Healthcare utilization and mortality among veterans of the Gulf War

The authors conducted an extensive search for published works concerning healthcare utilization and mortality among Gulf War veterans of the Coalition forces who served during the 1990-1991 Gulf War. Reports concerning the health experience of US, UK, Canadian, Saudi and Australian veterans were reviewed. This report summarizes 15 years of observations and research in four categories: Gulf War veteran healthcare registry studies, hospitalization studies, outpatient studies and mortality studies. A total of 149728 (19.8%) of 756373 US, UK, Canadian and Australian Gulf War veterans received health registry evaluations revealing a vast number of symptoms and clinical conditions but no suggestion that a new unique illness was associated with service during the Gulf War. Additionally, no Gulf War exposure was uniquely implicated as a cause for post-war morbidity. Numerous large, controlled studies of US Gulf War veterans' hospitalizations, often involving more than a million veterans, have been conducted. They revealed an increased post-war risk for mental health diagnoses, multi-symptom conditions and musculoskeletal disorders. Again, these data failed to demonstrate that Gulf War veterans suffered from a unique Gulf War-related illness. The sparsely available ambulatory care reports documented that respiratory and gastrointestinal complaints were quite common during deployment. Using perhaps the most reliable data, controlled mortality studies have revealed that Gulf War veterans were at increased risk of injuries, especially those due to vehicular accidents. In general, healthcare utilization data are now exhausted. These findings have now been incorporated into preventive measures in support of current military forces. With a few diagnostic exceptions such as amyotrophic lateral sclerosis, mental disorders and cancer, it now seems time to cease examining Gulf War veteran morbidity and to direct future research efforts to preventing illness among current and future military personnel.     

The challenges of exposure assessment in health studies of Gulf War veterans

A variety of exposures have been investigated in Gulf War veterans' health studies. These have most commonly been by self-report in a postal questionnaire but modelling and bio-monitoring have also been employed. Exposure assessment is difficult to do well in studies of any workplace environment. It is made more difficult in Gulf War studies where there are a number and variety of possible exposures, no agreed metrics for individual exposures and few contemporary records associating the exposure with an individual. In some studies, the exposure assessment was carried out some years after the war and in the context of media interest. Several studies have examined different ways to test the accuracy of exposure reporting in Gulf War cohorts. There is some evidence from Gulf War studies that self-reported exposures were subject to recall bias but it is difficult to assess the extent. Occupational exposure-assessment methodology can provide insights into the exposure-assessment process and how to do it well. This is discussed in the context of the Gulf War studies. Alternative exposure-assessment methodologies are presented, although these may not be suitable for widespread use in veteran studies. Due to the poor quality of and accessibility of objective military exposure records, self-assessed exposure questionnaires are likely to remain the main instrument for assessing the exposure for a large number of veterans. If this is to be the case, then validation methods with more objective methods need to be included in future study designs.     

Multi-symptom illnesses, unexplained illness and Gulf War Syndrome

Explanatory models for the increased prevalence of ill health in Gulf veterans compared to those not deployed to the Gulf War 1990-1991 remain elusive. This article addresses whether multi-symptom reporting in Gulf veterans are types of medically unexplained symptoms and whether the alleged Gulf War Syndrome is best understood as a medically unexplained syndrome. A review of the epidemiological studies, overwhelmingly cross-sectional, describing ill health was conducted including those that used factor analysis to search for underlying or latent clinical constructs. The overwhelming evidence was that symptoms in Gulf veterans were either in keeping with currently defined psychiatric disorders such as depression and anxiety or were medically unexplained. The application of factor analysis methods had varied widely with a risk of over interpretation in some studies and limiting the validity of their findings. We concluded that ill health in Gulf veterans and the alleged Gulf War Syndrome is best understood within the medically unexplained symptoms and syndromes constructs. The cause of increased reporting in Gulf veterans are still not clear and requires further inquiry into the interaction between sociological factors and symptomatic distress.     

Introspectiveness and adolescent symptom reporting

A new measure of introspectiveness--the tendency to devote diffuse attention to thoughts and feelings about the self--was used to investigate adolescent symptom reporting. Introspectiveness was correlated with psychological distress (r = .40) and with physical symptoms (r = .27) in a random sample of college freshmen, and remained the strongest correlate of distress and symptoms when controlling for a variety of other measures. Women, Jews, and certain Hispanic groups were higher on introspectiveness than other students. An unanticipated, but possibly significant, result was that economic discontinuities and discontinuities involving significant others had markedly different relationships with health. Strong associations between perceptions of parental characteristics, adolescent introspectiveness, and health suggested the importance of socialization processes for understanding distress and symptoms. Finally, measures of emotional sensitivity and time spent alone were associated with introspectiveness and symptom reporting. Taken together, these findings suggest the importance of introspectiveness and its correlates for understanding the processes leading to adolescent symptom reporting.     

