WASHINGTON, DC—According to some of the authors of a Congressionally-mandated report on Gulf War Illness, the Institute of Medicine—the independent institute charged over a decade ago with examining the link between serving in the 1991 Gulf War and an increase in multi-symptom illnesses—has been lax when it comes to examining all of the existing medical data. The Research Advisory Committee on Gulf War Veterans’ Illnesses—a committee of professionals tasked by Congress to examine existing evidence on the issue—released a report in November 2008 that made definitive conclusions as to some of the causes of the multi-symptom illnesses suffered by Gulf War veterans. However, several volumes of IoM reports released over the last 10 years have failed to make such conclusive links.

While the scientific procedures followed by both groups were much the same, some members of the RAC state that the IoM committees chose to ignore some data and did not fully understand what IoM had been charged with doing.

The RAC Report

In 1998, Congress passed a law directing the Secretary of Veterans Affairs to task IoM with reviewing the available scientific and medical literature regarding possible Gulf War health hazard exposures and illnesses. The same law created the RAC, whose mission was to make recommendations to the VA Secretary on Gulf War research.

In November, the RAC released a report titled “Gulf War Illness and the Health of Gulf War Veterans.” The report consisted of a review of existing scientific literature and recommendations from RAC to VA. The report concluded that one out of every four Gulf War veterans is afflicted with Gulf War Illness. Gulf War Illness, also known as Gulf War Syndrome, is reported by combat veterans of the Gulf War, and characterized by a wide range of symptoms, including chronic fatigue, loss of muscle control, muscle and joint pain, memory loss, and breathing problems. The authors of the report also concluded that two of the definitive causes of GWI are pyridostigmine bromide pills, which were given to protect troops from the effects of nerve agents, namely sarin gas, and the extensive use of pesticides.

RAC Chairman James Binn testified to the House VA Subcommittee on Oversight and Investigations, which has made Gulf War Illness a priority during this Congress last month. He told legislators that the four existing comprehensive IoM reports on Gulf War exposures and illness have not presented VA or legislators with a clear picture of the state of the science.

“I have worked for three previous Secretaries of Veterans Affairs—all honorable men. But I have sadly seen VA staff continue to minimize the serious health problems of Gulf War veterans,” Binn told committee members. “Because of the stature of IoM, its reports have misled not only the Secretaries of Veterans Affairs, but also researchers, doctors, Congress, veterans’ families, and veterans themselves.”

Lea Steele, PhD, scientific advisor to the RAC, testified that the differences between RAC and IoM reports are not subtle and are not explained by minor discrepancies in review methods or how individual studies were weighted. “They reflect major differences in the types of questions asked by the reports and the scope of evidence examined by the reports,” she explained. Dr Steele observed that the IoM committee reports did not examine animal studies to the extent that they were available, did not take into account all categories of studies, including studies on combinations of toxins, and made little use of existing government reports on exposure. These include DoD reports that concluded that 40,000 troops were overexposed to pesticides while in theater.

For example, RAC concluded that the use of PB pills was a cause of GWI because their report looked at six studies indicating that PB is significantly associated with Gulf War Illness. “We also found a dose response effect,” Dr Steele explained. “Veterans that took PB for a week or longer had higher rates and also had significantly higher illness than veterans who took less PB. We also considered results of animal studies that showed brain effects that are not seen in low-dose PB exposure.”

The IoM report, on the other hand, was only able to conclude that PB is associated with short-term effects, and there was insufficient evidence to make any conclusions about the long-term. “IoM’s findings were based largely on clinical research done in humans that generally studied effects of PB taken over a short period, usually a few days, and had no long-term follow-up. The IoM findings [also] did not address whether PB is associated with undiagnosed illness. This is true for most of the [agents] looked at by IoM,” Dr Steele declared.

This difference in what evidence hs been taken into account by the two reports has a significant impact on how the extent of GWI is quantified. The RAC report found that 35 to 40% of Gulf War veterans have a defined pattern of multi-symptom illness over and above the background rates found in the comparison group. The IoM findings indicate just in excess of 13%. “The IoM reports were intended by Congress to be a comprehensive examination of evidence [on how exposure is associated to illness, but IoM’s reports do not provide findings of that type, and could not based on the evidence considered,” Dr Steele said. “Officials who rely on IoM reports will know very little about Gulf War illness, its characteristics, its impact on veterans, and its link to exposures during the Gulf War.”

Defending IoM

Doctor Lynn Goldman, professor of public health at Johns Hopkins University, chaired several of the IoM committees on Gulf War illness and

defended the work done by IoM. She indicated that the IoM committee did look extensively at animal studies, though there were sometimes thousands of animal studies on a single chemical agent alone, and so the committee did not review all existing studies.

While animal studies are not as useful when it comes to identifying symptoms, their value is undeniable. “Now, you can’t ask a dog about a headache, so with conditions that are based soley on symptoms, you’re going to have trouble elucidating much about those from animal studies,” Dr Goldman explained. “But you’re going to find a tremendous amount about how substances are absorbed and what they’re doing. And there’s no group of scientists that are going to say, ‘We’re going to ignore that.’”

As for why the RAC report found PB as a definitive cause, Dr Goldman said she does not believe the existing science bears such a claim out. “Even if PB is involved, which it could be in some of these illnesses, some of the studies published on multi-symptom illnesses that show high rates in Gulf War veterans are in groups of veterans who never deployed anywhere close to the [area where PB was used]. Groups of veterans that were on aircraft carriers the entire time also have high rates of illness.”

In fact, Dr Goldman declared, making any definitive judgment on exposure and GWI is very difficult, if not impossible. “This is not like Agent Orange, where you can go back years later and find traces of dioxins in people’s bodies. These substances that we reviewed—the exposures are fleeting, they do not leave an imprint that we today know how to identify,” she said. “Maybe someday we will, but today we don’t have a way of saying you were exposed to particulate matter from an oil well fire 20 years ago.”

Doctor Goldman used the bombing of Al Muthanna and subsequent fire at a chemical weapon plant in February 1991 as an example of how difficult it is to judge exposure effects. “We’ve only been able to use techniques like modeling to understand what consequences of exposures might be,” she said. “And it’s very difficult to model something when you don’t know the quantity of the material that was there, and you don’t know the temperature at which it was burning. You have some information about the weather and the wind speed, but some of the basic parameters for modeling are missing, so it’s very difficult to determine what the exposures have been.” She added, “The bottom line is that while these committees have looked at the potential exposures, as charged by Congress, it’s very difficult because off the lack of real exposure information for any scientific body to make any firm cause and effect conclusions about exposure for individuals or groups of individuals…and health outcomes.”

What both groups of researchers do agree on is that deployed Gulf War veterans suffer from multi-symptom illnesses at a higher rate than their non-deployed counterparts. They also agree that giving VA a laundry list of possible causes for the purpose of establishing service-connection is less important than getting those veterans the right care. “I think there needs to be a reexamination of how this whole scheme has worked in terms of the law and the idea of service-related illness and the hurdles that the veterans have had to leap over in order to be able to document service-related illnesses and what they’ve had to do in order to receive the services they’ve received,” Dr Goldman said. “It might make sense to take all of the conclusions—and there have been so many that have been made—and look at what the VA has done with them. And how this has or has not benefited the veterans. I think that’s the important thing, at the end of the day. Not how the committee has or has not reviewed these things, but what can be done to benefit the veterans and their health.”

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