were found in all cohorts, however, they may not be unique
and causally implicated in Gulf-War-related illness. A
specific mechanism may link vaccination against biological
warfare agents and later ill health, but the risks of illness
must be considered against the necessity of protection of
servicemen.
Lancet 1999; 353: 169–78
Introduction
From late 1990, the UK deployed 53 462 military
personnel to the Persian Gulf War. In the months after the
end of the war, anecdotal reports emerged in the USA of
various disorders affecting Gulf War veterans. In the UK,
similar observations surfaced in 1993, after a television
broadcast in June. Some UK Gulf War veterans have
experienced health problems since their return. Such
anecdotal reports cannot, however, establish whether these
complaints have any particular pattern, nor whether they
are related to Gulf War service.
Previous studies of the health of Gulf War veterans
have had limitations. Comparisons with non-military
populations may be misleading, since military recruitment
involves medical screening. Clinical assessment
programmes for non-randomly selected veterans with
symptoms cannot provide epidemiological information or
answer questions about links to active service.1 Some of
these limitations have been addressed. A large-scale study
of US veterans found no substantial differences in
admissions between Gulf War veterans and military
controls.2 However, only admissions to military hospitals
were included, without contact with outpatients, primarycare physicians, or civilian hospitals, which may have led
to bias towards sicker veterans.3 One cohort study used
complete outcome data from an unselected military
population, but looked only at mortality.4 The Centers for
Disease Control and Prevention (CDC) study 5 was
restricted to serving air-force personnel. Sicker veterans
are more likely to have left the services because of ill
health. To date, only one study has used a random sample
of veterans and tried to follow up still serving and
discharged personnel.6
We investigated, among UK male Gulf War veterans
from army, navy, and air force, whether there was a
relation between ill health and the Gulf War.
Methods
We carried out a cross-sectional epidemiological survey to
compare the health profiles of three randomly selected UK
military cohorts.
Participants
The target population was male and female Gulf War veterans
(n=53 462) who served in the Gulf region between Sept 1, 1990,
and June 30, 1991. We excluded special forces for security
Summary
Background Various symptoms in military personnel in the
Persian Gulf War 1990–91 have caused international
speculation and concern. We investigated UK servicemen.
Methods We did a cross-sectional postal survey on a
random sample of Gulf War veterans (Gulf War cohort,
n=4248) and, stratified for age and rank, servicemen
deployed to the Bosnia conflict (Bosnia cohort, n=4250)
and those serving during the Gulf War but not deployed
there (Era cohort, n=4246). We asked about deployment,
exposures, symptoms, and illnesses. We analysed men only.
Our outcome measures were physical health, functional
capacity (SF-36), the general health questionnaire, the
Centers for Disease Control and Prevention (CDC)
multisymptom criteria for Gulf War illness, and posttraumatic stress reactions.
Findings There were 8195 (65·1%) valid responses. The Gulf
War cohort reported symptoms and disorders significantly
more frequently than those in the Bosnia and Era cohorts,
which were similar. Perception of physical health and ability
were significantly worse in the Gulf War cohort than in the
other cohorts, even after adjustment for confounders. Gulf
War veterans were more likely than the Bosnia cohort to
have substantial fatigue (odds ratio 2·2 [95% CI 1·9–2·6]),
symptoms of post-traumatic stress (2·6 [1·9–3·4]), and
psychological distress (1·6 [1·4–1·8]), and were nearly
twice as likely to reach the CDC case definition (2·5
[2·2–2·8]). In the Gulf War, Bosnia, and Era cohorts,
respectively, 61·9%, 36·8%, and 36·4% met the CDC
criteria, which fell to 25·3%, 11·8%, and 12·2% for severe
symptoms. Potentially harmful exposures were reported
most frequently by the Gulf War cohort. All exposures
showed associations with all of the outcome measures in
the three cohorts. Exposures specific to the Gulf were
associated with all outcomes. Vaccination against
biological warfare and multiple routine vaccinations were
associated with the CDC multisymptom syndrome in the
Gulf War cohort.
