brain damage occurs in GWI patients, and this may account for the neurological signs and symptoms found in these patients.  Such changes may be due to brain inflammation and degeneration of nervous tissue.  This is strong evidence that GWI is not a psychological condition caused by stress.

GWI is not Post-Traumatic Stress Disorder

After the Gulf War most veterans’ illnesses were initially dismissed as post-traumatic stress syndrome or PTSD.  Since the signs and symptoms of GWI were not well established as criteria for specific illnesses, and they did not readily fit into the common diagnosis categories used by military and veterans' hospitals, this resulted in many veterans receiving diagnoses described as an "unknown" disorder, or worse, GWI patients were diagnosed with psychological problems, such as PTSD.  In fact, in many cases veterans were diagnosed with PTSD without careful analysis of their non-psychological medical problems.  

Most physicians and scientists that work on GWI do not accept that GWI can be easily explained by psychiatric or psychological diagnoses, nor can they be successfully treated with mood-altering drugs—commonly used for mental disorders.  Unlike PTSD, GWI has a number of significant signs that are different, such as neuromuscular problems, skin disorders, gastrointestinal problems, muscle and joint pain and intermittent fevers.  That many of the reported signs and symptoms do not fit the diagnosis of PTSD has not stopped military and veterans' hospitals from liberally using this diagnosis for GWI and treating GWI patients accordingly.  Although some GWI patients may undoubtedly have PTSD, this diagnosis has been overused by military and VA physicians who have been directed to first diagnose GWI as PTSD.

Possible Causes of GWI: Chemical Exposures

 	Part of the confusion in diagnosing GWI is that the overlapping chronic signs and symptoms displayed by GWI patients can be caused by quite different types of exposures.  Veterans of the Gulf War could have been exposed to chemical, radiological and/or biological agents, or more likely combinations of these exposures.  Accurate diagnosis and successful treatment of GWI depends on identifying the underlying exposures involved, because the illnesses caused by toxic exposures are treated differently if their origins are chemical, radiological or biological.

Gulf War veterans were exposed to a variety of chemicals, including insecticides, such as the insect repellent NDT or N,N-dimethyl-m-toluamide, the insecticide permethrin and other organophosphates, fumes and smoke from burning oil wells, the anti-nerve agent pyridostigmine bromide (PB), 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.  

Over the years the DoD has continually denied that unconventional weapons were used in the Gulf War but the evidence collected by various government agencies strongly suggests otherwise.  Iraq still has extensive stockpiles of mustard (blister agent HN or HT), lewisite (blister agent L), sarin (nerve agent GB or GF), tabun (nerve agent GA) and other CW agents, and extensive stores of these weapons were released into the atmosphere during the air campaign and by the destruction of Iraqi storage bunkers after the first Gulf War.  The Iraqis also had several methods of delivery of CW (and Biological or BW) agents.  They still possess stores of CW artillery shells, land mines, rockets such as SS-1 SCUD missiles equipped with Soviet-designed airburst warheads, aircraft equipped with sprayers and other sources.  

Did Iraq use unconventional weapons in the Gulf War?  After the war, this author received a map of the Riyadh, Saudi Arabia from a USMC LTC that showed the approximate impact sites of high explosive SS-1 ground burst and low yield airburst (approximately one-third of the total) detonations.  The airburst warheads were likely the typical Soviet-designed CBW warheads used on SS-1 missiles, and illnesses were reported in the areas near airburst detonations.  These warheads also release a substance called Prussian Blue, which is designed to destroy the filters in CW/BW protective gear.  Iraqi Prussian Blue was manufactured in Boca Raton, Florida, and its shipment to Iraq (even just before the Gulf War) was facilitated by members of President Bush Sr. cabinet.  Recently other types of short-range missiles, including Chinese-made Frogs, have been found by U.N. investigators to contain suspicious warheads containing bomblets that could be used for CBW delivery.  Intelligence sources also indicate that Iraqi Special Forces units may carry CW/BW agents to attack specific targets.  Although not a very effective method of CW/BW deployment, this could actually come into play in urban areas during an infantry assault.  Iraq has a history of using CW and possibly BW against its own civilians, so it is logical to conclude that they would certainly use it during a full-scale invasion.

