Millennium Cohort

US Acts to Stem a Gulf War Legacy 

DAVID BROWN / Washington Post 21jan03

Military Hopes New System Keeps Health Syndrome at Bay

As it lays the groundwork for another war with Iraq, the US military is engaged in a massive effort to prevent the reappearance of Gulf War syndrome.

Over the decade that followed the 1991 Persian Gulf conflict, the chronic illnesses that tens of thousands of veterans described ultimately marred the U.S. victory. The agonizing investigation of what came to be known as Gulf War syndrome eroded trust in the military, cost hundreds of millions of dollars and consumed thousands of years of human labor.

The military requires each soldier deploying  
to leave a serum sample in cold storage  
for testing if symptoms develop. 
(Michael Williamson/Post)

As American troops prepare to face the same enemy in the same place, military planners hope that this time they can keep the perplexing phenomenon at bay. Their weapons include health questionnaires, epidemiological studies, a powerful computer system, soil-sampling kits, a new generation of detectors for nerve gas and biological threats, and millions of tubes of human serum stored at 25 degrees below zero.

"Is a replay a concern? The answer is definitely yes," said Col. Robert F. DeFraites, an Army epidemiologist who investigated the first vague physical complaints that Gulf War veterans reported 10 years ago this spring. "I think we feel it could come back again."

It is not too much to say that the experience of Gulf War syndrome in a small way is remaking the art of modern warfare. The damage and confusion it wreaked has created a new world of things for commanders to worry about. No longer is it enough to bring well-trained fighters to a place where they can engage the enemy. Now, the military is determined to document each soldier's sense of his own health, counsel him on what to fear beyond bullets and bombs, and test the air he breathes and the soil below his billet.

"Our focus used to be only on winning the battle, and that still is the focus," said Lt. Col. Karl Friedl, director of operational medical research for the Army. "But now there's this greatly increased attention on post-deployment health. We didn't use to think about that."

The sheer number of people complaining of illness after the Gulf War helped change that view. Perhaps as many as 160,000 of the nearly 700,000 men and women who served in Operation Desert Storm may have suffered lingering physical symptoms in its aftermath. Over a decade, the government funded 224 research projects, costing $213 million, to try to uncover the cause, extent and best treatment for the illness.

The investigation has taken so long partly because so many questions raised by veterans could not be answered. Were all the chemical weapons alarms that sounded on or near the battlefield false alarms? Were toxic chemicals in the ground and air? Who received the anthrax vaccine? Where were troops on particular days? What was the physical and mental state of the soldiers before they shipped out?

The military's inability to give clear answers to these and many other questions, while understandable to some observers, fueled the belief that horrible events may have occurred during the war, and might have been averted.

In the end, however, military health officials and most civilian researchers who studied the subject do not believe anything unusual or undiscovered occurred in the Gulf War to cause chronic illness. This time, the military is determined to begin and conclude the conflict with much better information.

The preventive medicine machine that will roll into battle with U.S. soldiers if war erupts serves two purposes. The first is to monitor and mitigate actual threats to health. The second is to collect data that will allow everyone from the secretary of defense to doctors to better answer the questions from veterans after this or other deployments.

Perhaps the most widespread belief among those with Gulf War syndrome is that they encountered toxic substances during the conflict that later made them ill. While most scenarios were implausible, this did not keep the military from coming under withering criticism by Congress, panels of experts and the media for not knowing enough about the battlefield environment, and who was in it.

A New Focus on Hazards Today, about 500 active-duty soldiers are trained to routinely monitor air, water and soil wherever troops go. This new focus on environmental hazards began right after the Gulf War. When American peacekeeping troops went to Bosnia, 2,500 samples were processed, and in Kosovo, 1,500. More than 1,000 have been taken so far in Afghanistan and Central Asia.

A profile of environmental hazards has been added to this information, gleaned from decades of surveillance photography and other intelligence, for many parts of the world where U.S. troops might be sent. This information, along with the lab test results, routinely goes to commanders for use in planning missions.

Much of this work is coordinated by civilian scientists and planners at the U.S. Army Center for Health Promotion and Preventive Medicine at Aberdeen Proving Ground in Maryland. On Dec. 28, the center began getting daily reports of troop locations, down to the company level, for American soldiers deployed to Central Asia, effectively capturing the other side of the exposure equation. A request has been made to obtain similar reports from Iraq if troops go there.

"That whole culture didn't exist in 1991 as it does now," said John Resta, the center's director of health risk management.

