Gulf War Syndrome: A Condition Felt By Many, But Known By Few
by Jameson Goodell
Veterans often face many adverse effects from serving in combat. There are combat-related injuries and often many mental health effects. However for many veterans who served in the First Persian Gulf War there is another major health effect caused by their service. Gulf War Veterans’ Medically Unexplained Illness (more colloquially known as “Gulf War Syndrome”) is a cluster of unexplained symptoms suffered by veterans who have served in the Gulf Theater.[i] Because an estimated 30% of the 700,000 U.S. soldiers deployed to Saudi Arabia and Kuwait during this conflict are afflicted with this condition, it is important for all veterans and civilians to understand how the war has followed these people home in an unexpected way.[ii] It is important for all to educate themselves to learn what this devastating condition is and what the potential causes are so it can be better treated and prevented in the future. It is also useful for veterans who believe they may have this condition to learn how the Department of Veterans Affairs (VA) rates and awards compensation to individuals suffering from this condition.
One of the biggest problems when it comes to diagnosing and treating veterans afflicted with Gulf War Syndrome is that there is no specific set of symptoms that underlie the condition and many veterans can display a wide array of symptoms. Notable is that various treatment agencies cannot even agree on an official name for Gulf War Syndrome. The VA calls it “Gulf War Veterans’ Medically Unexplained Illness”,[iii] the Committee on Gulf War and Health (“the Committee”) calls it “Chronic Multi-symptom Illness”,[iv] and the greater veteran population calls it “Gulf War Syndrome.” Nevertheless, most agree as to what the condition entails and what its most common symptoms are. The Committee defines the condition as:
The presence of a spectrum of chronic symptoms experienced for 6 months or longer in at least two of six categories—fatigue, mood and condition, musculoskeletal, gastrointestinal, respiratory, and neurologic—that may overlap with but are not fully captured by known syndromes (such as [irritable bowel syndrome], [chronic fatigue syndrome], and fibromyalgia) or other diagnoses.[v]
This definition is extremely broad and can cover a wide variety of symptoms based on these six categories. Some examples of specific symptoms listed by the VA include: abnormal weight loss, fatigue, cardiovascular disease, muscle and joint pain, headache, menstrual disorders, neurological and psychological problems, skin conditions, respiratory disorders, and sleep disturbances.[vi] Also included can be symptoms of other conditions such as chronic fatigue syndrome, fibromyalgia, or functional gastrointestinal disorders like irritable bowel syndrome, functional dyspepsia, or abdominal pain syndrome.[vii] Once any number of these conditions manifest together, then they can be considered diagnosed with Gulf War Syndrome for treatment purposes, if there is no independent explanation for the symptoms.
Because Gulf War Syndrome can exhibit itself in many different ways with different symptoms, treatment for the condition can be as difficult as the diagnosis. The most effective treatments target the actual symptoms involved and many effective treatments match treatments for similar conditions that have similar symptoms.[viii] There is some evidence that certain neurological pharmaceuticals along with group cognitive behavioral therapy can be effective at treating many of the related symptoms.[ix] However, because there is no “one-size-fits-all” approach to managing this condition, an individualized approach is necessary.[x]
Probably the greatest mystery regarding Gulf War Syndrome is what actually causes it. Though many veterans of combat feel psychological effects from their time in war (such as veterans suffering shell shock after World War I), Gulf War Syndrome is different because it also includes severe physical effects. Thorough studies have been conducted to try to determine what the cause is, but it has been difficult to pinpoint an exact cause due to the large population of those affected and the different exposures those individuals faced. These studies have narrowed down the list of potential causes to about a half dozen potential causes. These include general psychological stress of war, exposure to smoke from Kuwaiti oil fires, depleted uranium, ingestion of pyridostigmine bromide (PB) pills (used as a protective measure against nerve gas exposure), pesticide use, and potential low-level exposure to sarin nerve gas.[xi] Of these, the most likely causes are ingestion of PB and pesticide use as there is evidence linking these to illnesses related to Gulf War Syndrome and these were almost exclusively used by soldiers in the Gulf War conflict.[xii]
An important point for all veterans who suffer from or believe they do suffer from Gulf War Syndrome is how to obtain benefits from the VA for their condition. The VA has very specific rules and regulations regarding service connection and disability rating for unexplained conditions suffered by Gulf War veterans. Generally for service connection a veteran must show that a certain condition was incurred coincident with service in the Armed Forces, or was a pre-existing condition that was aggravated during their service.[xiii] However, because of the difficulties in diagnosis with Gulf War Syndrome and the fact that symptoms can appear much later, there are different rules regarding service connection related to this illness.
