Transcript Document

THE FOLLOWING LECTURE HAS BEEN APPROVED FOR
ALL STUDENTS
BY BIRMINGHAM CITY UNIVERSITY
This lecture may contain information, ideas,
concepts and discursive anecdotes that may be
thought provoking and challenging
Any issues raised in the lecture may require
the viewer to engage in further thought,
insight, reflection or critical evaluation
health.bcu.ac.uk/craigjackson
The Psychology of
Gulf War Syndrome
A strange and curious
condition caused by an
unusual war
Prof. Craig Jackson
Head of Psychology Division
BCU
[email protected]
Headlines of Gulf War
BABY IS GULF WAR
SYNDROME VICTIM
JABS LINKED TO GULF
WAR SYNDROME
MORE THAN 10,000 DEAD
FROM GULF WAR SYNDROME!
History of Gulf War
Aug 1990: Iraq invaded Kuwait
Aug 1990 - Jun 1991:
Allied Troop Deployment
697,000 by USA
53,000 by United Kingdom
4,500 by Canada
Feb 1991:
Iraq expelled from Kuwait
History of Gulf War Symptoms
Within months of end of war some veterans reported symptoms
Some studies tried to identify the key clinical features of ill health in veterans
US Government invited sick veterans to join voluntary medical registries
Many presented with non-specific symptoms
Non-Specific????
Most common primary diagnoses among 20,000 vets were:
musculoskeletal disorders (18.6%)
psychological conditions (18.3%)
multi-system conditions (17.8%).
No evidence of a unique illness
Joseph 1997
History of Gulf War Symptoms
Collection of symptoms in soldiers who served in Persian Gulf War (1990-1991)
Highly variable
Include:
• Rash
• Fatigue
• Muscle pain
• Joint pain
• Headache
• Irritability
• Depression
• Sleep disturbance
• Gastrointestinal problems
• Respiratory problems
• Cognitive deficits
SOLDIER HAILS GULF
CASE WIN
Dilemma of Gulf War Symptoms
The studies demonstrate an increase in reporting of symptoms in veterans
who served in the Gulf conflict, compared to those not deployed or who have
served elsewhere.
However, similar symptoms were reported in all control groups
No obvious unique collection of symptoms in Gulf War veterans
Data rely on self-reported symptoms, and lend themselves to response biases
Dilemma of Gulf War Symptoms
Variety and multiplicity of symptoms no consistent pattern exists . . .
. . . Therefore impossible to suggest a common underlying disease process
This makes it unlikely that a single cause will explain ill health in Gulf veterans
No study has found consistent abnormal clinical or laboratory findings among
ill Gulf veterans
The Veterans’ Case
1. Military authorities exposed service personnel to unreasonable medical
and environmental hazards
2. Military authorities have since failed to
a) generate, record and act on information of relevance to veterans’
illnesses
b) have withheld and destroyed information
c) have distributed misleading information
a) A nd have obstructed enquiries by others.
3. Diagnosis and treatment of illness has been impeded by the
unprecedented nature of the medical conditions, but also by the military
authorities’ own obstructive behaviour.
The UK Ministry of Defence
“The Ministry of Defence accepts some veterans have become ill
Many believe this ill health is unusual and directly related to service in the Gulf
UK Gulf veterans report more ill-health than other comparable groups
(Unwin et al 1999)
This is not unique to Gulf veterans as the same symptoms are seen in UK
military personnel who did not deploy to the Gulf
Gulf Conflict veterans report having more of the symptoms and are suffering
more severely from them
Some veterans have recognised medical conditions, but a large number of nonspecific, multi-system, medically unexplained symptoms are also reported”
Theory #1 Vaccine Overload
The Theory. . .
GW1Vs received at least 17 different
Vaccines: e.g. Pyridostigmine
Established vaccines
Poliomyelitis
Yellow fever
Cholera
Experimental vaccines
Anthrax
Botulinum toxoid
Pertussis
MOD says UK troops received 10 types
Adjuvants and viral genomes!