Managing future Gulf War Syndromes: international lessons and new models of care

After the 1991 Gulf War, veterans of the conflict from the United States, United Kingdom, Canada, Australia and other nations described chronic idiopathic symptoms that became popularly known as 'Gulf War Syndrome'. Nearly 15 years later, some 250 million dollars in United States medical research has failed to confirm a novel war-related syndrome and controversy over the existence and causes of idiopathic physical symptoms has persisted. Wartime exposures implicated as possible causes of subsequent symptoms include oil well fire smoke, infectious diseases, vaccines, chemical and biological warfare agents, depleted uranium munitions and post-traumatic stress disorder. Recent historical analyses have identified controversial idiopathic symptom syndromes associated with nearly every modern war, suggesting that war typically sets into motion interrelated physical, emotional and fiscal consequences for veterans and for society. We anticipate future controversial war syndromes and maintain that a population-based approach to care can mitigate their impact. This paper delineates essential features of the model, describes its public health and scientific underpinnings and details how several countries are trying to implement it. With troops returning from combat in Afghanistan, Iraq and elsewhere, the model is already getting put to the test.     

Local complications and subsequent symptom reporting among women with cosmetic breast implants

Epidemiologic studies have found no association between breast implants and cancer or well-defined connective tissue diseases. However, women with cosmetic breast implants continue to report specific as well as nonspecific physical and psychological symptoms after receiving their implants. In an attempt to determine whether local complications of implantation may contribute to this excess of symptom reporting, the authors studied a large cohort of women in Sweden with cosmetic breast implants (n = 1280) and a comparison cohort of women who had cosmetic breast reduction surgery (n = 2211). Both groups of women had operations between 1969 and 1996. Medical record reviews of local complications revealed that approximately 31 percent of the women with cosmetic breast implants had an implant change, implant leakage, or a capsulotomy. Capsulotomies occurred more often in women who were age 35 or older at the time of the operation, had ever smoked, and had implants with a smooth surface. On self-administered questionnaires, symptoms were reported more often by the women who had implants regardless of whether they had local complications. Twenty of the 28 symptoms occurred more frequently among women with local complications and breast implants, compared with the women in the breast reduction comparison group or the women with breast implants but no local complications. This study suggests that local complications, particularly capsular contractures as indicated by capsulotomy, may be an important factor to consider when studying symptom reporting among women with breast implants.     

Self-transcendence as a measure of spirituality in a sample of older Australian twins.

Measures of self-transcendence, physical health and psychological well-being were included in a self-report Health and Lifestyle questionnaire administered to Australian twins aged over 50 between 1993 and 1995. Self-transcendence appears to be higher among older Australian women than men, and was significantly associated with religious affiliation, marital status (in women) and age (in men). No strong correlations were observed between self-transcendence and any measure of psychological or physical health. Additive genetic effects were found to be important in influencing self-transcendence, with heritability estimates of 0.37 and 0.41 for men and women respectively, whilst shared environment effects were not found to be significant. Multivariate modelling of self-transcendence scores and self-reported church attendance behavior indicated substantially different etiologies for these variables, with implications for methods of investigation of religiosity and spirituality.     

Gulf War Syndrome: A Reaction to Psychiatry’s Invasion of the Military?

Following the 1991 Gulf War, a number of soldiers who fought there began to complain of various symptoms and disorders, the collection of which came to be known as Gulf War syndrome (GWS). A debate has raged about the nature and cause of this illness, with many suggesting that it is a psychiatric condition. GWS continues to be a contested illness, yet there is no disputing that many Gulf veterans are ill. This article considers the way in which GWS sufferers understand their illness to be physical in nature and the way in which they negotiate and resist psychological theories of their illness. Based on 14 months of ethnographic fieldwork in the United Kingdom, data for this article were collected mainly by in-depth, semistructured interviews with GWS sufferers, their family members, doctors, and scientists, as well as healthy Gulf veterans. A total of 93 informants were interviewed, including 67 UK Gulf veterans, most of whom were ill. The paper argues that despite the increasing presence of psychiatry in military discourse, GWS reveals the way that people are able to transform, negotiate and even negate its power and assumptions.     

