Elsevier

The Lancet

Volume 353, Issue 9148, 16 January 1999, Pages 169-178
The Lancet

Articles
Health of UK servicemen who served in Persian Gulf War

https://doi.org/10.1016/S0140-6736(98)11338-7Get rights and content

Summary

Background

Various symptoms in military personnel in the Persian Gulf War 1990–91 have caused international speculation and concern. We investigated UK servicemen.

Methods

We did a cross-sectional postal survey on a random sample of Gulf War veterans (Gulf War cohort, n=4248) and, stratified for age and rank, servicemen deployed to the Bosnia conflict (Bosnia cohort, n=4250) and those serving during the Gulf War but not deployed there (Era cohort, n=4246). We asked about deployment, exposures, symptoms, and illnesses. We analysed men only. Our outcome measures were physical health, functional capacity (SF-36), the general health questionnaire, the Centers for Disease Control and Prevention (CDC) multisymptom criteria for Gulf War illness, and post-traumatic stress reactions.

Findings

There were 8195 (65·1%) valid responses. The Gulf War cohort reported symptoms and disorders significantly more frequently than those in the Bosnia and Era cohorts, which were similar. Perception of physical health and ability were significantly worse in the Gulf War cohort than in the other cohorts, even after adjustment for confounders. Gulf War veterans were more likely than the Bosnia cohort to have substantial fatigue (odds ratio 2·2 [95% CI 1·9–2·6]), symptoms of post-traumatic stress (2·6 [1·9–3·4]), and psychological distress (1·6 [1·4–1·8]), and were nearly twice as likely to reach the CDC case definition (2·5 [2·2–2·8]). In the Gulf War, Bosnia, and Era cohorts, respectively, 61·9%, 36·8%, and 36·4% met the CDC criteria, which fell to 25·3%, 11·8%, and 12·2% for severe symptoms. Potentially harmful exposures were reported most frequently by the Gulf War cohort. All exposures showed associations with all of the outcome measures in the three cohorts. Exposures specific to the Gulf were associated with all outcomes. Vaccination against biological warfare and multiple routine vaccinations were associated with the CDC multisymptom syndrome in the Gulf War cohort.

Interpretation

Service in the Gulf War was associated with various health problems over and above those associated with deployment to an unfamiliar hostile environment. Since associations of ill health with adverse events and exposures were found in all cohorts, however, they may not be unique and causally implicated in Gulf-War-related illness. A specific mechanism may link vaccination against biological warfare agents and later ill health, but the risks of illness must be considered against the necessity of protection of servicemen.

Introduction

From late 1990, the UK deployed 53·462 military personnel to the Persian Gulf War. In the months after the end of the war, anecdotal reports emerged in the USA of various disorders affecting Gulf War veterans. In the UK, similar observations surfaced in 1993, after a television broadcast in June. Some UK Gulf War veterans have experienced health problems since their return. Such anecdotal reports cannot, however, establish whether these complaints have any particular pattern, nor whether they are related to Gulf War service.

Previous studies of the health of Gulf War veterans have had limitations. Comparisons with non-military populations may be misleading, since military recruitment involves medical screening. Clinical assessment programmes for non-randomly selected veterans with symptoms cannot provide epidemiological information or answer questions about links to active service.1 Some of these limitations have been addressed. A large-scale study of US veterans found no substantial differences in admissions between Gulf War veterans and military controls.2 However, only admissions to military hospitals were included, without contact with outpatients, primary-care physicians, or civilian hospitals, which may have led to bias towards sicker veterans.3 One cohort study used complete outcome data from an unselected military population, but looked only at mortality.4 The Centers for Disease Control and Prevention (CDC) study5 was restricted to serving air-force personnel. Sicker veterans are more likely to have left the services because of ill health. To date, only one study has used a random sample of veterans and tried to follow up still serving and discharged personnel.6

We investigated, among UK male Gulf War veterans from army, navy, and air force, whether there was a relation between ill health and the Gulf War.

Section snippets

Methods

We carried out a cross-sectional epidemiological survey to compare the health profiles of three randomly selected UK military cohorts.

Responses

We received 8195 (65·1%) questionnaire replies (2961 [70·4%] Gulf War cohort, 2620 [61·9%] Bosnia cohort, 2614 [62·9%] Era cohort). Addresses were not available for 152 participants. 503 (4·0%) servicemen refused to respond. 980 (7·9%) questionnaires were returned undelivered to the research team by the Post Office at the end of the three mailings (figure 1). If the undelivered questionnaires are taken into account, the minimum effective response rate was 70·6%. The characteristics of the Gulf

Discussion

UK veterans of the Gulf War report higher rates of many symptoms and disorders and have a decreased perception of well being than servicemen who were not deployed to the Gulf War, despite no evidence of increased frequencies and no excess of objective outcomes, such as birth defects, cancers, or death.1, 2, 4 By contrast, we report that servicemen in the Gulfwere about three times more likely to fulfil criteria for chronic fatigue, post-traumatic stress reaction, or the CDC multisymptom

Study limitations

As in similar studies, the most important factor for participation in the survey was our ability to find accurate addresses.5, 6, 13, 14 The second factor influencing response was demography. Young men generally change addresses frequently and are not inclined to respond to lengthy questionnaire surveys,15 which has been experienced in previous studies of Gulf War veterans.

A key question is whether or not participation was biased towards those with health complaints. Responders were more likely

Implications

The finding that active military service has led to long-term adverse health effects is not new and has been reported in US and Australian Vietnam veterans,22, 23 and inferred after earlier conflicts.24 Furthermore, the US study of Gulf veterans most comparable to ours reported a similar decline in self-reported health status and higher rates of various symptoms and disorders.6

The most obvious explanation for this increase in symptoms in the Gulf War veterans is that it relates to different

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