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Ill Treated

Is America protecting its soldiers?

From a medical standpoint, the first Gulf war was a disaster. Of the 700,000 American men and women who returned from Operation Desert Storm, roughly 30 percent went on to file disability claims for a host of ailments, including skin lesions, rheumatism, reproductive problems, depression, chronic fatigue, and impaired cognitive function. These have since been grouped under the name Gulf War Syndrome (GWS). After 224 studies and more than $200 million in research, the causes remain uncertain. But experts generally agree that these symptoms arose from exposure to any of 33 toxic agents--including pesticides, oil smoke, and nerve agents--present in the area at the time. As one scientist put it, Desert Storm was the "most toxic war in the history of mankind."

Compounding the problem was the fact that the U.S. military had no way to track its soldiers' well-being. The scarcity of data on soldiers' health before and after battle made it impossible to ascertain what triggered their symptoms, and poor records on environmental conditions and troop movements during the war have impeded attempts to determine what areas, and what divisions, may have been affected by specific toxins. As a result, scientists and physicians have had difficulty treating veterans for precisely what ails them.And, in the absence of sufficient empirical evidence, sick vets have a hard time claiming service-related medical benefits.

One would hope the health lessons from the first Gulf war would have made their way into the military planning for this one. After all, the current war in Iraq may well turn out to be more dangerous than the last. Already the ground war has been longer--there were only four days of ground fighting in Desert Storm--and more intense. "We're already seeing more battlefield trauma," notes GWS expert Lea Steele, an epidemiologist at the Kansas Health Institute. Unfortunately, when it comes to protecting American soldiers' health, the second Gulf war looks a lot like the first.

If there is one message the Pentagon has drummed into the ears of the American public, it's that this time the military is ready. "We have learned our lessons," Brigadier General Stephen Reeves, head of the U.S. military's chemical and biological defense program, told a reporter in January in reference to the Pentagon's strategy for preventing another round of GWS-type chaos. "We have applied the lessons of Desert Storm." Anna Johnson-Winegar, deputy assistant to the defense secretary for chemical and biological defense, added, "I can tell you without equivocation that this department has made the protection of our men and women one of its very highest priorities." As The Washington Post reported in January, two months before the fighting began, "[T]he U.S. military is engaged in a massive effort to prevent the reappearance of Gulf War Syndrome."

In fairness, the Department of Defense (DOD) has made some improvements in the way it monitors the health of its soldiers. The military is using new tools to identify toxins and measure levels of exposure in Iraq as well as enhanced technology to mitigate their effects. Military personnel are collecting air, water, and soil samples that, together with data from the now-ubiquitous Global Positioning System (which was not generally available during Desert Storm), can later be used to identify troops who have been exposed to chemical or biological contaminants.

But these advances are eclipsed by the many appalling oversights in the DOD's health-protection strategy. The most egregious lapse has been the simplest: the failure to provide soldiers with rudimentary medical evaluations prior to entering battle. Such tests are vital not only to determine if a soldier is fit for war but also to provide before and after pictures of a soldier's health. The lack of adequate medical data is precisely what has frustrated attempts to link GWS to wartime exposures in Desert Storm and to treat veterans appropriately. Which is why the Clinton administration passed a law in 1997 requiring "predeployment medical examinations and post-deployment medical examinations (including an assessment of mental health and the drawing of blood samples)" for all soldiers sent into battle overseas. These basic procedures impart a wealth of information to doctors and researchers investigating post-combat disorders. Blood tests, for example, can show traces of chemical toxins or infectious agents that were present on the battlefield. Mental health exams can detect cognitive deficiencies, which are common to GWS, or posttraumatic stress disorders. These records in turn help physicians isolate the causes of postwar ailments and guide treatment regimes.

