A: Yes. I started pretty much with the Civil War, because that's when we
really come into our own with modern scientific medicine, where data is
reported that could be compared with modern clinical and epidemiologic data.
So I looked at, oh, articles going back all the way to the Civil War on
war-related health problems. And it took over a year, actually, to find all
the articles. This is an area that there's been a lot published on, but the
previous publications aren't included in the computerized databases because the
articles are so old.
Q: And these are written by military physicians in the past?
A: Most of the articles that I reviewed, that I concentrated on, were articles
written by the physicians at the time or shortly after the war. I wanted
sources who had actually observed the illnesses and examined the patients. I
didn't want to rely just on secondary sources and authorities who hadn't been
in the wars.
Q: Talk a bit about some of the things you found. Start with the Civil War.
A: Starting with the Civil War, we had a war-related health problem that was
known as "irritable heart" or DaCosta syndrome. And it presented somewhat
similar--similarity to the illnesses that we're seeing now amongst Gulf War
veterans. The veterans complained of fatigue and shortness of breath and
headache and problems with sleeping and problems concentrating and memory--the
same sort of symptoms that we're seeing now amongst Gulf War veterans. In
fact, after all the major wars, the veterans have had the sort of physical
complaints that we're seeing amongst Gulf War veterans.
Q: Now, it's interesting, different names have been given. "Irritable heart."
What was the rationale, for this name?
A: They thought it was due to a heart condition, initially. And that's why it
was called "irritable heart". Later on it was called DaCosta syndrome, because
it was pretty much shown that heart disease was not the problem.
Q: Talk about the First World War. What kinds of things showed up there?
A: At the beginning of the First World War, there was a major problem when the
British had to evacuate soldiers from the front in France, because of condition
known as "effort syndrome" or neurocirculatory asthenia. And again, like in
the Civil War, this condition presented with fatigue and headache, shortness of
breath, and problems remembering and concentrating. And it was a major problem
for the British. They had to evacuate a lot of soldiers from the front. When
the Americans entered the war, it was a problem again for us.
Q: What was it called again? Effort syndrome?
A: It's called "effort syndrome" in the United Kingdom; or it was also called
DaCosta syndrome. It had a number of other names. United States, we gave it a
different name. We called it neurocirculatory asthenia.
Q: But the idea, the notion of "effort syndrome" was, it took an effort to
breathe?
A: The idea behind calling it "effort syndrome" was, it seemed like at the
beginning that symptoms were worse with effort. But later on, that was pretty
much shown not to be the case. But nevertheless the name stuck.
Q: Move on to Second World War.
A: "Effort syndrome" was again a major consideration at the beginning of the
Second World War, when the British entered the war. There was a major question
at the end of World War I whether effort syndrome was a psychological condition
or a unidentified organic disease. And that question still persisted at the
beginning of World War II. Some very well known studies were conducted by a
famous doctor at the time, a renowned doctor, Dr. Paul Wood. And he determined
that effort syndrome was a psychoneurosis and was not a heart condition or some
other kind of medical condition. So after the first few years of the war, we
did not hear much more about effort syndrome.
Q: So that's really the turning point. I mean, prior to this, these kinds of
syndromes were thought by most physicians as being physical. But you're
saying, around the Second World War it--
A: Oh, not most physicians. There was major controversy as to whether or not
these symptoms were due to an organic physical disease, or whether they were
due to a psychological condition. It was a major debate at the time, getting
all the way back to the Civil War and going through the First World War and
World War II. It's very similar to the debate we're having now as to whether
Gulf War veterans' symptoms are mainly an occult, an unidentified physical
disease, or whether or not they have a psychological basis.
Q: But you're saying, around the time after the Wood study, that it seemed to
resolve it?
A: At that time, the idea that effort syndrome was caused by a physical
condition lost favor, because of his studies. The questions still were never
totally resolved at that time. But for most individuals, most physicians and
professionals, the effort syndrome was attributed to psychological factors
after that. These were very well done studies at the time.
Q: Now, going back to the Second World War-- was this issue of a stigma being
attached to a psychological condition something that was present? Was this a
problem even then?
A: Yes. That goes back for a very long period of time. And it was-- It was
found back in the First World War and particularly in the Second World War that
if individuals were diagnosed as having a psychological condition, they were
much less likely to be rehabilitated and return to the front. When it was
recognized that symptoms and illnesses were caused by extreme stress from
life-threatening experiences and wars, and this was recognized and not labeled
as an illness, uh, the troops who were affected by these psychological
conditions were much more likely to be rehabilitated and have a better
long-term outcome.