A chronic fatigue syndrome – related proteome in human cerebrospinal fluid

Background  

Chronic Fatigue Syndrome (CFS), Persian Gulf War Illness (PGI), and fibromyalgia are overlapping symptom complexes without objective markers or known pathophysiology. Neurological dysfunction is common. We assessed cerebrospinal fluid to find proteins that were differentially expressed in this CFS-spectrum of illnesses compared to control subjects.     

On being a Gulf veteran: an anthropological perspective

There is no doubt that Gulf service has affected the well-being of some of the members of the UK armed forces who served in that conflict, yet the reason for this remain unclear. At present, the debate surrounding Gulf War Syndrome (GWS) has become stagnant and highly polarized. This paper argues that a new perspective is needed to further improve our understanding of the problem and suggests that the methods and theories of anthropology, with its focus on nuances and subtleties, can provide new insights. Data were generated from 14 months of ethnographic fieldwork in the UK including participant observation, semi-structured interviews and document analysis. Anthropology provides a unique way of approaching and understanding somatic symptoms and suggests that GWS symptom reporting can be seen as a form of communication. The work focuses on the sufferers' accounts, the symptoms themselves and the context within which we find them in order to better understand what was being expressed and commented upon. Although necessary to contextualize GWS through situating it among other emergent illnesses and widespread health beliefs, this paper shows there is a need to bring back the particular. This work seeks to make sense of the cultural circumstances, specific and general, which gave rise to the illness.     

On the measurement of health and its effect on the measurement of health inequality

We examine the extent to which self-reported health measures suffer from income-related reporting heterogeneity and then characterize how this reporting heterogeneity affects the estimation of income-related health inequality. We run a comprehensive set of tests of reporting heterogeneity using several self-reported health measures and several clinical measures of health from the National Health and Nutritional Examination Surveys. We propose the use of a multidimensional measure using clinical indicators of health in the context of measuring income-related health inequality, and we examine the extent of income-related health inequality, as measured by the concentration index, using both self-reported measures of health and the multidimensional clinical measure. Our results confirm the existence of significant, positive, income-related reporting heterogeneity and also suggest that higher income individuals react more strongly to a change in clinical health measures. Using self-assessed health suggests that income-related health inequality is about three times larger than when using more objective, self-reported health measures and ten times larger than when using the multidimensional clinical measure of health.     

Physical symptom reporting and health perception among type A and B college males

This investigation studied the relationship of Type A behavior to physical symptom reporting and self-appraised health status. The student version of the Jenkins Activity Survey was administered to thirty male college seniors during a high-stress period of the semester. Results showed that Type A's reported relatively fewer physical symptoms and perceived themselves as being more healthy than Type B's. Type A individuals also rated themselves as healthier than their peers, whereas Type B individuals rated themselves as being less healthy than their peers. In addition, symptom reporting and health perception were negatively correlated in the Type B subsample; however, this relationship was not evident in the Type A subsample. In the discussion, it was suggested that the attentional style of Type A's may contribute to lower levels of symptom reporting and faulty appraisals of health status. The notion of an attributional bias whereby Type A's define internal somatovisceral states differently than Type B's was also discussed. Finally, the results were discussed in terms of their implications for understanding the mechanisms through which Type A behaviors might translate into increased coronary heart disease (CHD) risk.     

Effect of oral contraceptives and some psychological factors on the menstrual experience

This study attempts to clarify the etiology of menstrual distress by using objective measures of menstration, enlightened statistical treatment and standardized measures of psychological factors. In addition to observing the traditionally associated psychological factors, measures of health locus of control, preventive health behavior and menstrual socialization (e,g., age at menarche) are included in order to assess the relevance of attitudes towards health. 57 women (mean age=23.5 years), 1/2 of whom (29) used an oral contraceptive, completed Moos' menstrual distress questionnaire at each of the 3 menstrual phases. In addition they kept menstrual diary cards for 50 days, recording days on which menstrual blood loss occurred. During an intermenstrual phase, they completed a general information questionnaire with questions on menstrual socialization and demographic variables; Eysenck's personality inventory; the multidimensional health locus of control scale; the Bem sex role inventory; and a measure of preventive health behavior. Analyses investigating the effects of pill use and psychological factors on the incidence and intensity of menstrual distress found few significant associations between these measures, especially when symptom changes over the menstrual cycle were the dependent variables. The results generally support the notion that menstruation is a negative event for most women (2/3 of the sample). Neuroticism was found to correlate with all the premenstrual MDQ scores except the positive aspect of increased arousal, with negative affect at both menstrual and intermenstrual phases, with menstrual pain and with intermenstrual concentration. The regression analyses indicate that changes in symptoms of menstrual distress over the menstrual cycle are not well predicted by the measures investigated in this study. Of the few significant associations noted, most are explicable in common sense terms. The more objective approach adopted in this study gives little support for a psychological etiology of distres. However, it also queries the appropriateness of a physiological explanation because of the limited differences found between pill users and nonusers. The inability of locus of control scores, menstrual socialization measures and a preventive health behavior measure to contribute to the definition of a woman at risk, suggests that distress is not related to an individual's general health concepts nor perceived control. 1 aspect not investigated in this study and a topic for future research is the role of a woman's expectations on her experience.     