Interpretation Service in the Gulf War was associated with
various health problems over and above those associated
with deployment to an unfamiliar hostile environment. Since
associations of ill health with adverse events and exposures
Health of UK servicemen who served in Persian Gulf War
Catherine Unwin, Nick Blatchley, William Coker, Susan Ferry, Matthew Hotopf, Lisa Hull, Khalida Ismail,
Ian Palmer, Anthony David, Simon Wessely
ARTICLES
THE LANCET • Vol 353 • January 16, 1999 169
Gulf War Illness Research Unit, Guy’s, King’s, and St Thomas’s
Medical School, London SE5 8AF, UK (C Unwin MSc, S Ferry MSc,
M Hotopf MRCPsych, L Hull BSc, K Ismail MRCPsych, Prof A David MD,
Prof S Wessely FRCP); Office of National Statistics, London
(N Blatchley BSc); Flight Medicine, United States Air Force Medical
Operations Agency, Washington DC, USA (W Coker FRCP); and
Royal Defence Medical College, UK (I Palmer MRCPsych)
Correspondence to: Prof Simon Wessely
(e-mail: s.wessely@iop.bpmf.ac.uk)
Articles
ARTICLES
reasons. We recruited a random stratified sample of 4250
personnel into the Gulf War cohort, which would give sufficient
power to detect an expected increased relative risk of chronic
fatigue syndrome (CFS) of between 1·2 and 1·3. The key
variables for stratification were service (Royal Navy, Army, Royal
Air Force), sex, age, service status (regular or reservist), rank
(officer or other), and fitness (army and air force only). By
stratified selection we aimed to represent the population who
served in the Gulf War. We deliberately over-sampled women.
As comparison cohorts, we randomly selected, from 39 217
personnel who had served in Bosnia, 4250 servicemen deployed
between April 1, 1992, and Feb 6, 1997 (Bosnia cohort), and,
from the 250 000 personnel serving in the armed forces on Jan 1,
1991, who were not deployed to the Gulf War, we selected 4246
(Era cohort) according to the stratification variables used for
the Gulf War cohort. For the Era cohort, we used all the
stratification variables; for the Bosnia cohort we used only age,
sex, and rank because only the army served in Bosnia; reservist
status and fitness data were not available. For any serviceman who
died during follow-up, we excluded their data and recruited
another.
We restricted our analyses to men. Although 1235 women
served in the UK armed forces during the Gulf War, their roles
and background health complaints were not the same as those for
men and results will be reported elsewhere.
Methods
After an initial pilot phase, we sent questionnaires to all
particpants in August and September, 1997. Two further mailings
of non-responders were done between November, 1997, and
June, 1998 (figure 1). Follow-up ended on Nov 11, 1998.
We obtained addresses from the Ministry of Defence. For
personnel still in service we obtained current addresses and for
those who had left the forces (discharged) we obtained the
last known addresses in the UK or overseas. We used
multiple tracing mechanisms for non-responders. For personnel
who had left the services we used the National Health
Service central registry to obtain health authority ciphers
and current addresses. We used the electoral register to check
current addresses. For those still in service, various service
bodies provided regularly revised addresses, including
discharge and pension address sources. Several media appeals
were made by the research teams, with additional support from
the Ministry of Defence, and we posted a study website on the
internet.
In the third mailing, for serving participants, we sent
questionnaires in batches to unit commanding officers with a
letter asking them to facilitate the delivery of the questionnaires to
servicemen. After 1 month, we again approached the
commanding officers with the highest non-response rates.
170 THE LANCET • Vol 353 • January 16, 1999
4246 of 53462
Gulf war veterans
sent questionnaires
7115 participants
did not respond and
questionnaire resent
567 questionnaires
undelivered by Post
Office and resent
4248 of 250000
Era servicemen sent
questionnaires
4250 of 39217
Bosnia veterans
sent questionnaires
4910 questionnaires
completed from
first mailing
12592 questionnaires sent
1825 questionnaires
completed from second mailing
201 participants
refused to respond
7682 questionnaires sent
4583 participants
did not respond and
questionnaire resent
1073 questionnaires
undelivered by Post
Office and resent
1460 questionnaires
completed from third mailing
302 participants
refused to respond
5656 questionnaires sent
2914 participants
did not respond
980 questionnaires
undelivered by Post
Office
Figure 1: Profile of mailing and response rates
To assess potential response bias, we tried after two mailings to
trace a randomly selected sample of 100 participants in the Gulf
War cohort, 50 in the Bosnia cohort, and 50 in the Era cohort
who were non-responders and separated equally into still serving
and discharged. We sent questionnaires by registered post,
contacted family physicians if we could trace them, as well as the
Driving and Vehicle Licensing Agency, and did interviews by
telephone with a shortened version of the questionnaire.
The questionnaire was constructed from existing measures,
questionnaires used in similar studies in the USA, and from our
interviews with UK servicemen. We tested the questions on
several military samples, including Gulf War veterans, and refined
them to ensure that the questionnaire was understandable and
acceptable to the intended recipients. We dropped items that were
irrelevant to UK experiences or because of length.
The questionnaire that we used in the study asked about
demographic details (age, sex, education, military history), alcohol
intake and cigarette smoking, exposure history (29 items), medical
symptoms (50 items), and medical disorders (39 items). We
included several symptoms of post-traumatic stress disorder taken
from the Mississippi scale,7 physical health and functional capacity
from SF-36,8 the 12-item general health questionnaire,9 a
shortened measure of symptoms of possible chemical sensitivity,10
and a chronic fatigue scale.11
We asked participants in the Gulf War and Bosnia cohorts to
give details of vaccinations received 2 months before and during
each conflict. If copies of vaccination records were available, we
asked participants to refer to them when completing the
questionnaire. We asked about vaccination side-effects and
ingestion of pyridostigmine bromide tablets.