Q: We were talking yesterday with Dr. Hamburg, and he was talking about General
Patton and--- Was there, up until the forties and fifties certainly, a certain
lack of sympathy towards the idea of a psychological disease?
A: Certainly that's very true in the past, and it persists today. There's
something of a lack of sympathy for psychological conditions, because people
feel that you have some control over them.
Amongst medical professionals, though, we recognize that psychological
conditions cause just as much pain and suffering as any medical or surgical
condition, and we treat them very much the same.
Q: Similar kinds of things sort of emerged in the Korean War and in the Vietnam
War. Could you talk about any differences?
A: Not so much in the Korean War, but in the Vietnam War the Vietnam veterans
had these same sort of symptoms that were seen amongst Gulf War veterans and we
saw in World War I, World War II veterans, and Civil War veterans. They report
these symptoms at higher rates than the veterans of the same era that did not
go to Vietnam.
Q: And would you say, after Vietnam there's something of a breakthrough in
terms of getting these established as legitimate medical entities--with post
traumatic stress disorder, for instance?
A: Well, the psychological conditions associated with the war received much
more legitimacy after the Vietnam War, because they were recognized as a unique
condition. But if you read the medical literature going back with all major
wars, the troops suffered from psychological problems after the wars. Anyone
who's been traumatized or life has been threatened, is going to have some
problems afterwards.
Q: One of the things I think the public perception of the Gulf War is the
actual combat period is very, very short; it's over quickly; there's very few
casualties on our side, and so forth. Therefore people tend to perceive it as
a low-stress war.
A: Well, having served in Desert Storm, I can certainly directly speak to that
issue. It was not a low-stress war. There was less direct combat for a
shorter period of time than in previous wars. But there was a long build-up
period over 5 months. And we're looking at this retrospect. Now, we know we
won a quick and decisive victory. But no one knew that at the time. And for
all of those troops who were deployed before the war, there was a lot of
anticipation, a lot of anxiety and worry about the outcome of the war and about
the use of chemical weapons or--or other types of weapons of mass destruction.
So there was a lot of stress on all the troops, who were yanked out of their
normal lives and sent to the Persian Gulf. And again, you can't just look at
this now, after we know that it was a quick and decisive victory. No one knew
that before the war ended.
Q: So it was the anticipation that caused the stress?
A: That, and the unexpected nature of the war: people being ripped out of their
normal lives and sent over to the Persian Gulf, and not knowing what was going
to happen in this wartime deployment. It was a stressful period for everyone.
And certainly for all troops, even if they weren't involved in direct combat,
there was the possibility of the Scud missile launches causing death and
debility amongst all the troops. So all the troops were correctly threatened,
even if they didn't see combat personally.
Q: But when the war was over, did you expect that we'd see a phenomenon like
this? There was relatively little post traumatic stress disorder, in terms of
the acute stress of individual [men]. That hadn't happened, had it?
A: No, I have to say, at least personally, no. We had very low rates of-- much
fewer deaths than we initially feared in this war, and the disease non-battle
injury rate, the amount of non-death medical problems we saw during this war,
was lower than in any of our previous major military deployments. And so as
far as the health of the troops during the deployment, during this wartime
deployment, they were very healthy, compared to previous wars. And so based on
that, we didn't anticipate as many problems after this war.
Q: Before we leave the actual battlefield, talk about the environment itself.
One of the things in the debates afterwards has been, people have spoken about
experiences they had there, like for instance seeing dead animals with dead
insects and so forth on them. Is this kind of an unusual environment? And are
the kinds of weapons spoken about, unusual? People don't have experience of
them. Is it less constrained as regards their imaginations [than
previously]?
A: This environment was unique, as everyone knows. In some ways it had a lot
of health threats; in other ways it was a more healthy environment than, say, a
jungle sort of environment, where our Vietnam troops fought.
It's a complex picture. As far as the oil well fire smoke and those sort of
known threats, it was a harmful environment, because people were breathing in
harmful substances. But as far as the desert environment goes, our troops were
deployed into barren desert locations, away from major population areas, and
away from the oases and other areas where a lot of diseases are transmitted.
In some ways, they were isolated from some disease threats. We had much better
control over the use of alcohol and other sort of problems we've seen in other
deployments.
So in some ways the troops were separated from some of the health threats, and
in other ways there were increased health threats, like from the oil well fire
smoke. So it's a complex picture. In some ways, it was a healthier
environment than Vietnam; in other ways, it was worse.