Some CW agent exposure may have occurred in the first Gulf War 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.  Although the official DoD position is that there was no offensive CW use in the Gulf War, veterans were notified by the DoD of possible CW exposures from destruction of bunkers, such as Khamisiyah in Southern Iraq, containing stores of CW and BW agents.  Testimony to the U.S. Congress indicated that over 14,000 chemical alarms sounded during but not before or after the air and ground offensive.  To claim that all of these were false alarms, which is what DoD did, is an insult to our collective intelligence.  Testimony to the U.S. Congress indicated that soldiers were awarded medals for the detection of CW agents during the war and casualties were treated for suspected CW exposures.

If the chemical detection systems were so bad as to cause nothing but false alarms in 1991, what equipment do we have in place for force protection in 2003?  Unfortunately, the equipment currently deployed is the same or no better than deployed over a decade ago.  Deployed units still have the M256 Chemical Agent Detection Kit, the Chemical Agent Monitor, the Remote Sensing Chemical Agent Alarm, the M8A1 Automatic Chemical Agent Alarm System (now mostly removed from service), a new detector called the Automatic Chemical Agent Detector Alarm or ACADA as well as the highly sophisticated Fox Nuclear Biological and Chemical Reconnaissance Vehicle.  The DoD claims in a report released on 31 May 2001 that any of the units above could produce a false positive indication for a CW agent in the presence of other chemical substances, such as insecticides, a condition that unfortunately is not unique during war.  And the DoD has asked for deployment of some of the same units, such as the Czech chemical detection unit that DoD criticized after the first Gulf War because of their identification of offensive CW agents that the DoD initially claimed were false.
 
The same chemicals are in the Kuwaiti/Iraqi theater of operations now as were present in 1990-1991.  Although there may now be an attempt to minimize the effects of combination chemical exposures, basically little has changed in the last decade.  As an example of this, the DoD recently obtained a waiver from the FDA to again use the anti-nerve agent pyridostigmine bromide (PB) to counter Iraqi CW, but this agent is used for soman, and it is not as effective against sarin, the main Iraqi CW agent.  Many reported from mild to severe side effects from using PB and voluntarily discontinued its use.  As an anti-nerve agent PB is unproven in humans, and it should be considered an Investigational New Drug requiring informed consent before use.  Although the DoD does not have immediate plans to issue PB to Gulf-deployed personnel, they plan to keep it available for use.

The main defense against CW agents is personal protective gear to prevent exposures.  In 1991 this was the MOPP (Mission Oriented Protective Posture) gear with charcoal inserted between protective plastic layers.  Such suits are useful for only a short time, especially if a CBW attack occurs, but due to shortages during the Gulf War our personnel were often required to wear their MOPP gear for longer times than recommended, in some cases to the point where the charcoal filler began to spill out of the suit.  Newer suits, the Battle Dress Overgarments (BDO), require replacement often or within one day of a CW attack, but many of these suits have been found to be defective with stitching holes that can allow exposure to CW or BW.  The DoD claims that they have withdrawn all of the defective BDOs, even though the they have apparently lost track of 250,000 defective units out of just under 800,000 purchased by the U.S. Army.  The next generation protective suit, the Joint Service Lightweight Integrated Suit Technology (JSLIST), can be used in the field for up to 45 days if no exposures occur.  If CW or BW exposures occur, the JSLIST suits must be replaced within 24 hours.  However, deployed units may not have enough (two per soldier/three per marine are now stored in Kuwait) of the new (untested in battle) JSLIST suits, requiring the backup BDOs to be issued.  It is not clear whether highly mobile airborne, mechanized infantry and armored forces will have enough of these protective units readily available in the field in case of CBW attacks.