Unfortunately, the Pentagon has nakedly ignored the congressional mandate. In place of hands-on physical and mental evaluations, the DOD is giving out cursory health questionnaires before and after deployment that provide only a rough sketch of a soldier's medical condition. Soldiers are asked to rank their own health on a five-tier scale from "Excellent" to "Poor," a relatively unscientific measure. All the remaining questions are yes/no--"Are you pregnant? (FEMALES ONLY)"; "Do you have any medical or dental problems?"; "During the past year, have you sought counseling or care for your mental health?"--which won't help at all in analyzing soldiers' specific symptoms after the war.What's more, military sources say, respondents frequently fill out the questionnaires incorrectly. Ten percent, for example, fail to indicate their sex, and one in three forms are handed back incomplete. "[L]ittle worthwhile data will be forthcoming from the forms currently used for pre- and post-deployment health assessment," noted Johns Hopkins epidemiologist Manning Feinleib, who was director of the National Center for Health Statistics at the Centers for Disease Control and Prevention, in recent testimony before Congress.

But, even if the forms were more comprehensive, they would still hardly substitute for an actual medical exam, which would rule out preexisting disorders and help doctors determine which postwar illnesses are combat-related. For example, Lou Gehrig's disease, a degenerative nerve disorder, is twice as common among veterans of Desert Storm as among the rest of the military, which some researchers blame on their low-level exposure to nerve agents in Iraq. Similarly, many veterans of the first Gulf war suffer from severe upper-respiratory problems that could have been caused by exposure to smoke from the roughly 600 oil-well fires ignited by retreating Iraqi brigades. But, without medical data about the soldiers' prewar health and their encounters during the war, it is harder both to diagnose these disorders and to tie them to service in the Gulf.

Finally, instead of drawing blood from troops before and after they are deployed, as the 1997 law required, the Pentagon is relying on serum samples used for HIV testing, which are taken annually but are of limited clinical value for two reasons. First, certain tests for exposure require whole blood as opposed to serum, especially those that look at the subject's DNA for any chromosomal damage caused by chemical or radiological agents. Second, chemical traces generally vanish from the blood within a few months of exposure.Because of this, samples should be taken immediately before service, to establish a baseline, and immediately after, to maximize the chance of detecting toxins encountered during combat. But the Pentagon's annual serum samples are not coordinated with soldiers' deployment dates, and their post-combat sample will likely be taken months after they return, when the chances of detecting toxins will have decreased substantially.

The upshot is that, if symptoms of GWS recur after this war or if a new syndrome appears, veterans and the doctors who treat them will face the same obstacles that plagued them in the past. Without up-to-date blood samples and baseline medical records, researchers will again be unable to locate the source of these ailments. And, because different illnesses can cause similar symptoms, physicians will be forced to treat the symptoms rather than the underlying disease, as has been the case with veterans of Desert Storm. Depression and post-traumatic stress disorder, for example, are associated with service in many wars. But their symptoms, including memory loss and fatigue, can mimic neurological disorders common among Gulf war veterans who were exposed to sarin gas in Iraq. Each requires different treatment, but the lack of proper prewar and wartime tracking obscures the root causes. "We're treating the symptoms without understanding what the underlying cause of the symptoms might be," explains Steven Hunt, director of the Gulf War Veterans' Clinic in Seattle.

This scarcity of medical data will also hurt veterans' chances of collecting disability. After Desert Storm, thousands of vets were denied compensation by the Department of Veterans Affairs because they lacked medical records. Legally, if veterans cannot demonstrate that their ailments were caused by the war, their claims can be denied. "Because they have not collected the baseline data, the post-deployment data will be almost meaningless," notes Stephen Robinson, executive director of the National Gulf War Resource Center. "It means veterans are going to get screwed because, in order for a veteran to receive care and compensation from the Department of Veterans Affairs, they have to prove that their illness or injury is connected to the service in which they are claiming it happened." This hardly amounts to the "comprehensive system to provide overall protection from chemical and biological agents," be they unconventional or environmental, that the Pentagon has boasted about. And it's far from what the doctor--or Congress--ordered.