As far as the dead animals, that was one of the first questions raised. When I
was deployed to Saudi Arabia in August, 1990, I was asked, because I'm an
infectious disease specialist, about the dead animals in the desert. And I saw
at least a half a dozen or more piles of these dead animals in the desert. And
there's large herds in this region--the Bedouin maintain--of camels, sheep, and
goats. And when animals die, they pile them up in specific locations and they
get compensation from the government when their animals die. And so these dead
animals, these piles of dead animals, were in the desert at least five months
before the war began.
These piles of dead animals were not considered a direct threat to our troops,
because most of them weren't camped directly on top of the animals. They'd
locate their camps away from these dead animals. But they were considered
potential breeding grounds for insect-transmitted diseases. And so we
recommended that these piles of dead animals be thoroughly sprayed with
insecticides. And this may explain some of the reports of dead insects on
these piles of dead animals. I didn't spend much time, myself, looking closely
at these dead animals, but I know that they were thoroughly sprayed with
insecticides by our military personnel.
Q: Now let's leave the war and come afterwards. You've been quite a close
observer of what's happened, both as a scientist but as a person in the
military. Talk a bit about your observations, about when this surfaced and
people first started using the word "Gulf War syndrome". What did you think at
the time? What did you notice?
A: I didn't really know what to think. I mean, this is somewhat different than
the sort of medical conditions that we usually deal with, because it's ill
defined. And my first thought was that it might be due to, say, leishmaniasis
infection, since that's my field, infectious diseases. And we were actively
looking for cases of leishmaniasis, trying to determine whether or not this was
causing problems amongst our veterans. So my first thought was: Are we
dealing with something like that?
Q: But then you went on and you found that many of these symptoms were these
ill defined symptoms. Could you describe them for us? What kinds of things?
A: Well, the most common symptoms reported by the veterans are fatigue,
headache, joint pains, problems with sleeping, insomnia, nightmares, difficulty
concentrating, difficulty remembering. These are the main sort of symptoms
our veterans are complaining of. These are also the sort of non-specific
somatic symptoms, physical symptoms that we've observed in veteran populations
going all the way back to the Civil War. These are very common symptoms [in]
veterans, and they're also very common symptoms in the general population.
Q: So when you did your research and you found that, what did you conclude from
that? That there was a big psychogenic component for this? What was your
conclusion?
A: It's very interesting to observe the historical record. What we found is,
these symptoms that had been difficult to explain after every major war, some
of-- And there's been a major debate as to the cause of these symptoms.
Sometimes the symptoms are attributed to psychological factors, and in other
patients these symptoms are attributed to a unknown organic disease. And we've
seen this same pattern going all the way back to the Civil War--similar sort of
symptoms in our veterans, and this question whether or not they're due to
psychological conditions or whether or not they're some sort of unidentified
disease.
Q: Now, several blue ribbon panels looked at this problem. They have concluded
that the popular risk factors are not very probable, and that stress is a
contributing factor. Why has stress been such a hard sell?
A: Well, somewhat inexplicable as a physician, because we know that stress
causes a lot of suffering in population, and that the individual suffering from
psychological illnesses or stress deserve our compassion and our help. And so
it's difficult to explain why this has been stigmatized--the idea that there
may be stress-related illnesses. I think that there's still a certain
perception among some people that for some reasons, stress and psychological
illnesses aren't real, which is certainly not the case.
There's going to be a certain level of disease in any adult population,
particularly as that population gets older. And so in any war veteran
population, you're going to see lots of psychological illnesses and lots of
medical diseases over time. This is going to occur. This occurs in all
populations. And the question always is: Are these illnesses related to the
wartime experience? And it's difficult to determine that, because we see
diseases and illnesses in all populations.whether it's lung disease or kidney
disease or cancer or any other conditions.
The real question is: Are these veterans having these diseases, these
illnesses at higher rates? Are they [at] more risk of developing these
diseases than other groups of adults? That's the real question. Not that
they're having these diseases.
Q: Now, some of these questions have been addressed, like mortality, acute
morbidity, birth defects and so forth. Give us just a summary of what it looks
like so far.
A: There's been a large number of studies conducted amongst this veteran
population. And we know at the present time, based on the number of deaths in
Gulf War veterans, and based on hospitalizations, and also based on over
100,000 medical examinations of Gulf War veterans, we know that this population
tends to be more healthy than the general population of adults.