Chronic Illnesses Associated with Multiple Chemical Exposures

Exposures to mixtures of toxic chemicals can result in chronic illnesses, even if the exposures are at low-levels.  Such low-level exposures can cause a wide variety of signs and symptoms, including chronic neurotoxicity and immune supression.  For example, at Duke University researchers found that combinations of PB, the insect repellent NDT (N,N-dimethyl-m-toluamide) and the insecticide permethrin produced neurotoxicity, diarrhea, salivation, shortness of breath, muscular dysfunctions, tremors, and other impairments.  Similarly, USDA researcher John Moss found that mixtures of chemicals similar to those encountered by veterans of the Gulf War are much more toxic than the sum of the individual chemicals' toxicity.  This means that multiple low-level chemical exposures could cause illnesses where exposures to single chemicals would not cause illness.  Chemical mixtures are much more toxic than individual chemicals, and few studies have examined the effects of low-level chemical mixtures on health.

Exposure data for various single chemicals indicate that most exposures during the Gulf War were probably below usual toxic levels.  Although low levels of individual organophosphate chemicals did not cause signs and symptoms in exposed, non-deployed civilian workers, this does not rule out a causal role of multiple chemical exposures in causing chronic illnesses such as GWI.  Organophosphate-Induced Delayed Neurotoxicity (OPIDN) is an example of chronic illness that may be caused by multiple, low level chemical exposures.  This chronic illness is characterized by neurological problems, such as short-term memory loss, confusion, depression, impaired cognition (perception and intuition), headaches and other signs and symptoms.  Although some of the most commonly found signs and symptoms in most ill veterans cannot be easily related to multiple chemical exposures, chemically-related chronic illnesses are probably more common than thought among Gulf War veterans.  It is extremely difficult to determine if low-level exposures to CW agents that do not cause obvious, immediate neurological and neuromuscular symptoms in combination with other chemical exposures can eventually result in chronic illnesses.  Chemical exposures, however, do not explain transmission to immediate family members, unless the family member came in contact with the chemicals on gear or garments brought back from the Gulf.

One syndrome, although not universally accepted by the medical community, that could explain the effects of multiple chemical exposures is Multiple Chemical Sensitivity Syndrome (MCS).  MCS is a chronic condition that has been proposed to result from multiple low-level chemical exposures.  This syndrome is characterized by extreme sensitivity to certain chemicals, and it can present with many but not all of the signs and symptoms found in GWI patients.  Thus 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 exposures.  One problem in diagnosing such chemically caused illnesses is that each individual has different thresholds for different chemical effects, and exposures that could affect one person may not cause any problems in others. 

Arguments have been advanced by the DoD that such low-level toxic chemical exposures do not explain GWI, or that they may only be useful for only a small subset of GWI patients.  These arguments for the most part are based on published studies on the effects of large doses of single chemicals on industrial workers, not the multiple, complex exposures that were encountered by Gulf War veterans.  Since it is unlikely that one or even a few exposures will explain all the signs and symptoms found in GWI patients, examining clusters of exposed patients may be useful.  This could eventually allow practitioners to use unique combinations of treatments based on individual toxic exposures of veterans.

The onset of signs and symptoms of GWI for most patients was between six months and two years or more after the end of the war.  The slow onset of clinical signs and symptoms in chemically exposed individuals is not unusual for OPIDN.  Since low-level exposures to organophosphates were common in U.S. and probably other Gulf War veterans, the appearance of delayed, chronic signs and symptoms similar to OPIDN could have been caused by multiple low-level exposures to pesticides, nerve agents, anti-nerve agents and/or other organophosphates, especially in certain clusters of GWI patients.  This is a situation where common exposures in certain units may be important in understanding veterans’ illnesses, but such studies have not been undertaken in detail by the DoD or VA.

Treatment of GWI should follow from knowledge of the types of toxic exposures encountered.  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’ depot sites, usually fatty tissues, 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 may be necessary.  In some cases, skin contact with certain substances can cause strong reactions. 

GWI patients with MCS or OPIDN may benefit from dry saunas to remove chemicals through perspiration. Toxic chemicals have been successfully removed through a program of heat treatment, physical therapy, nutritional supplementation, and in some cases other therapies.  For example, treatment with hyperbaric oxygen or pure oxygen under pressure has been shown to mobilize stores of chemicals that can then be removed via the lungs by breathing oxygen under pressure.  In addition to heat, exercise and diet, a variety of medications may alleviate some symptoms in GWI patients but removal or reduction of offending chemicals may be necessary for recovery. 

