Gulf War Syndrome: all in the mind's eye

We have seen virtually identical patterns of delayed illness in veterans after every modern war, caused by the after-effects of anxiety and stress

Living in London this summer, I've been following the saga of Gulf War Syndrome in the British press. A wave of alarming articles about causes or cover-ups appears every week, subsides without follow-up or confirmation, and gives way to the next wave of headlines and accusations. Most recently, the suicide of Labour MP Gordon McMaster has been linked to a Gulf War Syndrome-like illness that he believed he had acquired through careless use of pesticides in the garden. "It was as if I had been struck by lightening," McMaster said of his illness. "I wanted just to lie down and not move."

GWS has been blamed on everything from flea collars to sheep dip, and British and American theories of causation are totally different. While British veterans' groups believe that multiple inoculations plus organophosphate insecticides (OPs) produced a toxic cocktail, American vets believe that vapourised sarin released by the bombing of a chemical dump at Khamisayah has caused the 123 reported symptoms of GWS.

But the real gulf in this illness is the one between alleged causes and proven effects. Even hard-nosed London journalists and cynical academics have swallowed extremely speculative and contradictory reports of possible infection, and accepted far-fetched claims of government conspiracy - often with the rationale that if Nicholas Soames denied it, it must be true. John Reid, New Labour's Armed Forces Minister in charge of investigating GWS, is making an overdue effort to win back confidence in the government's integrity with a pounds 2.25m research programme and greater openness to veterans' groups. But public enlightenment on the causes of Gulf War illness will demand much tougher coverage of medical and scientific evidence from the British media.

On 15 June, for example, British newspapers reported that a US Congressional report "fiercely critical" of the Pentagon's handling of GWS would shortly be released; this report, it was said, warned of the dangers of Iraqi biological weapons, and confirmed "widespread cover-up by the Clinton administration". Although the report was released on 17 June, I haven't read any more about it here. Could that be because this hasty study, carried out by the General Accounting Office, was immediately condemned by several government and independent researchers? The Department of Veterans Affairs, among others, noted a "lack of understanding of clinical research, epidemiology, and toxicology", and concluded that "the conceptual process by which GAO reached its conclusions are neither scientifically sound nor logical, and they are internally inconsistent."

On 17 June, however, the British press had moved on to the resignation of Lieutenant Colonel Banu Bhatt, the military doctor heading the Government's Medical Assessment Programme (MAP). "The Gulf veterans were not happy with him," said the Countess of Mar, who believes herself to have been infected by organophosphates. "For example, he dismissed the notion that organophosphate pesticides could have caused sickness." The former MAP director, Group Captain Bill Coker, agreed to fill in from his new post in Washington. "I am highly delighted at this decision," said Major Ian Hill, chairman of the National Gulf Veterans and Families Association. There is no doubt that he is the man for the job." Indeed, veterans suspected that Coker had been forced out because he was overly sympathetic to veterans. They eagerly awaited his medical report, which, John Reid told groups, had been withheld because it had been done on only 284 cases, but would be published with a larger sample this year.

No one seemed to know that Coker's study, "A Review of Gulf War Illness", has already been published - in the Journal of the Royal Naval Medical Service, in 1996. In it he concludes: "It is apparent even from these preliminary data, that the wide range of illnesses described ... were not triggered by exposure to a single agent, for in most cases there is no evidence of any such exposure. In many cases where an exposure is claimed, the symptoms and signs do not match the diagnostic criteria for such exposure. The nonspecific, multi-system nature of many veterans' symptoms is compatible with many of the manifestations of psychological stress and I would suggest that ... [this] is an important aetiological factor in a great deal of the less well-defined illness found in veterans." (The import of Group Captain Coker's original study is therefore the opposite of what the veterans wanted to hear.)

Similarly, on 14 July, the Daily Mail, among others, reported British Gulf veterans' fears that they have passed on illness to their wives and children without mentioning a major American study of 75,000 births which found no evidence that service in the Gulf had increased the risk of birth defects, miscarriages or infertility.

Most recently, on 30 July, newspapers reported Reid's announcement that a small number of British troops may have been exposed to vapourised sarin between 10 March and 13 March, 1991. The source of his story was a new expanded CIA computer model of the worst-case scenario if sarin and cyclosarin had been released into the air at Khamisayah.

But the British media (with the exception of The Independent on 26 July) have not explained that whether 100 or 100,000 troops may have been exposed to vapourised sarin, the likelihood that it could have caused any long- term symptoms is remote. As science editor David Brown noted in the Washington Post, "Nerve gases almost always cause immediate symptoms in people who encounter them and almost never cause permanent damage to those who survive. There is even less evidence that they can cause illnesses that first appear months after contact." There was not a single complaint of nerve gas poisoning during the conflict, despite unmissable symptoms of pinpoint pupils, runny nose, eye pain, sweating, nausea, diarrhoea, convulsions, and wheezing.

Three decades of research on nerve gases have produced no evidence of long-term damage from low-level exposure. At worst, the exposures at Khamisayah were extremely low. The most extreme level would have been between .01 and .99 milligram minutes per cubic meter, when 35 milligram minutes can incapacitate, and 100 can kill.

Evidence about the long-term effects of multiple vaccinations and pesticides is just as weak. With regard to multiple vaccines, the Presidential Advisory Committee concluded that "humans live among a vast population of hostile micro-organisms, and vaccinations - even multiple, contemporaneous vaccinations - are a small part of total immune stimulation. Individual vaccines can cause adverse effects, but several studies of the effects of giving multiple vaccinations at one time have found no adverse effects associated with the practice."

What about pesticides? The OP pesticides American troops used in the Gulf, similar to those in Britain, were registered with the Environmental Protection Agency, and are commonly used without special licence in the US. A few studies on animals have warned of dangers from pesticides used in combination with anti-nerve agents such as pyridostigmine bromide. But several research panels have dismissed these studies as misleading or inconclusive. In one much-publicised experiment, some chickens were given massive doses of chemicals for two months: four times the dosage of pyridostigmine bromide vets prescribed, 10 times the dosage that even a heavy insect-repellent user would slap on, and seven million times the daily Permethrin dose a soldier might have absorbed from his uniform. Even so, only three of the chickens eventually kicked the big chicken bucket.

A huge problem with most Gulf War illness stories is that symptoms are self-reported. While Tony Flint of the National Gulf War Veterans and Families Association in the UK claims that there have been 133 deaths from Gulf War illness, American epidemiological studies in The New England Journal of Medicine and Journal of the American Medical Association have established that Gulf War veterans have not died more than non-deployed counterparts, and have not been hospitalised more, but have a greater prevalence of self-reported symptoms, such as muscle pain, fatigue, and insomnia.

These veterans are indeed experiencing pain. But the reality of their symptoms does not depend on the establishment of a chemical cause or a government conspiracy. We have seen virtually identical patterns of delayed illness after every modern war, caused by the after-effects of anxiety and stress. Until we can create an environment of respect and compassion for psychologically caused illnesses, an environment in which the suicide of a man like Gordon McMaster can be seen as a warning about male depression rather than a warning about horticulture, Gulf War syndrome will continue to spread, and even millions of pounds of funding of scientific research will not lead us to prevention or cure.

Elaine Showalter teaches at Princeton University. Her most recent book `Hystories' (Picador) describes Gulf War Syndrome as one of the hysterical epidemics of the Nineties.