TESTIMONY
OF ROBERTA WHITE, PH.D., ABPP
PROFESSOR AND CHAIR,
DEPARTMENT OF ENVIRONMENTAL HEALTH
BOSTON UNIVERSITY SCHOOL OF
PUBLIC HEALTH
PROFESSOR AND ATTENDING IN
NEUROLOGY (NEUROPSYCHOLOGY)
BOSTON UNIVERSITY SCHOOL OF
MEDICINE
BEFORE
THE U.S. HOUSE OF REPRESENTATIVES,
COMMITTEE
ON VETERANS’ AFFAIRS,
SUBCOMMITTEE
ON OVERSIGHT AND INVESTIGATIONS
FOR
A FEBRUARY 23, 2016 HEARING ENTITLED:
“PERSIAN
GULF WAR: AN ASSESSMENT OF HEALTH OUTCOMES
ON
THE 25TH ANNIVERSARY”
Gulf War illness and
the health of Gulf War veterans: 25 years of progress and set-backs
It is the 25th anniversary of the Gulf War. Our
veterans won this conflict in less than a week. However, concern remains high
that the troops who produced this victory are and will remain ill, without legitimate
acknowledgement of their health problems and the associated disabilities, and
without effective treatment options now or in the future.
Despite decades of scientific evidence to the contrary, the
VA and the Institute of Medicine have recently produced documents that minimize
the poor health of these veterans by terming their illnesses as “functional ” disorders, a medical term for
psychiatric illness. This injustice is
then compounded by a treatment guideline that suggests ineffective, unproven,
purely palliative, and potentially harmful treatments for Gulf War illness that
focus on psychiatric symptomatology.
I speak as a clinician/scientist who has worked with Gulf
War veterans clinically and in research for over 20 years. My work on Gulf War illness is part of an
overall clinical and research career in which I have studied the effects of
exposures to neurotoxic chemicals on adults and children. For eight years, until last fall, I served as
scientific director of the Research Advisory Committee on Gulf War Veterans
Illnesses.
Science of Gulf War
illness
It has been known since a year or two after their return
from the Gulf that a subset of Gulf War veterans was experiencing debilitating
physical illness. (In fact, the
Department of Public Health at VA engaged clinical and research personnel at
the Boston VA Medical Center, including myself, in trying to figure out what
was going on with the veterans).
Research beginning at that time and continuing to the
present has produced a consensus of scientific knowledge about this
illness.
- Dozens of studies
in multiple countries reveal that approximately 30% of the 1991 Gulf War
veteran population suffers from a characteristic pattern of physical health
symptoms. This research has further revealed that this pattern of health
problems was seen in Gulf War veterans, but not veterans of other conflicts
(such as Bosnia), and that veteran populations from multiple coalition forces from
the Gulf War experienced the same disorder.
The health problems of Gulf War veterans are not vague and
extremely variable, as is often suggested.
There are two case definitions of the illness—the Kansas definition and
the Centers for Disease Control definition—that clearly allow researchers and
clinicians to decide whether an individual Gulf War veteran has the illness.
These definitions were supported by the Institute of Medicine in its Volume 9
report for use in clinical and research work.
I cannot think of any illness in which all patients have exactly the
same symptoms—diagnosis of diseases and disorders is based on critical masses
of signs and symptoms that cluster together to fit a case definition. Gulf War
illness is not different from any other disorder in this way.
- This illness is not
the result of stress or other psychiatric factors. It has been known since the 1990s that
post-traumatic stress disorder occurs at far lower rates in Gulf War
populations than Gulf War illness. Rates are typically less than 10%, in
contrast to the 30% for Gulf War illness.
Furthermore, research conducted in veterans with Gulf War illness has
repeatedly shown that post-traumatic stress disorder and other psychiatric
disorders do not predict whether a veteran will have Gulf War illness, that is
rates of Gulf War illness are not significantly higher in Gulf War veterans
with psychiatric diagnoses.