Possible Causes of GWI: Biological Exposures

	There were a number of possible biological toxins and microorganisms that veterans could have been exposed to in the Gulf, and some of these could have been BW agents.  A small number of veterans had confirmed infections with parasites, such as Malaria, Leishmaniasis and Schistosomiasis.  These infections could be the cause of illnesses in additional veterans, and such infections are often difficult to determine in the field.  Although these diagnoses may be difficult and are often not considered, characteristic signs and symptoms occur in these illnesses, and diagnostic tests are available in hospital facilities equipped with clinical laboratories. Leishmaniasis, transmitted by sandflies, causes fever, swollen lymph nodes and spleen. The prevalence of Leishmaniasis has been estimated at fewer than 100 cases in Gulf War veterans but some may have eluded diagnosis.  Similarly, mosquito-borne parasites, such as Malaria, are often endemic in many regions around the world.  These parasitic diseases are often difficult to treat but effective treatments are available.

	Manufactured biological toxins or BW agents were also present in the Kuwaiti Theater of Operations.  The Iraqi Army had offensive stores of aflatoxin (Aspergillus flavus toxin), ricin (from Ricinus communis or castor beans), Clostridium botulinum toxin and tricothecene mycotoxins produced by various species of fungi.  Some of these BW toxins can be fatal in very low doses, and they can be delivered by various airborne platforms.  Aflatoxin can cause delayed carcinogenic or immunosuppressive effects, and it is interesting that the incidence of unusual cancers in Gulf War veterans was far above expected levels.  The Iraqis produced large quantities of some of these BW agents (aflatoxin, ricin, mycotoxins) which when dried under the appropriate conditions can be stored for years as fully active BW agents.  

	Bacterial infections are suspected in many GWI patients.  Dr. Kathern Murray-Leisure, formally head of a VA referral center in Pennsylvania, described a subset of GWI patients whose illnesses were associated with sand exposure.  This illness may be caused by a transmissable agent found in sand that is endemic to the region.  The risk for sand-associated illness appeared to be highest in the fall.  Although no sand-associated agent has thus far been identified, the slow development of the same signs and symptoms in spouses and children of veterans with GWI suggests that a slow-growing microorganism has been transferred from veterans to family members.
 
Evidence for transmissible infectious agents has been found in large numbers of GWI patients.  One of the most commonly found is a chronic infection caused by a subclass of bacteria called mycoplasma. In many cases, the veterans' immediate family members appear to have later developed similar signs and symptoms, such as the Jones family mentioned in the introduction to this article.  One estimate derived from 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.  Not every family member developed a GWI-like illness, but those that did had similar signs and symptoms and similar evidence of infection.   Because of the apparent slow rate of transmission to immediate family members, the general public is probably not at high risk for contracting GWI from casual contact with GWI patients.  However, health care personnel and co-workers may be at some risk.

Evidence for infectious agents has been found in GWI patients' urine and blood.  Dr. Edward Hyman used a microscopic technique to identify remnants of bacterial cell walls in urine, and he successfully treated GWI patients with several courses of broad spectrum antibiotics.  We and now others have found that most of the signs and symptoms in a large percentage of GWI patients can be explained by chronic pathogenic bacterial infections, such as mycoplasmal infections.  In studies of over 2,000 U.S., British and Canadian veterans with GWI, approximately 40% of GWI patients have evidence of such infections, compared to a few percent in the non-deployed, healthy population.  This finding has now been confirmed in a large study of 1,600 veterans at over 30 VA and DoD medical centers.  

Historically, mycoplasmal infections were thought to produce relatively mild diseases limited to particular tissues or organs, such as urinary tract or respiratory system.  However, the mycoplasmas detected in GWI patients, such as Mycoplasma fermentans found in over 80% of mycoplasma cases, are highly virulent, colonize a wide variety of organs and tissues, and are difficult to treat, as is the case for Deborah Jones.  When civilian patients with Chronic Fatigue Syndrome were similarly examined for mycoplasmal infections, about 50% of these patients were positive, indicating another link between GWI and Chronic Fatigue Syndrome.  In contrast to GWI, however, several different species of mycoplasmas other than M. fermentans were found in Chronic Fatigue Syndrome patients.  Also, it remains unclear whether the M. fermentans found in Gulf War veterans was an incapacitating BW agent developed specifically to cause slowly evolving chronic illnesses.