The impact of the 1991 Gulf War on the mind and brain: findings from neuropsychological and neuroimaging research

Many veterans of the 1991 Gulf War (GW) have complained of somatic and cognitive symptoms that may be neurological in nature. However, whether or not changes in brain function are associated with GW service continues to be debated. Studies of GW veterans using objective, performance-based neuropsychological measures have yielded inconsistent findings, with those indicating deficits among GW veterans typically revealing only relatively mild levels of neuropsychological impairment. Further, performances on objective neuropsychological tasks show little correspondence to subjective perceptions of cognitive functioning. Although preliminary magnetic resonance spectroscopy (MRS) studies demonstrate reduced N-acetylaspartate-to-creatine (NAA/Cr) ratio in select brain regions among GW veterans who report health concerns, this work requires further replication with larger, more representative samples. There is no evidence from neuroimaging studies of a non-specific effect of GW service or of changes in brain structure or function related to health status when conventional radiological methods are used. Owing to the paucity of objective exposure, baseline health data, and the now significant time elapsed since the GW, aetiological issues may never be fully resolved. Therefore, research addressing clinical management of GW veterans with neuropsychological dysfunction and neuroimaging abnormalities may prove more fruitful than exclusive focus on aetiology.     

Neutrality at sea in transition: State practice in the gulf war as emerging international customary law∗

Abstract

This paper provides an appraisal of the continuing efficacy of the law of neutrality as it pertains to the balance of interests of belligerents and neutrals in the maritime environment. The author finds that international customary law of naval warfare pertaining to the rights of neutrals is emerging today as a result of State and extra‐State practice in the Gulf War. This is demonstrated by examination of belligerent and neutral conduct in the “Tanker War”; and various authoritative assessments of that conduct by the international community. The examination proceeds from an analysis of the underlying theory of the customary law‐making process and evolutionary nature of the law of neutrality since before World War II. State conduct in the Gulf War, including the employment of war‐exclusion zones, is critically examined against this backdrop. Discerned from this analysis are firm, “baseline”; standards of the law of neutrality against which State practice, belligerent as well as neutral, and ultimately the emerging customary law, may be assessed.     

Impact of geographic area level on measuring socioeconomic disparities in cancer survival in New South Wales,Australia: A period analysis

BackgroundArea-based socioeconomic measures are widely used in health research. In theory, the larger the area used the more individual misclassification is introduced, thus biasing the association between such area level measures and health outcomes. In this study, we examined the socioeconomic disparities in cancer survival using two geographic area-based measures to see if the size of the area matters.MethodsWe used population-based cancer registry data for patients diagnosed with one of 10 major cancers in New South Wales (NSW), Australia during 2004–2008. Patients were assigned index measures of socioeconomic status (SES) based on two area-level units, census Collection District (CD) and Local Government Area (LGA) of their address at diagnosis. Five-year relative survival was estimated using the period approach for patients alive during 2004–2008, for each socioeconomic quintile at each area-level for each cancer. Poisson-regression modelling was used to adjust for socioeconomic quintile, sex, age-group at diagnosis and disease stage at diagnosis. The relative excess risk of death (RER) by socioeconomic quintile derived from this modelling was compared between area-units.ResultsWe found extensive disagreement in SES classification between CD and LGA levels across all socioeconomic quintiles, particularly for more disadvantaged groups. In general, more disadvantaged patients had significantly lower survival than the least disadvantaged group for both CD and LGA classifications. The socioeconomic survival disparities detected by CD classification were larger than those detected by LGA. Adjusted RER estimates by SES were similar for most cancers when measured at both area levels.ConclusionsWe found that classifying patient SES by the widely used Australian geographic unit LGA results in underestimation of survival disparities for several cancers compared to when SES is classified at the geographically smaller CD level. Despite this, our RER of death estimates derived from these survival estimates were generally similar for both CD and LGA level analyses, suggesting that LGAs remain a valuable spatial unit for use in Australian health and social research, though the potential for misclassification must be considered when interpreting research. While data confidentiality concerns increase with the level of geographical precision, the use of smaller area-level health and census data in the future, with appropriate allowance for confidentiality     