In the absence of a valid or agreed definition of ill health arising
after Gulf War service, we used the subjective health perception
and the physical functioning subscales of the SF-36 as the
principal outcome measures. These were supplemented by
a-priori syndromes created from the items and scales used in the
questionnaire. We used the conventional cut-off for the fatigue
questionnaire (3/4) and general health questionnaire (2/3) to
define whether or not respondents were “cases”. We created a
ARTICLES
THE LANCET • Vol 353 • January 16, 1999 171
Characteristic Sample (%)
Sex
Men 3905 (92·0)
Women 341 (8·0)
Age at 1 Jan, 1991 (years)
<20 497 (11·7)
20–24 1503 (35·4)
25–29 1036 (24·4)
30–34 623 (14·7)
35–39 342 (8·1)
>40 244 (5·7)
Rank
Officer 537 (12·7)
Other 3708 (87·3)
Status
Regular 3644 (96·3)
Reservist 141 (3·7)
Fitness*
Highest 3516 (92·9)
Mid 33 (0·9)
Lowest 5 (0·1)
Unknown 231 (6·1)
Service
Army 2992 (70·5)
Navy 460 (10·8)
Royal Air Force 794 (18·7)
*Not available for navy.
Table 1: Sample characteristics for Gulf War cohort
Characteristic Region p Gulf vs Bosnia‡ p Gulf vs Era‡
Gulf (n=2735) Bosnia (n=2393) Era (n=2422) %
Sex
Male/female 2527 (92·4%)/208 (7·6%) 2184 (91·3%)/209 (8·7%) 2245 (92·7%)/177 (7·3%) 0·16 0·68
Current age
>25 0 502 (21·0%) 266 (1·1%)
25–29 692 (25·3%) 866 (36·2%) 518 (21·4%) <0·001 <0·001
30–34 826 (30·2%) 517 (21·6%) 751 (31·0%)
35–39 569 (20·8%) 299 (12·5%) 540 (22·3%)
>40 648 (23·7%) 211 (8·8%) 586 (24·2%)
Marital status
Married or living with partner 2070 (75·7%) 1453 (60·7%) 1846 (76·2%)
Never married 432 (15·8%) 744 (31·1%) 339 (14·0%) <0·001 0·07
Separated, divorced, widowed 232 (8·5%) 196 (8·2%) 240 (9·9%)
Education
Lower than ‘O’ levels 517 (18·9%) 388 (16·2%) 448 (18·5%)
‘O’ levels 1592 (58·2%) 1517 (63·4%) 1335 (55·1%) <0·001 0·01
‘A’ levels and higher 626 (22·9%) 488 (20·4%) 639 (26·4%)
Currently in employment 2581 (94·4) 2333 (97·5%) 2269 (93·7%) <0·001 0·30
Alcohol intake (units per week)
None 257 (9·4%) 158 (6·6%) 223 (9·2%)
1–3 629 (26·5%) 479 (20·0%) 610 (25·2%)
4–10 829 (30·3%) 689 (28·8%) 765 (31·6%) <0·001 0·43
11–20 585 (21·4%) 589 (24·6%) 552 (22·8%)
>21 336 (12·3%) 479 (20·0%) 274 (11·3%)
Smoking history
Currently smoke 968 (35·4%) 912 (38·1%) 761 (31·4%)
Ex-smoker 662 (24·2%) 498 (20·8%) 620 (25·6%) <0·001 <0·001
Never smoked 1102 (40·3%) 984 (41·1%) 1041 (43·0%)
Still in service/discharged 1469 (53·7%)/ 266 (46·3%) 2120 (88·6%)/272 (11·4%) 1402 (57·9%)/1020 (42·1%) <0·001 <0·001
Rank
Officer 366 (13·4%) 306 (12·8%) 310 (12·8%)
Other 2368 (86·6%) 2087 (87·2%) 2076 (85·7%) 0·54 0·32
Serving status†
Regular 2702 (98·8%) 2393 (100·0%) 2405 (99·3%) . . 0·08
Medically discharged† 41 (1·5%) Not known 51 (2·1%) . . 0·10
*Denominators for three groups differ slightly because of non-response on some items.
†Statistic not calculated for Gulf vs Bosnia because of empty cells. ‡x2 or heterogeneity.
Table 2: Characteristics of responders
ARTICLES
variable for post-traumatic stress reaction: the experience of one
symptom in each of four classifications—intrusive thoughts,
avoidance, arousal and irritability—and at least two further
symptoms of unrefreshing sleep, fatigue, alcohol intolerance,
forgetfulness, poor concentration, loss of sexual interest, and
decrease in appetite.