Approximately one-half of GWI patients also show fragile genetic regions that are more easily degraded by cellular enzymes, resulting in release of characteristic fragments.  But this might be due to the action of intracellular bacteria, such as M. fermentans, that are known to release substances that cause similar genetic damage.  Similarly, the finding of activation of the coagulation system in most GWI patients could also be related to chronic infections that are known to cause blood coagulation disturbances.

A few other chronic infections have been found in GWI patients.  In contrast to an early official report, we have found preliminary evidence in GWI patients for another type of bacteria commonly found in livestock (Brucella).  Inhalation of Brucella melitensis can cause brucellosis, a chronic disease that can result in many but not all of the signs and symptoms of GWI.  Another bacterial infection found in small numbers of cases includes Q Fever, caused by the bacteria Coxiella burnetii, which tends to cause high fevers and other distinctive signs and symptoms.

Once they occur bacterial infections can be treated with the appropriate antibiotics along with immune support.  Treatment with antibiotics can result in improvement and even recovery in patients made ill by bacteria or mycoplasmas like M. fermentans.  The recommended treatments for mycoplasmal infections require long-term antibiotic therapy, because few patients recover after only a few weeks or even months of treatment.  This may be a reflection of the locations of most mycoplasmas inside cells, the slow-growing nature of these microorganisms, or their inherent resistance to antibiotics.  Once our patients recovered and were able to return to pre-illness levels of activity, mycoplasmas could no longer be detected. Interestingly, Chronic Fatigue Syndrome and GWI patients with such infections that slowly recovered on antibiotic therapy become less environmentally and chemically sensitive.  If these patients had illnesses that were caused by stress or solely by chemical exposures, they would not have responded to the antibiotics.

Similar to CW agents, biologicals can be delivered by missile, aircraft, landmine, artillery, among other methods.  Since the Iraqi Army operates under Soviet War Doctrine, they would be expected to mix CW and BW agents in the same attack to confuse diagnoses and make treatment more difficult.  One delivery method that has received little attention is the use of Italian-made BW sprayers that were deployed during the Gulf War to Southern Iraq and Kuwait.  These sprayers can fit on trucks and may have been used to disperse BW on the sand.  Approximately 60 fully deployed Iraqi BW sprayers were found during the war, but information on their contents has been classified.  Recently the Iraqis have been found to be developing airborne drones to remotely deliver CW/BW agents but it is not known how many of these are currently operational.

The Family Study: Role of GWI Chronic Infections

Although it is hotly denied by the VA and DoD, in families of Gulf War veterans with GWI like the Jones family, there is strong evidence of transmission of the illness to spouses and children.  In our study families were not randomly chosen; they were families in which one or more veteran members were found to be positive for a mycoplasmal infection and one or more family members also reported chronic illnesses.  We found that the majority of these family members in which a Gulf War veteran was diagnosed with GWI and had a positive test for a mycoplasmal infection showed symptoms of Chronic Fatigue Syndrome in adults and teenagers and Autism in young children.  Among symptomatic family members, over 70% had the same type of mycoplasmal infection found in the family member with GWI.  Only a few non-symptomatic family members had similar infections.  Thus when the incidence of mycoplasmal infections was compared within families, the symptomatic family members were significantly more likely to have mycoplasmal infections of the type found in the member with GWI compared to non-symptomatic family members.

 	The young children (less than 6 years-old) in these families were of interest because they had signs and symptoms somewhat different from their parents.  Symptomatic children were mostly diagnosed with Autism, Attention Deficit Hyperactivity Disorder (ADHD) and other chronic disorders.  Similar to their parents, they were also infected with mycoplasmas at high incidence, but this was not seen in aged-matched control subjects.  Some of the non-symptomatic family members may be carriers and some may eventually present with Chronic Fatigue Syndrome or other illnesses related to mycoplasmal or other chronic infections.  Since such infections are very slowly transmitted, taking 6 months to up to two years to develop in immediate family members after the veteran showed signs and symptoms of GWI, most families do not consider their illnesses to be connected to the Gulf War.  We also did not find differences in the incidence of infection or type of infections between males and females, children versus adults or spouses versus other family members.  The logical conclusion is that veterans with GWI infections returned to their families and inadvertently spread their infections to family members who then slowly became symptomatic.  Ignoring the possible transmission of infectious agents to family members has unfortunately resulted in the spread of infections into the communities where veterans and their families live.