The surveillance technologies that have undergone the biggest change are chemical and biological weapons detectors.

The military's main chemical sensor during the Gulf War, the M8A1, gave frequent false alarms, which frayed nerves and forced soldiers repeatedly to don protective suits. It has been replaced by devices that are much better at distinguishing between true threats, such as nerve gas and mustard agents, from innumerable other contaminants in the air.

Among the four new chemical detection systems is one that can detect vapors and aerosols at a distance.

Sampling for biological agents -- a much more difficult task -- was not done routinely during the Gulf War. Now, there are five types of biodetectors in use that can detect bacterial or viral threats such as anthrax, botulinum toxin or plague.

"We have learned our lessons," Army Brig. Gen. Stephen Reeves, head of chemical and biological defense, said last week. "We have applied the lessons of Desert Storm."

Many of the disease surveillance and prevention efforts take place far from the battlefield. Some rely on decades-old methods that have been updated and given greater prominence by the Gulf War experience. Others are wholly new.

Among those is the requirement that every soldier fill out a "health assessment" questionnaire just before deploying and right after returning. The forms have fewer than 10 questions. Some can be answered by filling in circles -- "Would you say your health in general is" followed by five choices. Others, not mandatory, call for written responses, such as, "Do you currently have any questions or concerns about your health?" and "Do you have concerns about possible exposures or events during this deployment?"

The form serves two purposes. A doctor reviews it upon completion, and thus "it allows the provider to interact with the patient" just before deployment, said Lt. Col. Mark V. Rubertone, an epidemiologist who heads the Army Medical Surveillance Activity.

Later transformed into digital files, the form goes into the Defense Medical Surveillance System, part of the military's computerized medical record, where the scannable answers can be easily studied en masse. Researchers wanting to read the answers can call up a digital image of the completed form. Amassed with hundreds or thousands of others, the forms make possible something approaching "instant epidemiology."

Among the sorts of things that Army researchers are now able to determine is that 61.7 percent of troops deployed in 2000 and 2001 reported the same health status on the before and after questionnaires. Forty eight percent of soldiers returning from Uzbekistan last year expressed concern about exposures, with uranium, radiation, asbestos, chemical agents and tuberculosis topping the list. Soldiers who went to Southwest Asia, however, were only half as likely to be concerned about possible exposures as their comrades who went to Bosnia.

The medical surveillance system also records each soldier's history of outpatient medical care and hospitalizations. There has been a particular effort -- not entirely successful, several officials said -- to include a full immunization record. Many ailing Gulf War veterans said they received vaccines that were never recorded in their charts.

Human Clues to the Illness Supplementing this information is the Department of Defense Serum Repository, located in Silver Spring. It holds 30 million samples from 7.5 million individuals -- the world's largest such collection.

The repository began in 1989 when the military began archiving blood left over from routine AIDS testing. The Gulf War experience, however, has made it a working tool. Every deployed soldier now must have a sample not more than 12 months old in the repository before shipping out.

Serum is the watery straw-colored liquid left over after red and white cells have been removed from a sample of blood. It contains proteins, antibodies and traces of any unusual chemicals a person may have absorbed recently. It cannot answer every health question. But it can answer some.

Recently, for example, a military researcher used it to address the concerns of 62 Gulf War veterans with hepatitis C who believed they acquired the viral infection in the Gulf. He tested their pre-war samples and found that 58 were infected before they left.

The military is also sponsoring or running several studies seeking to assess the physical and mental state of military units and their members before they go overseas.

Before the Bosnia deployment, for example, members of a Massachusetts National Guard unit took a 15-minute test of verbal and math processing, reaction time and memory. They took it again in the Balkans, and a third time when they came home. The results have not been published. About 2,000 people in two battalions in Fort Lewis, Washington, are now undergoing neuropsychological testing in anticipation of going to Iraq. These studies may lead to routine testing in the future.

"Our goal would be to eventually baseline everyone," Lt. Col. Friedl said.

Perhaps the most ambitious epidemiological project is a long-term study of a randomly chosen sample from all branches of the armed services. Called the Millennium Cohort, it has enrolled 75,000 people and will add 20,000 more in 2004 and 2007. Its members answer a long questionnaire about their health, habits, symptoms and daily functioning -- exactly what was not known about Gulf War veterans before they got ill. They will be resurveyed every three years for 21 years.

"It's fair to say that the Gulf War experience was largely responsible for its creation," said Cmdr. Margaret A.K. Ryan, the Navy epidemiologist in charge of the Millennium Cohort.