Although not in the original protocol, we added a further
outcome measure based on the multisymptom empiric syndrome
identified by the CDC study,5 which we have labelled the CDC
multisymptom syndrome. Mapped on to our questions, this
outcome required one or more symptoms in at least two
classifications of: fatigue, mood/cognition (depression, poor
concentration or memory, moodiness, anxiety, word-finding
difficulties, sleep difficulties), and musculoskeletal (joint pain,
joint stiffness, muscle pain).
For all outcomes we used only current symptoms, defined as
occurring in the past month because evidence suggests that
questionnaire data alone are reliable only for that length of time.12
Statistical analysis
We analysed data with SPSS (version 7.5) and STATA (version
5.0). Data for SF-36 were entered on to SPSS twice. The
proportions of symptoms, disorders, and exposures were
compared between the Gulf cohort and the two comparison
cohorts by calculation of odds ratios and 95% CIs. We controlled
for potential confounders (sociodemographic factors: age, marital
status, rank, education, employment, still serving or discharged;
lifestyle factors: smoking, alcohol consumption) by logisticregression analysis. We assessed relations between a-priori
outcomes (fatigue, general health questionnaire score, SF-36,
traumatic stress) and reported exposures, stratified by
deployment.
In the Bosnia cohort, 800 of 4250 servicemen had also been
deployed to the Gulf conflict, but we took them to be part of the
Gulf War cohort. The Bosnia cohort consisted of servicemen who
had served only in the Bosnia conflict.
Results
Responses
We received 8195 (65·1%) questionnaire replies (2961
[70·4%] Gulf War cohort, 2620 [61·9%] Bosnia cohort,
2614 [62·9%] Era cohort). Addresses were not available
for 152 participants. 503 (4·0%) servicemen refused to
respond. 980 (7·9%) questionnaires were returned
undelivered to the research team by the Post Office at the
end of the three mailings (figure 1). If the undelivered
questionnaires are taken into account, the minimum
effective response rate was 70·6%. The characteristics of
the Gulf War cohort at the start of the study are shown in
table 1.
Responders did not differ from non-responders by sex,
but were older (mean age: responders 34·7 years, nonresponders 29·3, p<0·001) and more likely to be still in
service (66·4 vs 61·1%, p<0·001, table 2). The number of
medical discharges among responders and non-responders
did not differ across the entire sample (1·8 vs 2·0%,
p=0·44) or by deployment (Gulf War cohort 1·5 vs 1·3%,
p=0·59; Bosnia cohort, not known; Era 2·1 vs 2·6%,
p=0·28). Some veterans had attended the medical
assessment programme established by the Ministry of
Defence for Gulf War veterans with symptoms, but
because of confidentiality, we did not know which
veterans. The Ministry of Defence, however, did an
anonymous record linkage on our behalf. In our Gulf War
cohort, 158 (4·0%) veterans had attended the programme.
Of these veterans, 79% responded to the survey, compared
with 67·3% of the two control groups (p<0·01).
The Bosnia responders were more likely to be still in
service, were younger, and more servicemen were
unmarried, as expected from the chronology of the conflicts.
They also drank more alcohol. The Era cohort was similar
to the Gulf sample, but contained more non-smokers.
We also assessed non-response by differences in the
health of responders to the third mailing, since they would
have been non-responders without a third mailing. The
responders from the first, second, and third mailings did
not differ significantly for a-priori key outcome measures.
Mean SF-36 ratings of health perception were 71·3, 71·1,
and 71·5, respectively (p=0·91). Ratings of physical
function were 92·5, 92·5, and 92·1 (p=0·64). The mean
total symptom score declined by mailing (8·1, 7·3, 7·0,
p<0·001), which shows that servicemen with the most
symptoms replied first. There was no significant
interaction between deployment, late response, and health
outcome (p=0·42), since Gulf War late responders did not
differ from the Bosnia or Era late responders.
200 serviceman who had not responded after two
mailings were randomly chosen for intensive follow-up
(table 3). 139 (69·5%) returned the questionnaire or
completed a telephone survey, 22 (11·0%) refused to
participate, 11 (5·5%) questionnaires were returned
undelivered, and 28 (14·0%) did not respond. The
intensive follow-up group contained more discharged
172 THE LANCET • Vol 353 • January 16, 1999
60
50
40
30
20
10
0
Most frequent
Percentage
Gulf
Bosnia
Era
Least frequent
Frequency of symptoms (%)
Figure 2: Symptoms by deployment
Characteristic Intensively Responders p
followed up (n=7375)*
(n=139)
Age
<25 3·6% 7·0%
25–29 18·7% 27·8%
30–34 14·4% 27·6% <0·001
35–39 31·7% 18·5%
Ä40 31·7% 19·1%
Marital status
Married or living with partner 77·8% 72·5%
Never married 10·4% 18·9% 0·03
Separated, divorced, widowed 11·9% 8·6%
Education
Lower than ‘O’ levels 29·7% 18·7%
‘O’ levels 57·8% 59·9% <0·001
‘A’ levels and higher 12·5% 21·4%
Currently in employment 93·4% 95·6% 0·21
Medically discharged 0·7% 1·3% 0·56
Still in service/discharged 47·8/52·2% 67·1%/32·9% <0·001
Mean (SD) health outcomes
Health perception 66·3 (25·5) 71·3 (23·6) 0·01
Physical functioning 90·3 (17·3) 92·5 (15·8) 0·11
*Denominators differ slightly because of non-response on some items.