Low paraoxonase in Persian Gulf War Veterans self-reporting Gulf War Syndrome

Exposure to organophosphate (OP's) insecticides and nerve gases during the Persian Gulf War has been implicated in the development of Gulf War Syndrome. Paraoxonase (PON1) present in human serum detoxifies OP's. We determined the levels of PON1 in the serum of Gulf War Veterans and compared these to those found in a control population. One hundred fifty-two Gulf War Veterans from the UK who self-reported the presence of Gulf War Syndrome via a questionnaire and 152 age and gender matched controls were studied. PON1 activity, concentration, and genotype were determined. In the Gulf War Veterans, paraoxon hydrolysis was less than 50% of that found in the controls (100.3 (14.8-233.8) vs 214.6 (50.3-516.2) nmol/min/ml, P < 0.001). This low activity was independent of the effect of PON1 genotype. The serum PON1 concentration was also lower in the Gulf War Veterans (75.7 (18.1-351.3) vs 88.2 (34.5-527.4) microg/ml, P < 0.00025), which was again independent of PON1 genotype. There was no difference in the rate of diazoxon hydrolysis between the groups (10. 2 +/- 4.1 micromol/min/ml vs 9.86 +/- 4.4, P = NS). A decreased capacity to detoxify OP insecticides resulting from low serum PON1 activity may have contributed to the development of Gulf War Syndrome.     

Toxicological assessments of Gulf War veterans

Concerns about unexplained illnesses among veterans of the 1991 Gulf War appeared soon after that conflict ended. Many environmental causes have been suggested, including possible exposure to depleted uranium munitions, vaccines and other drugs used to protect troops, deliberate or accidental exposure to chemical warfare agents and pesticides and smoke from oil-well fires. To help resolve these issues, US and UK governments have sought independent expert scientific advice from prestigious, independent scientific and public health experts, including the US National Academies of Science and the UK Royal Society and Medical Research Council. Their authoritative and independent scientific and medical reviews shed light on a wide range of Gulf War environmental hazards. However, they have added little to our understanding of Gulf War veterans' illnesses, because identified health effects have been previously well characterized, primarily in the occupational health literature. This effort has not identified any new health effects or unique syndromes associated with the evaluated environmental hazards. Nor do their findings provide an explanation for significant amounts of illnesses among veterans of the 1991 Gulf War. Nevertheless, these independent and highly credible scientific reviews have proven to be an effective means for evaluating potential health effects from deployment-related environmental hazards.     

Chloroplast genome sequence confirms distinctness of Australian and Asian wild rice

Cultivated rice (Oryza sativa) is an AA genome Oryza species that was most likely domesticated from wild populations of O. rufipogon in Asia. O. rufipogon and O. meridionalis are the only AA genome species found within Australia and occur as widespread populations across northern Australia. The chloroplast genome sequence of O. rufipogon from Asia and Australia and O. meridionalis and O. australiensis (an Australian member of the genus very distant from O. sativa) was obtained by massively parallel sequencing and compared with the chloroplast genome sequence of domesticated O. sativa. Oryza australiensis differed in more than 850 sites single nucleotide polymorphism or indel from each of the other samples. The other wild rice species had only around 100 differences relative to cultivated rice. The chloroplast genomes of Australian O. rufipogon and O. meridionalis were closely related with only 32 differences. The Asian O. rufipogon chloroplast genome (with only 68 differences) was closer to O. sativa than the Australian taxa (both with more than 100 differences). The chloroplast sequences emphasize the genetic distinctness of the Australian populations and their potential as a source of novel rice germplasm. The Australian O. rufipogon may be a perennial form of O. meridionalis.     

A normative construction of Gulf War syndrome

In early 1992, U.S. troops returning from the Gulf War began reporting a variety of nonspecific symptoms such as fatigue, skin rash, headache, muscle and joint pain, and loss of memory.These reports marked the beginning of what was to be identified as the Gulf War Syndrome (GWS). In the years since the war, as many as 100,000 troops have claimed they suffer from this mysterious disease. In our culture, the existence of disease as a specific entity is fundamental to ensuring the validity of that disease.The legitimacy of GWS has been repeatedly called into question because no specific physiological etiology has been confirmed, and it is becoming more and more likely that the origin of GWS will never be clearly delineated. The purpose of this paper is to illustrate the complicated process of defining GWS as a legitimate illness in the absence of etiological evidence and to suggest a method of treatment for individuals who still suffer from its sequelae.