- Research over the
past 20 years has also shown that occurrence of Gulf War illness is associated
with exposures to chemicals present in the Gulf War theater, especially
pesticides and use of pyridostigmine bromide (and possibly other chemicals,
including nerve gas agent sarin and particulate matter from oil well fires).
Epidemiologic, clinical, and animal research involving Gulf War
veterans and other populations with similar types of exposures has converged to
show that these chemicals affect the central nervous and immune systems,
producing chronic signs and symptoms that affect multiple body systems.
As suggested by the Institute of Medicine in its recent Volume 10 report, there is a mind/body continuum here. However, it is not that these veterans have a psychiatric condition that is affecting their physical health; it is that exposures to the chemicals present in the Gulf theater affect brain systems that mediate cognition, emotion, and immune function simultaneously. Thus, ill veterans have multiple cognitive, physical and emotional complaints and signs and symptoms.
The previous Institute of Medicine report, Volume 8,
reflected the scientific consensus on Gulf War illness that I have just described,
concluding that “[t]he excess of unexplained medical symptoms reported by
deployed Gulf war veterans cannot be reliably ascribed to any known psychiatric
disorder” and that “it is likely that Gulf War illness results from an
interplay of genetic and environmental factors."
Like the reports of the Research Advisory Committee, the
Volume 8 Institute of Medicine report called for rigorous research to find
effective treatments for the illness, including “studies to identify . . .
modifications of DNA structure related to environmental exposures, . . .
signatures of immune activation, or brain changes identified by sensitive
imaging measures.”
Effective treatments for Gulf War illness and other
illnesses induced by exposures that damage the brain do not exist. This is true for exposures such as lead,
mercury and solvents as well as the pesticides, pyridostigmine bromide,
low-level chemical warfare agents, and air pollutants to which our Gulf War
veterans were exposed. However, recent research has identified potential
treatments of Gulf War illness that target specific nervous system and
immunological mechanisms. These
treatments are now being piloted. They
are consistent with the types of treatments recommended in the Volume 8
Institute of Medicine report and hold promise for effective treatment of Gulf
War veterans, other veterans who experience chemical exposures, future troops
at risk of similar exposures, and people who are exposed to pesticides
occupationally and environmentally.
The progress made over the past 20 years in understanding
the mechanisms and causes of Gulf War illness, the physiological effects of
exposure to chemicals such as pesticides, and the treatment of these effects is
extremely exciting for the health of the military and the population as a
whole. The scientific findings from this
research hold great scientific promise.
In addition, they are the only source of hope for veterans with Gulf War
illness who are suffering from the disorder and wish to lead healthier, more
productive lives.
VA treatment
recommendations
However, recent recommendations from VA concerning the
diagnosis and treatment of ill Gulf War veterans threaten the viability of the
promise emanating from two decades of research.
These recommendations are summarized in a document entitled, VA/DoD
Clinical Practice Guideline: Management of Chronic Multi-symptom Illness, 2014.
The recommendations contained in this document are
regressive in terms of the knowledge that science and medicine have provided on
the disorder. They are consistent with
the stance that VA has taken since the Gulf War illness issue was first
discovered in the early 1990s, when VA staff published papers saying that the
health problems of Gulf War veterans represented post-traumatic stress disorder
or “effects seen in all wars,” statements that were made before any scientific data had been collected on ill Gulf War veterans.
The treatment recommendations include immediate referral for
mental health evaluation. In addition,
cognitive behavioral therapy is suggested.
This is a palliative treatment that might allow veterans to manage their
lives better but was already found in a major VA study to help less than 6% of
GW veteran patients and to provide only a 1 point improvement on a scale of
100.