Table 3: Characteristics of intensively followed up vs main
study responders
personnel than the main study (p<0·001), were more likely
to be married (p=0·03), and more likely to have lower
educational achievement (p=0·001). They were older
(p<0·001, table 3) and did not differ significantly by
medical discharges, employment status, alcohol
consumption, and smoking (data available on Lancet
website, www.thelancet.com).
For the three cohorts combined, individuals who
underwent intensive follow-up reported slightly worse
health perception (SF-36) than the main study responders
(66·3 vs 71·3). Physical function scales did not, however,
differ significantly (table 3).
Symptoms
The Gulf War cohort reported all symptoms and disorders
on the questionnaires more frequently than the
comparison cohorts (figure 2). In addition to the 15 most
frequent outcomes included in the tables, there were
differences for other outcomes of interest, such as selfreported chronic fatigue syndrome.
We present logistic regression results for only the 15
most frequently reported symptoms and complaints (tables
4 and 5), since only one symptom (vomiting) became nonsignificantly associated with Gulf War service after
adjustment for all confounders. Gulf War service was,
however, associated with increased psychological distress,
measured by the full general health questionnaire, and we
entered this variable into a second model that also
controlled for demographic and lifestyle factors. There was
a slight general decrease in the association between
symptoms and Gulf War service (table 4). Only unintended
weight loss of more than 10 lbs became non-significant.
Adjustment for possible confounders and psychological
disorders lessened the associations for symptoms in the
Gulf War cohort, but most remained significant (tables 4
and 5). The strongest association was for self-reported
chronic fatigue syndrome, although it was infrequently
reported in all three cohorts.
For SF-36 variables, by linear regression differences in
physical functioning between the three cohorts were nonsignificant, but that all other outcomes were significantly
associated with Gulf War service (tables 6 and 7).
ARTICLES
THE LANCET • Vol 353 • January 16, 1999 173
Symptoms Frequency (%) Gulf vs Bosnia Gulf vs Era
Gulf Bosnia Era Univariate Odds ratio Odds ratio Univariate Odds ratio Odds ratio
(n=3284) (n=1815) (n=2408) odds ratio model 1* model 2† odds ratio model 1* model 2†
Feeling unrefreshed after sleep 56·1 33·0 31·6 2·6 (2·3–2·9) 2·4 (2·1–2·8) 2·3 (1·9–2·7) 2·8 (2·5–3·1) 2·7 (2·4–3·1) 2·3 (2·0–2·6)
Irritability or outbursts of anger 55·2 33·6 25·8 2·4 (2·2–2·7) 2·3 (2·0–2·6) 2·1 (1·8–2·4) 3·5 (3·2–4·0) 3·7 (3·3–4·2) 3·2 (2·8–3·7)
Headaches 53·5 36·0 35·6 2·0 (1·8–2·3) 1·9 (1·7–2·3) 1·8 (1·6–2·1) 2·1 (1·9–2·3) 2·1 (1·9–2·3) 1·8 (1·6–2·0)
Fatigue 50·7 26·3 27·7 2·9 (2·5–3·3) 2·5 (2·2–2·9) 2·4 (2·0–2·8) 2·7 (2·4–3·0) 2·7 (2·4–3·1) 2·2 (2·0–2·6)
Sleeping difficulties 48·0 30·7 28·4 2·1 (1·8–2·4) 1·9 (1·6–2·2) 1·7 (1·5–2·0) 2·3 (2·1–2·6) 2·4 (2·1–2·7) 1·9 (1·7–2·2)
Forgetfulness 44·9 19·9 17·1 3·3 (2·8–3·7) 2·8 (2·4–3·2) 2·8 (2·3–3·3) 3·9 (3·5–4·5) 4·2 (3·6–4·8) 3·7 (3·2–4·4)