Q: So they're not dying, and they're not getting ill at a--
A: From the studies that have been conducted so far, their health seems to be
better than the general population of adults. And we would expect that,
because soldiers, military personnel are selected for good health. But at the
present time, they seem to be healthier than general population. We have seen
a slight increase in stress-related illnesses, which we expect after every war.
Any time a population's life is threatened, any time an individual's life is
threatened, they're going to have some psychological problems afterwards.
Q: So from your point of view, do you see a mystery disease?
A: Well certainly, we haven't seen in the overall veteran population evidence
of greatly increased ill health. The symptoms that some veterans are
complaining of, we haven't totally explained. And this has been true after
previous wars. And so there is a mystery, if you will, as to what is--is
causing these symptoms amongst some of our veterans.
Q: But is it unique to this war?
A: No, it's not. And it's not unique to any adult population. Any busy
physician in a clinic will deal with these sort of symptoms on a daily basis:
complaints of fatigue or joint pain or headache. These sort of symptoms are
very common in all adult populations.
Q: Now, are there any lessons from this?
A: Well, if you look at the historical record and these questions that have
been raised about these symptoms after previous wars, it's usually taken a
couple of decades before there's been a consensus about the cause of these
symptoms. After previous wars, there was the thought that these unexplained
symptoms were due to some unidentified disease. When a disease was not
identified over a 10-, 20-, 30-year period, most of the symptoms were
attributed to psychological factors, or to the sort of normal complaints that
every-- that every adult population experiences.
And so we may have a certain amount of closure over time. Most diseases will
manifest themself after a while. And if there's a disease we currently can't
detect, it'll probably show itself over time. And so there should be a certain
amount of closure involved with this issue. It's still early days, to a
certain extent. We've only followed these veterans for about six years.
Q: So you're saying, over a couple of decades, if it's there, it'll show
itself. If it doesn't show itself, what?
A: Usually that's true. In the historical record, what it indicates is, --if a
disease is not identified and confirmed over time, that generally these
symptoms are attributed to psychological factors or to the normal complaints
that any adult population experiences.
Q: And you're not worried about this argument that we started too late in the
day to investigate this thing?
A: No. t would have been good if we had had more time-- a greater amount of
wartime records of potential exposures, and if we had had more documentation of
certain events. But the real question is here is whether there's a unique
disease that our veterans are suffering from. And we don't have to wait to
examine that issue. And we can examine veterans who have symptoms at any time.
If there's a disease there, we can look for it right now. And the fact that
we're six years away from the war doesn't make any difference on that
account.
Q: Are there any lessons for handling future post war syndromes?
A: Difficult to explain symptoms are found in all adult populations. And
unless we can totally explain these symptoms in all populations, we're going to
see them after future wars. And we should be prepared for that. I do think we
have a moral duty to take care of the health problems caused by this war. Also
think at the same time, it's very important that we do not stigmatize all Gulf
War veterans as being sick, or as having a health problem, a public health
problem. These veterans who fought for their country shouldn't suffer by being
unable to obtain jobs or insurance because of misconceptions about their
health.
Q: I see. So even the ones who aren't presenting symptoms might be
stigmatized?
A: I think that that's a possibility that we worry about, that there will be
this perception that all Gulf War veterans are sick, or that they are causing
some sort of public health problem. And I think that's wrong. Individuals who
fought for their country should not suffer in obtaining insurance or obtaining
a job, based on misconceptions about their health.
Q: Last thing. What do you think is the most important thing you want people to
understand about this affair?
A: I think the most important thing to understand is, this is a very complex
medical and scientific issue. And answers don't come easy in these complex
issues. These sort of questions about these symptoms are raised in lots of
other populations, not just amongst war veterans. We haven't solved all these
questions in the past. And it's going to be very difficult to sort through all
these questions and all these issues and provide answers that everyone will
agree upon.
Q: Now, you say that they exist in all populations, whether they're military or
not. Do you think that's something that's just not very well appreciated?
Are you saying that in any group of citizens, we'll get these kinds of
symptoms?
A: Well, all of us at time complain of fatigue or headache or joint pains,
problems sleeping, problems remembering--particularly as we get older. So
these symptoms are quite common. The real question is: Where do we divide
these sort of normal complaints from illness?
That's a question that has been raised repeatedly over the question of chronic
fatigue syndrome. When do the individuals have fatigue that is so great that
they have a unique illness, chronic fatigue syndrome? And when are these
symptoms the sort of symptoms that all of us experience?
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