Squalene polymer antibodies
Rook & Zumla (1997)
Theory #1 Vaccine Overload
The Evidence
GWS symptoms X3 more likely in vaccinated vets
GWS in 34% vaccinated vets
12% vaccinated but non-deployed vets
4% in non-vaccinated vets
GWS lowest in troops on ships (21%)
GWS highest in those in Iraq / Kuwait (42%)
Steele 2001
Theory #1 Vaccine Overload
The Evidence
Compared with troops in Bosnia conflict, and those not deployed in Gulf:
GWVs reported significantly more symptoms:
Twice as likely to have GWS diagnosis
Number of vaccinations increased likelihood of GWS:
Vaccination before conflict less problematic than vaccination during
conflict
Ismail 2002
Theory #1 Vaccine Overload
The Evidence
US Department of Defence (1997)
Initiated Anthrax Vaccination Immunization Program
2.4 Million military personnel
Adverse reactions in personnel were similar to symptoms of GWS
French troops were not exposed to the same cocktail of drugs as British and
US service personnel, and have not reported any 'Gulf War Syndrome'
Theory #2 Depleted Uranium
The Theory. . .
DU – Low-level radioactive material
Nephrotoxic when internalised in large quantities
Amour piercing
Those handling munitions were appropriately protected and no adverse
health effects have been reported in these troops
Theory #2 Depleted Uranium
The Evidence. . .
Elevated incidence of renal dysfunction have not been
observed in personnel exposed to DU during the conflict
MoD is continuing research via an independent oversight
board
Several major reviews have concluded that it is unlikely
to be implicated in Gulf veterans' illnesses
Three-fold increase in birth defects in Iraq since 1991
The Royal Society 2003
Theory #3 Oil Fire Smoke
The Theory. . .
After ground war hundreds of oil wells
were set alight
Plumes of smoke across the battlefields
Smoke is known to cause respiratory tract irritation
Personnel involved in tackling the blazes were appropriately protected
Health of individuals working in the proximity of the fires was closely
monitored
Theory #3 Oil Fire Smoke
Theory #3 Oil Fire Smoke
The Evidence. . .
Monitoring studies found no evidence of increased levels of toxic gases
Was an increase in the level of fine particulate matter
Gulf veterans have commonly reported respiratory symptoms
Little evidence of pulmonary damage attributable to oil well smoke
Theory #4 Chemical / Biological Warfare Agents
The Theory. . .
Nerve Gas
Sarin
VX
Lewisite
Bacteria
Virus
Toxins
-
Cholinesterase Inhibition
Headaches, Diarrhoea, Paralysis
Theory #4 Chemical / Biological Warfare Agents
The Evidence. . .
There is no objective evidence that Iraq utilised any chemical or biological
warfare (CBW) capability
Documented that many detection devices alarmed
during the war
Many personnel believed they were under
chemical attack
Frequent false alarms occurred as the devices were
exquisitely sensitive, obtained at the expense of some
specificity
Theory #5 Post Traumatic Stress Disorder
The Theory. . .
Many attribute ill health to post-traumatic stress disorder
12% of all the veterans who attended were suffering from PTSD and somatic
symptoms (MoD's Medical Assessment Programme)
Gulf veterans were under considerable stress, not least from the constant
threat of chemical and biological weapons
Each conflict is associated with a unique
environment / type of warfare and a unique
combination of physical and psychological
stressors that may contribute to ill health
Theory #5 Post Traumatic Stress Disorder
The Evidence. . .
Large numbers of veterans suffering from symptoms who do not have
psychological dysfunction - suggests that stress alone cannot account for ill
health in all veterans
Symptoms in Gulf veterans are similar to those reported after other conflicts
(Hyams et al 1997)
The Gulf War cannot compare with previous wars in terms of human
casualties and other environmental factors
Impossible to compare research done on different wars owing to changing
nature of medicine, technology, and cultural factors
Media reporting in society contributes factors for ill health reporting
Theory #6 Pesticides / Insecticides
The Theory. . .