Joint stiffness 40·0 21·8 23·5 2·4 (2·1–2·7) 2·7 (2·3–3·3) 2·6 (2·1–3·1) 2·2 (1·9–2·4) 2·8 (2·4–3·3) 2·4 (2·0–2·8)
Loss of concentration 39·7 17·2 15·1 3·2 (2·8–3·7) 2·8 (2·4–3·3) 2·9 (2·4–3·5) 3·7 (3·2–4·2) 4·0 (3·4–4·6) 3·6 (3·0–4·2)
Flatulence or burping 34·1 16·4 21·5 2·6 (2·3–3·0) 2·1 (1·8–2·5) 2·0 (1·7–2·4) 1·9 (1·7–2·1) 2·0 (1·8–2·3) 1·8 (1·5–2·0)
Pain without swelling or redness 32·2 13·8 14·4 3·0 (2·5–3·5) 2·1 (1·8–2·4) 1·9 (1·6–2·2) 2·8 (2·5–3·2) 2·2 (2·0–2·6) 1·9 (1·7–2·2)
in several joints
Feeling distant or cut off from 28·1 15·2 11·0 2·2 (1·9–2·5) 2·0 (1·7–2·4) 1·8 (1·5–2·3) 3·2 (2·7–3·7) 3·4 (2·9–4·0) 2·8 (2·3–3·3)
others
Avoiding doing things or situations 26·8 13·0 10·3 2·4 (2·1–2·9) 2·0 (1·7–2·4) 1·8 (1·5–2·3) 3·2 (2·7–3·7) 3·5 (2·9–4·1) 2·8 (2·3–3·4)
Chest pain 25·3 13·2 11·8 2·2 (1·9–2·6) 2·0 (1·7–2·4) 1·9 (1·6–2·3) 2·5 (2·2–2·9) 2·6 (2·2–3·0) 2·1 (1·8–2·5)
Tingling in fingers and arms 24·7 8·7 11·1 3·4 (2·8–4·1) 2·7 (2·2–3·3) 2·5 (2·0–3·1) 2·6 (2·3–3·1) 2·7 (2·3–3·2) 2·3 (2·0–2·7)
Night sweats 24·6 12·8 9·9 2·2 (1·9–2·6) 2·0 (1·7–2·4) 1·9 (1·5–2·2) 3·0 (2·5–3·5) 2·9 (2·5–3·5) 2·5 (2·1–2·9)
*Controlled for age (continuous variable [years]), smoking, alcohol consumption, marital status, educational attainment, officer or other ranks, employment status, and civilian or
military status on follow-up.
†As for model 1, but adds general health questionnaire score (0–12). Odds ratio (95% CI).
Table 4: 15 most frequent self-reported symptoms by deployment
Complaints Frequency (%) Gulf vs Bosnia Gulf vs Era
Gulf Bosnia Era Unadjusted Odds ratio Odds ratio Unadjusted Odds ratio Odds ratio
(n=3284) (n=1815) (n=2408) odds ratio model 1* model 2† odds ratio model 1* model 2†
Back disorders 35·7 23·9 27·6 1·8 (1·5–2·0) 1·5 (1·3–1·7) 1·4 (1·2–1·6) 1·5 (1·3–1·6) 1·5 (1·3–1·7) 1·3 (1·1–1·5)
Hayfever 21·6 18·7 15·8 1·2 (1·0–1·4) 1·2 (1·0–1·5) 1·2 (1·0–1·4) 1·5 (1·3–1·7) 1·5 (1·3–1·8) 1·4 (1·2–1·6)
Dermatitis 21·3 13·7 12·3 1·7 (1·5–2·0) 1·8 (1·5–2·1) 1·6 (1·3–2·0) 1·9 (1·7–2·2) 1·9 (1·6–2·2) 1·6 (1·4–1·9)
Sinus disorders 19·6 11·7 12·0 1·8 (1·5–2·2) 1·6 (1·3–1·9) 1·4 (1·2–1·8) 1·8 (1·5–2·1) 1·7 (1·5–2·0) 1·5 (1·3–1·8)
Migraines 18·1 10·2 9·2 1·9 (1·6–2·3) 1·7 (1·4–2·1) 1·6 (1·3–1·9) 2·2 (1·8–2·6) 2·1 (1·8–2·5) 1·7 (1·4–2·1)
Disease of hair or scalp 16·5 7·6 8·6 2·4 (2·0–2·9) 2·4 (1·9–3·0) 2·2 (1·8–2·8) 2·1 (1·8–2·5) 2·0 (1·7–2·4) 1·8 (1·5–2·1)
Ear infection 12·3 7·2 8·8 1·8 (1·5–2·2) 1·5 (1·2–1·9) 1·4 (1·1–1·8) 1·5 (1·2–1·7) 1·4 (1·2–1·7) 1·2 (1·0–1·5)
Loss of hearing 11·8 5·9 9·4 2·1 (1·7–2·7) 1·5 (1·1–1·9) 1·4 (1·0–1·8) 1·3 (1·1–1·5) 1·4 (1·1–1·6) 1·1 (0·9–1·4)
Arthritis or rheumatism 9·7 4·1 7·9 2·5 (1·9–3·3) 1·5 (1·1–2·0) 1·3 (0·9–1·7) 1·2 (1·0–1·5) 1·4 (1·1–1·7) 1·1 (0·9–1·4)
Sexual problems 9·0 3·0 3·1 3·2 (2·4–4·3) 2·2 (1·5–3·1) 1·9 (1·3–2·7) 3·0 (2·3–3·9) 3·2 (2·4–4·2) 2·2 (1·7–3·0)
High blood pressure 8·8 4·3 6·6 2·2 (1·7–2·8) 1·4 (1·0–1·9) 1·3 (1·0–1·8) 1·5 (1·1–1·7) 1·5 (1·2–1·9) 1·2 (1·0–1·6)
Eczema or psoriasis 7·8 5·8 6·7 1·4 (1·1–1·8) 1·3 (1·1–1·7) 1·3 (1·0–1·6) 1·2 (1·0–1·5) 1·2 (1·0–1·5) 1·2 (0·9–1·5)
Asthma 6·5 4·5 3·7 1·5 (1·1–1·9) 1·2 (0·9–1·6) 1·2 (0·8–1·6) 1·8 (1·4–2·3) 1·8 (1·4–2·4) 1·6 (1·2–2·1)