Multiple Vaccines and GWI

	A possible source for immune system disturbances and chronic infections found in many GWI patients is the multiple vaccines that were administered close together at the time of deployment to the Persian Gulf.  Several studies have found a strong association between GWI and the multiple (including BW) vaccines that were administered to British and American veterans.  One British investigator also noted an association specifically with the anthrax vaccine and GWI symptoms in British and Canadian veterans.  Kansas State epidemiologist Lea Steele found a three-fold increased incidence of GWI in nondeployed veterans from Kansas who had been vaccinated in preparation for deployment. Other investigators found a two-fold increased incidence of GWI symptoms in deployed U.S. veterans who recalled they had received anthrax vaccinations at the time of the Gulf War, versus those who thought they had not.  

	GWI signs and symptoms have developed in personnel who recently received the anthrax vaccine.  On some military bases this has resulted in chronic illnesses in as many as 7-10% of personnel receiving the vaccine.  The chronic signs and symptoms associated with anthrax vaccination are similar, if not identical, to those found in GWI patients, suggesting that at least some of the chronic illnesses suffered by veterans of the Gulf War were caused by vaccines.  Undetectable microorganism contaminants in vaccines could have resulted in illness, and may have been more likely to do so in those with compromised immune systems.  This could include individuals with chemical exposures, or personnel who received multiple vaccines in a short period of time.  Since contamination with mycoplasmas has been found in commercial vaccines, the vaccines used in the Gulf War should be considered as a possible source of the chronic infections found in GWI.

	Vaccines have been used since the Revolutionary War to protect our Armed Forces, and they have been an important element in force protection since these times.  Thus they are considered an integral part of our strategy to prevent BW casualties.  However, these vaccines were not designed to be used together with 20 or more other vaccines within a few day period during deployment.  This can result in immune suppression and leave vaccinated personnel more not less vulnerable to infection.  Thus our strategy of vaccine use must be considered as one of the elements in explaining illnesses associated with the Gulf War.

Possible Causes of GWI: Radiological Exposures

Depleted uranium (DU) was used extensively in the Gulf War, and it remains an important contaminant of Southern Iraq.  DU, a by-product of uranium processing, is used in armor-penetrating ammunition and in protective armor on tanks and other armored vehicles.  DU was thought to contain only uranium isotopes and small amounts of highly radioactive 235U and 234U.  However, when DU in U.S. munitions was analyzed, it was found to contain small quantities of highly radioactive plutonium and other isotopes, which are much more toxic than DU itself.

When a DU penetrator hits an armored target, it ignites, and between 10% and 70% of the warhead aerosolizes, forming very, very small uranium oxide particles.  The particles that form settle quickly onto vehicles, bunkers and the surrounding sand due to their high density, and they can be easily inhaled, ingested or re-aerosolized.  Vehicles and bunkers destroyed by DU munitions should be avoided.

If contamination occurs, the organs where DU can be found include the lungs and regional lymph nodes, kidney and bone.  However, the Armed Forces Radiological Research Institute (AFRRI) also found DU in blood, liver, spleen and brain of rats injected with DU pellets.  Researchers at the AFRRI further noted that "cells exposed to DU are transformed to tumorigenic cells in immune-compromised mice." It is therefore possible that the immune-compromising effects of DU itself or other exposures have led to DU-inducing cancer in some Gulf War veterans, and also that DU can produce adverse fetal effects.  Although it is not clear how many veterans were exposed to DU, studies should be initiated as soon as possible to determine the prevalence of DU contamination, and extent of body stores of uranium and other radioactive heavy metals in veterans.  

