Emerging Infectious Diseases 1998; 4: 707-709.

Hospitalization for Unexplained Illnesses Among U. S. Veterans of Persian Gulf War

Katherine Murray Leisure, Nancy L. Nicolson and Garth L. Nicolson

Knoke et al., Naval Health Research Center, San Diego, California, published two articles on military hospitalizations in Persian Gulf War veterans, the most recent in Emerging Infectious Diseases [1, 2].  

Although the titles of both articles indicated general hospitilizations, Knoke et al. studied only military hospitalizations among selected, mostly healthy, active-duty Persoan Gulf War veterans.  Both studies focused only on military hospitalizations in active-duty personnel enlisted as of 1994 and compared military hospitalizations among active duty Gulf War veterans (cases) with hospitalizations of active-duty era veterans not in the Persian Gulf between 1990 and 1991 (controls).  “Healthy warrior” effects would have predicted low military hospitalization rates for both cases and controls [3].

The studies were “restricted to active-duty personnel” hospitalized in military  facilities because active-duty personnel were “rarely hospitalized outside of DoD facilities” [1].  However, of 150 surgical procedures obtained by 85 sick active-duty and reservist Persian Gulf veterans from Pennsylvania (mostly intestinal and skin biopsies) between 1991 and 1995, more than one-third, 58 (39%) were performed in private facilities.  Not shown is how most of the federal procedures were done in Veterans Administration (VA), not military, hospitals.  Many active duty, sick Persian Gulf veterans in Pennsylvania, Texas and California deliberately avoided military facilities between 1991 and 1997 due to concerns about competence, convenience, confidentiality, and career opportunities during an era of down-sizing and closing of military facilities [3].

In addition, Knoke et al. excluded at least five groups of high-risk, sick Gulf War veterans from their limited case studies: (1) those treated in VA and private hospitals, (2) those from the Reserves and National Guard units, (3) those who retired early largely due to illness, (4) those who consented to long military hospitalizations within the DoD  Comprehensive Clinical Evaluation Program (CCEP) for Gulf War veterans, and (5) those who had obstetric complications after returning home from Desert Shield.  Thus many sick Gulf veterans were effectively excluded from their case studies.  Some sick Persian Gulf veterans were not treated in military and VA hospitals in the 1990’s because it was unclear whether their new illnesses had been acquired in the Persian Gulf.  

Not only were the populations studied unusual, but recent workers and travelers to the Middle East were not excluded from the control populations.  Nondeployed controls were allowed to include recently deployed Persian Gulf military personnel as long as nondeployed personnel worked in the Gulf after 1991.  Some of those late-deployed Persian Gulf workers also fell ill with the same illnesses as veteransdeployed between August 1990 and 1991.  An alternative interpretation of the Navy’s hospitalization studies maybe that admitting officers in these military facilities effectively prevented sick Persian Gulf War veterans from obtaining medical care within their facilities.  Illnesses from late Persian Gulf deployments might explain excess hospitalizations seen in nondeployed controls.  All late-deployed personnel from the Persian Gulf and Middle East should also have been excluded from the nondeployed controls.

Finally, medical ICD-9 diagnoses, while interesting, were incomplete and nonspecific.  Common medical diagnoses should have been listed in addition to unexplained illnesses.  In addition, more than one unexplained illness category should have been tabulated per patient, because the “Gulf War Syndrome” is a multi-system illness or illnesses.  We challenge the condensed diagnostic list presented because diagnoses from DoD hospitalizations of Persian Gulf patients frequently did not capture common clinical and laboratory abnormalities, including (but not limited to) ulcerative colitis, Crohn’s colitis, inflammatory bowel disease, intestinal bleeding due to inflammatory colonic polyps, skin acne, nodules, plaques, psoriasiform skin rashes, nose ulcers, nose bloods, leukocytosis, neutropenia, elevated alanine transaminase (SGPT/ALT) liver enzymes, hepatosplenomegaly, thrombocytopenia, nephrolithiasis (kidney stones), and fevers of unknown origin.

More research is needed on hospitalizations in addition to deaths, births, and new diseases found in Persian Gulf War veterans [3].  Civilian scientists and physicians must collaborate closely with other diverse federal and perhaps nonprofit organizations in order to study Gulf War Illnesses objectively [4].  The health problems seen in Gulf War veterans may be part of a new complex of illneses [5-8].

Katherine Murray Leisure,* 
Nancy L. Nicolson‡ and
Garth L. Nicolson‡

*Infectious Diseases, Lebanon, Pennsylvania, USA; and 
‡The Institute for Molecular Medicine, Huntington Beach, California, USA

References

1. Gray GC, Coate BD, Anderson CM, Kang HK, Berg SW, Wignall RS, et al.  The postwar hospitalization experience of U. S. Persian Gulf War veterans compared with other veterans of the same era.  New Engl J Med 1996; 335: 1505-1513.

2. Knoke JD, Gray GC. Hospitalizations for unexplained illnesses among U. S. veterans of the Persian Gulf War.  Emerg Infectious Diseases 1998; 4: 211-219.

3. Haley RW.  Bias from the “Healthy Warrior Effect” and unequal follow-up in three government studies of health effects of the Gulf War.  Am J Epidemiol  1998; 148: 315-323.

4. Nicolson GL, Nicolson NL.  Gulf War Illnesses: complex medical, scientific and political paradox.  Medicine Conflict & Survival  1998; 14: 74-83.

5. Magill AJ, Grogl M, Gasser RA, Wellington S, Oster CN.  Viscerotropic leishmaniasis caused by Leishmania tropica in soldiers returning from Operation Desert Storm.  New Engl J Med 1993; 328: 1383-1387.

6. Magill AJ, Grogl M, Johnson SC, Gasser RA.  Visceral infection due to Leishmania tropica in a veteran of Operation Desert Storm who presented two years after leaving Saudi Arabia.  Clin Infect Diseases 1994; 19: 805-806.

7. Ferrante MA, Dolan MJ.  Q fever meningoencephalitis in a soldier returning from the Persian Gulf War.  Clin Infect Diseases 1993; 16: 489-496.

8. Centers for Disease Control.  Unexplained illness among Persian Gulf War veterans in an Air National Guard unit: Preliminary report, Aug 1990-March 1995.  Morb Mortal Week Rep 1995; 44: 443-447.