Bronchitis 4·4 2·2 2·5 2·0 (1·4–2·9) 1·7 (1·1–2·5) 1·5 (1·0–2·3) 1·8 (1·3–2·5) 1·7 (1·2–2·3) 1·4 (1·0–1·9)
Disease of genital organs 3·8 3·3 2·2 1·1 (0·8–1·6) 1·6 (1·1–2·4) 1·5 (1·0–2·3) 1·7 (1·2–2·4) 1·5 (1·1–2·2) 1·3 (0·9–1·8)
Chronic fatigue syndrome or 3·3 0·8 0·8 4·2 (2·4–7·4) 2·5 (1·3–4·8) 2·1 (1·1–4·0) 4·4 (2·7–7·3) 4·2 (2·5–7·2) 2·7 (1·6–4·6)
myalgic encephalitis
Multiple chemical sensitivity 0·8 0·4 0·3 1·9 (0·8–4·4) 1·1 (0·4–3·1) 1·0 (0·4–2·8) 2·2 (1·0–4·9) 2·2 (0·9–5·3) 1·7 (0·7–4·0)
*Controlled for sociodemographic and lifestyle variables (as for table 4).
†Controlled for sociodemographic variables plus general health questionnaire.
Table 5: 15 most frequently self-reported medical disorders, plus chronic fatigue syndrome and multiple chemical sensitivity, by
deployment
vaccine, only 2·8% of veterans without records
remembered receiving pertussis vaccine, compared with
36·2% of those with records (table 10), which is
strong evidence that records were used. The outcome
measure did not differ between those with and without
records.
Vaccines were divided into biological warfare vaccines
(plague and anthrax plus adjuvant pertussis) and routine
vaccinations, which include IgG for hepatitis A (table 10).
There was a relation between reporting biological warfare
vaccination and outcome, irrespective of the use of records
(table 11). The pattern for routine vaccines was less clear.
Servicemen who had served in the Gulf War showed a
weak relation between receiving individual non-biological
warfare vaccines and the outcome, but this relation was
not seen in the Bosnia cohort. The relation for routine, as
opposed to biological warfare vaccines, was, however, seen
only in Gulf War veterans who did not use their records.
Because there has been much speculation that veterans
who received multiple vaccinations were at risk of illness,
we added the total number of vaccinations received. This
was broken down into quintiles (40% of veterans reported
receiving no vaccines and form the first two quintiles).
Overall, there was a significant effect that was specific to
ARTICLES
When we tested the CDC multisymptom syndrome,5 for
severe symptoms only, the outcome frequencies fell to
25·3% for the Gulf cohort, 11·8% for the Bosnia cohort,
and 12·2% for the Era cohort, but the pattern of symptom
reporting did not change. The addition of
a time criterion (only symptoms since the Gulf
deployment) made little difference (24·6% in the Gulf War
cohort). Our severe criteria were not directly comparable
with those of the CDC because not every symptom in our
questionnaire included a severity dimension.
Exposures
For exposures (table 8), we checked reports of unusual
exposures in the particular deployments, and all responses
were true with no data-entry errors. We report associations
with exposures only for self-reported physical health, the
CDC syndrome, and post-traumatic stress reactions (table
9). There was no difference in the pattern of results for the
other three main outcome measures (self-reported health
perception, general health questionnaire, and fatigue
cases). There was no difference in the pattern of responses
to ingestion of pyridostigmine bromide tablets and all
outcomes.