Procedures have been developed for analysis of DU metal fragments and DU in urine.  However, urine testing does not detect uranium in all body sites.  Analysis of DU-contaminated Gulf War veterans has not shown them to have the signs and symptoms of GWI, but few veterans have been studied.  Allegations that DU has led to leukemia in European troops serving in Kosovo (of whom scores have died from leukemia) and Bosnia are being taken seriously by our allies.  NATO has called for testing troops from all 19 NATO members for DU contamination.  The results of these tests have not been made available.

Other Environmental Exposures and GWI

	In addition to the chemicals and fumes from diesel-powered heaters in tents and surrounding areas, soldiers were exposed to burning oil well fires and ruptured petroleum pipelines as well as fine, blowing sand.  The chemicals in the environment could have contributed to the overall chemical burden in deployed personnel.  Although not nearly as toxic as CW agents, prolonged exposure to environmental chemicals can result in chronic illnesses and thus unnecessary exposures should be limited.  Most environmental chemical exposures are not nearly as neurotoxic as CW agents that have been designed to directly attack nervous systems.

	The very small size of sand particles in Southern Iraq and the relatively constant winds in the region probably resulted in some sand inhalation.  The presence of small sand particles deep in the lungs can produce an inflammatory disorder that can progress to a condition called pneumonitis or Al-Eskan Disease.  Al-Eskan disease is characterized by reactive or extremely sensitive airways, and usually presents as a chronic condition that can eventually progress to pulmonary fibrosis, and possibly immune suppression followed by opportunistic infections.  Although it is doubtful that many GWI patients have Al-Eskan Disease, the presence of silica-induced immune suppression in some soldiers could have contributed to persisting opportunistic infections often found in these veterans.  Unfortunately, there is no known treatment for Al-Eskan Disease, but the condition may slowly resolve in some patients.

The French Connection and Lack of GWI

	Interestingly, the French Ministry of Defense reported very few GWI cases in their deployed forces.  During the Gulf War the French forces did not use vaccines as a primary defense against Iraqi BW, and they did not use anti-nerve agents extensively as a defense against Iraqi CW agents. Instead, they used antibiotics to counter BW agents and depended on their protective suits to counter CW agents.  Although there were apparently a few cases of GWI in French forces, these have not been studied and compared to American, Canadian and British veterans with GWI.  The French Ministry of Defense has been urged to investigate the role of vaccinations, obtained by small numbers of French troops while serving with U.S. and British forces, in French soldiers who have now developed GWI.

	Some efforts should be made to determine the relative effectiveness of these very different chemical and biological prophylactic and treatment strategies used by different nations to counter CW and BW attacks.  Although NATO countries have invested heavily in vaccines to counter BW agents, this may not be the most effective strategy to prevent BW infections.

Final Comments

Recent attention to the role of chemical and radiological exposures, hormonal and other alterations, and biological exposures (infections with microorganisms that may originate from the use of multiple vaccines) in GWI patients has allowed physicians to successfully treat some GWI cases.  However, these approaches have not been widely used within VA and DoD facilities, thus many GWI patients remain ill and on antidepressants and other mood-altering drugs with little chance for eventual recovery.  It is necessary and should be immediately mandated that veterans should be extensively evaluated and if ill successfully treated, not forced out of the military on the basis of weak psychiatric diagnoses.  Sick Gulf War veterans and their families need to be effectively treated, not ignored and their illnesses listed for convenience as PTSD or other psychological conditions.  Our stature as a nation is, in part, judged by how we treat our veterans and their families.  It is time that they receive at least a small fraction of the attention and financial consideration given to military operations.
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Garth L. Nicolson, Ph.D., is the President, Chief Scientific Officer and a Research Professor at the Institute for Molecular Medicine in Huntington Beach, California.  He is also a Professor of Integrative Medicine at Capitol University in Washington DC.  Professor Nicolson is a COL (Honorary) in the U.S. Army Special Forces and a honorary U.S. Navy SEAL.  For further information on illnesses associated with vaccines and the Gulf War and how to obtain testing and treatment information, consult the Institute for Molecular Medicine website: www.immed.org.

Chart 1.  Comparison of the prevalence of signs and symptoms of Gulf War Illness (650 patients) with Chronic Fatigue Syndrome (250 patients).