Even worse, when these palliative therapies do not satisfy
the patient, the treatment guidelines recommend eleven drugs, ten of them
psychiatric. All eleven drugs are noted
in the guidelines to have significant adverse side effects, including suicidal
ideation. Even more disturbing, these medications have not been studied
with regard to effectiveness in the treatment of Gulf War illness. They are
not the medications or treatment approaches of choice among the VA clinicians
with extensive clinical treatment experience who have discussed their
approaches with the Research Advisory Committee on Gulf War Veterans
Illnesses. And the advice of such experts
does not seem to have been solicited for this treatment document.
In my experience as a neuropsychologist, I have had many
patients whose neurological illnesses were initially thought to be
psychiatric—the term “functional” was, in fact, sometimes used to describe
them. These patients include people with
multiple sclerosis, small vessel strokes, dementias and exposures to chemicals
such as solvents or mercury. Treating
Gulf War illness with an antidepressant is akin to treating multiple sclerosis
with one. The patient might feel a
little more optimistic, but the medication will do nothing to reverse or
prevent the brain damage that the multiple sclerosis disease process is
inflicting on his or her brain.
Furthermore, the VA treatment document says its advice is
also appropriate for mild traumatic brain injury, suggesting that recent Iraq
and Afghanistan veterans who suffered blast injuries from improvised explosive
device (IED) exposures should also be treated as psychiatric cases.
IOM report Volume 10
The recent Volume 10 Institute of Medicine report further
contributes to the worsening plights of ill Gulf War veterans by minimizing
their health problems and again placing a psychiatric cast on them.
This report was written by a committee that (purposefully)
included no one with clinical experience treating Gulf War veterans or in-depth
epidemiological expertise in the phenomenology of Gulf War illness.
The report supports the VA stance that Gulf War illness is a
functional disorder without evaluating the extensive scientific evidence that
demonstrates just the opposite.
Although the Volume 10 Institute of Medicine report states that
the science has not changed since the Volume 8 report, its conclusions fly in
the face of the scientific consensus on Gulf War illness that I have described,
a consensus that was embraced in the Volume 8 report. The Volume 10 report distorts and disavows
the Volume 8 report’s finding that Gulf War illness “cannot be reliably
ascribed to any known psychiatric disorder” by saying that the illness “cannot be fully explained by any …psychiatric
disorder.”
Unlike prior reports that support mechanistic scientific
research on Gulf War illness, Volume 10 suggests that “it is time research
efforts focus on the [mind-body] interconnectedness” and that “further research
to determine the relationships between Gulf War exposures and health conditions
in Gulf War veterans should not be undertaken.”
To recommend stopping research into the mechanisms
underlying the disease, just as research into these mechanisms has begun to
make real progress, is shockingly shortsighted. And to suggest that psychiatric research has
been neglected could not be further from the truth.
During the fifteen years after the war, federal Gulf War
research focused mainly on psychiatric issues. For example, 51% of VA research funding in
2003 for Gulf War illness focused on psychological stress and psychiatric
illness. This research revealed that the answer to the Gulf War illness problem
could not be found in the psychiatric arena.
It is unthinkable that the scientific progress now being made should be
halted and to return to that era.
Conclusion
When I think of the problem of Gulf War illness and the
health problems and disabilities of the many Gulf War veterans whom I know or
have evaluated, I am painfully reminded of the veterans of World War I who were
exposed to mustard gas in the trenches of Europe. The gas was known to be present and widespread
and it was known that mustard was designed to make people very sick or kill
them. However, these veterans did not receive support for their health problems
or the hardships their families endured due to their disabilities when they
returned from combat.
We are experiencing the same phenomenon with the 1991 Gulf
War. It is well known and established
that Gulf War veterans were exposed to poisons such as pesticides,
pyridostigmine bromide, sarin gas and air pollutants from oil well fires that
are harmful to health. However, groups like the Institute of Medicine and VA
state that with current technology we cannot identify exactly which chemicals
and which dosages each individual veteran was exposed to. This leads them to
claim that we do not know enough to conclude that the Gulf War veteran
population was over-exposed to toxic chemicals and that individual veterans are
ill. This is not the approach to population environmental health problems that
we should expect.
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