Widespread use of pesticides containing organophosphates (Ops) to combat
desert pests
Pyridostigmine bromide was given prophylactically as a counter-measure
against chemical attacks
Pyridostigmine reversibly inhibits acetylcholinesterase at the neuromuscular
junction and prevents subsequent binding
of nerve agents
Causes cholinergic crisis (nerve paralysis)
Theory #6 Pesticides / Insecticides
The Evidence. . .
The associations between reported exposure to pesticides and measures of ill
health showed no significant difference between Gulf and Bosnia & Era
veterans (Unwin et al 1999)
Usually gross evidence of toxic effects of high doses of OPs, there were no
obvious acute effects in the war theatre
Delayed effects of low-level exposure are not fully understood
Is plausible that there may be some role in veterans' illnesses
The MoD maintains it is unlikely to play a major role, but has commissioned a
detailed study into the effects of OPs
Possible Theories
(Multiple) Vaccines
Post Traumatic Stress Disorder
DU
Oil Fire Smoke
Chemical/ Biological Agents
Pesticides / Insecticides
Theory of a combination of
stress and vaccinations
having effects
Hotopf et al (2000)
Complications. . .
Military populations generally healthier than civilians (Healthy Warrior effect)
Gulf vets death rates are not higher than non Gulf vets
(including suicide and cancer)
Gulf vets have more accidents than non Gulf vets ! ? !
Over decade after deployment some GV still suffer ill-health
No unique Gulf war syndrome
Only common GV related experience involves “perceptions of ill-health”
GVs symptoms are worse for lower ranks
Huge bias - recalling more exposures, incidents, and inoculations
Health Perceptions of Vets
Military populations generally healthier than civilians (Healthy Warrior effect)
17% of UK vets believe they have GWS (Chalder et al 2001)
Belief in having GWS linked to:
1) Knowing someone else with GWS
2) Being ill afterwards
3) No longer in military
4) High number of vaccinations before deploy
Health Perceptions of Vets
Characteristics of Vets responding
To the survey
Chalder et al (2001)
Health Perceptions of Vets
Relationship between GWS and other outcomes
Chalder et al (2001)
The Future for GW1 Vets?
Legally, GWS exists - - - - Medically, GWS does not exist
Upto 9000 UK troops (of 53,000 deployed) may have GWS
2800 (approx) UK vets have attended MOD
assessment programme
This number is declining
What of GWII?
Same problems to emerge?
How will any symptom reports be handled?
Crackpots and the Convinced
Conspiracy Theorists
It didn’t
The Future for GW1 Vets
Organised
Medical recognition wanted
Legal recognition acquired
Care for GWS sufferers
Info dissemination
References
Joseph S, and the Comprehensive Clinical Evaluation Program Evaluation Team. A
comprehensive clinical evaluation of 20,000 Persian Gulf War veterans. Milit Med, 162:
149-55, 1997.
Unwin C, Blatchley N, Coker W, et al. Health of UK servicemen who served in the Persian Gulf
War. Lancet 353: 169-78, 1999.
Lee HA, Gabriel R, Bolton JPG, et al. Health status and clinical diagnoses of 3,000 UK Gulf War
veterans. J R Soc Med 95: 491-497, 2002.
Ministry of Defence. Gulf Update. Issue 4. London: MoD, 2002.
Coker WJ. A Review of Gulf War illness. J R Nav Med Serv 82: 141-146, 1996.
Rook G & Zumla A. Gulf War Syndrome: is it due to a systemic shift in cytokine balance towards a
Th2 profile? Lancet 349: 1831-1833,1997.
Hotopf M, David A, Hull L, et al. Role of vaccinations as risk factors for ill health in veterans of the
Gulf War: cross-sectional study. BMJ 320: 1363-1367,2000.
Hyams KC, Wignall FS, Roswell R. War syndromes and their evaluation: from the US Civil War to
the Persian Gulf War. Ann Intern Med 125: 398-405, 1997