The VA presumes that certain chronic, unexplained symptoms existing for 6 months or more are related to Gulf War service without regard to cause.[xiv] These presumptive illnesses must have appeared during active duty in the Southwest Asia theater of military operations or by December 31, 2021 and be at least 10 percent disabling under the VA’s disability ratings charts.[xv] It is important to note that this is not limited to service in the Persian Gulf War in 1991, but can also include any service in Iraq and the Middle East to present day.[xvi] There is some evidence and many individual cases that suggest that Gulf War Syndrome can occur in veterans of the current conflicts in the Middle East and VA recognizes this in allowing presumptive service connection for veterans who suffer this condition and served recently.[xvii]
The presumptive illnesses VA looks at are chronic fatigue syndrome, fibromyalgia, functional gastrointestinal disorders, and “undiagnosed illnesses.”[xviii] This means that if any of these four conditions are shown to have lasted for at least 6 months and the veteran served in the Southwest Asia theater of operations, then the condition is presumed to be service connection and no further evidence of cause need be presented. Chronic fatigue syndrome and fibromyalgia are well-defined on their own, but “functional gastrointestinal disorders” and “undiagnosed illnesses” are quite vague and reflect the unknown and varied nature of Gulf War Syndrome. The VA states that functional gastrointestinal disorders relate to chronic symptoms of the gastrointestinal tract which can include irritable bowel syndrome, functional dyspepsia, and abdominal pain syndrome.[xix] “Undiagnosed illnesses” relate directly to general symptoms such as fatigue, muscle and joint pain, headaches, skin conditions, sleep disturbances, and several others often felt by veterans with Gulf War Syndrome.[xx]
The second step in any VA claim is how the condition will be rated based on the VA’s disability ratings chart. Gulf War Syndrome is unique because its symptoms vary widely and it is difficult to measure these compared to other conditions. When it comes to Gulf War Syndrome, the VA rates each symptom separately, based on the closest analogous condition within the disability ratings chart. For example, if a veteran’s Gulf War Syndrome symptoms include fatigue, headaches, and a skin rash, then each of those symptoms would be rated separately based on the closest analogous condition. General fatigue can be rated as “chronic fatigue syndrome,” headaches can be rated under “migraine headaches,” and the skin rash can be rated as a general skin condition.
War can always leave a lasting impact on those fighting it. But for veterans suffering from Gulf War Syndrome, they endure significantly greater hardship than their peers. It is important for everyone, veterans and civilians alike, to educate themselves and understand the plight that these individuals face every day due to their service to our country. It is also useful for those who suffer from Gulf War Syndrome or think they may suffer from it to know how to treat their symptoms and how to navigate the VA claims process in order to receive compensation for their condition incurred during service.
[i] Gulf War Veterans’ Medically Unexplained Illnesses, U.S. Dep’t of Veterans Affairs (Oct. 21, 2016) http://www.publichealth.va.gov/exposures/gulfwar/medically-unexplained-illness.asp. [hereinafter VA on Gulf War Syndrome].
[ii] Steven Wilson, Gulf war illness is real: research consortium publishes main causes of illnesses impacting Persian Gulf War veterans, 58 Disabled American Veterans Magazine 22 (2016).
[iii] VA on Gulf War Syndrome, supra note 1.
[iv] Institute of Medicine of the National Academies, Gulf War and Health: Treatment for Chronic Multisymptom Illness 1 (2013) [hereinafter Treatment for Chronic Multisymptom Illness].
[v] Id. at 23.
[vi] VA on Gulf War Syndrome, supra note 1.
[viii] Treatment for Chronic Mutisymptom Illness, supra note 4, at 185.
[ix] Id. at 184-85.
[x] Id. at 185.
[xi] Research Advisory Committee on Gulf War Veterans’ Illnesses, Gulf War Illness and the Health of Gulf War Veterans: Scientific Findings and Recommendations 224-26 (2008).
[xii] Id. at 227.
[xiii] Principles relating to service connection, 38 C.F.R. § 3.303(a) (2016).
[xiv] VA on Gulf War Syndrome, supra note 1.
[xvi] See id.; see also Gulf War Service, U.S. Dep’t of Veterans Affairs (June 3, 2015) (listing countries considered part of “Southwest Asia theater of military operations), http://www.publichealth.va.gov/exposures/gulfwar/military-service.asp.
[xvii] See Stella M. Gwini, et. al., Multisymptom Illness in Gulf War Veterans: A Systematic Review and Meta-Analysis, 58 Journal of Occupational and Environmental Medicine 659, 664 (2016).
[xviii] VA on Gulf War Syndrome, supra note 1.