We found an association with the belief of exposure to a
chemical attack. This exposure was associated with the
lowest health perception (Gulf War cohort, odds ratio 2·4
[95% CI 1·8–31·2]) and had the strongest association with
the CDC syndrome (2·6 [1·9–3·5]), followed by the
general health questionnaire case criteria (2·0 [1·5–2·5])
and fatigue case criteria (2·2 [1·7–2·9]).
Vaccinations
31·8% of the Gulf War cohort reported that they had
vaccination records. Few were forwarded, but checks
suggested that most individuals used their records when
completing the questionnaire. Of a random sample of 100
respondents who retained their records, 29 included the
details of the vaccine batch number, the exact date of
vaccination, or both. We recontacted a further 20
servicemen who reported that they possessed their records
but whose responses did not indicate that they used them
when completing the questionnaire. 16 (80%) said they
had copied the vaccination records directly. Finally,
although pertussis was always administered with anthrax
174 THE LANCET • Vol 353 • January 16, 1999
Exposures Gulf† (%) Bosnia (%) Era (%)
Diesel or petrochemical fumes 84·0 75·9 68·5
NBC suits 81·7 3·1 3·3
Pyridostigmine bromide 81·6 1·9 5·2
Exhaust from heaters or generators 78·2 79·3 61·5
Smoke from oil-well fires 72·4 3·9 3·1
Sound of chemical alarms 70·7 2·7 6·6
Personal pesticides 69·2 48·9 38·2
Local food‡ 69·1 65·9 . .
Burning rubbish or faeces 66·7 58·7 33·1
Diesel or petrochemical fuel on skin 66·6 60·7 53·3
Dismembered bodies 66·3 39·7 25·1
Other paints or solvents 63·9 54·9 54·0
Dead animals 56·6 57·1 23·0
Handled prisoners of war 53·6 28·7 10·0
Maimed soldiers 48·0 32·0 25·2
Pesticides on clothing or bedding 38·4 25·5 18·3
*All exposures except dead animals and exhaust from heaters or generators were
more frequent in Gulf cohort than Bosnia and Era.
†Ordered by frequency in Gulf cohort.
‡Not asked in Era group.
Table 8: 15 most frequently self-reported exposures* by
deployment
Frequency (%) Gulf vs Bosnia (95% CI) Gulf vs Era (95% CI)
Gulf Bosnia Era Unadjusted Model 1 Model 2 Unadjusted Model 1 Model 2
(n=3284) (n=1815) (n=2408) odds ratio adjusted adjusted odds ratio adjusted adjusted
odds ratio odds ratio odds ratio odds ratio
General health questionnaire 39·2 26·3 24·0 1·8 (1·6–2·0) 1·6 (1·4–1·8) · · 2·0 (1·8–2·3) 2·1 (1·9–2·4) · ·
Post-traumatic stress reaction 13·2 4·7 4·1 3·1 (2·4–3·9) 2·6 (1·9–3·4) 2·3 (1·7–3·2) 3·6 (2·8–4·4) 3·8 (2·8–4·9) <2·7 (2·1–3·6)
Fatigue case 46·9 25·8 20·5 2·5 (2·2–2·9) 2·2 (1·9–2·6) 2·2 (1·9–2·7) 3·4 (3·0–3·8) 3·6 (3·2–4·2) <3·5 (2·9–4·1)
CDC Gulf 61·9 36·8 36·4 2·8 (2·5–3·1) 2·5 (2·2–2·8) 2·4 (2·0–2·8) 2·8 (2·5–3·2) 2·9 (2·6–3·3) <2·4 (2·1–2·8)
*Controlled for sociodemographic and lifestyle factors.
†Controlled for model 1 variables plus general health questionnaire score.
Table 7: Odds ratios for health outcomes in three groups
Outcome (mean [SD]) Gulf vs Bosnia Gulf vs Era
Gulf Bosnia Era Unadjusted Model 1 Model 2 Unadjusted Model 1 Model 2
(n=3284) (n=1815) (n=2408) mean difference adjusted mean adjusted mean mean difference adjusted mean adjusted mean
difference* difference† difference difference†
SF-36 health perception‡ 65·5 (25·1) 76·3 (20·8) 75·3 (22·0) 10·8 (9·4–12·1) 8·3 (6·8–9·7) 6·0 (4·7–7·4) 9·8 (8·5–11·0) 9·6 (8·4–10·8) 5·6 (4·5–6·7)
SF-36 physical functioning‡ 91·2 (16·4) 95·0 (12·6) 92·3 (17·0) 3·8 (2·9–4·7) 1·4 (0·4–2·3) 0·5 (0·4–1·4) 1·1 (0·2–1·9) 1·2 (0·3–2·0) 20·6 (1·4–0·3)
*Controlled for sociodemographic and lifestyle factors.
†Controlled for model 1 variables plus general health questionnaire score. ‡Higher scores show better health. Odds ratio (95% CI)
Table 6: SF36 and other health outcomes in three groups
the Gulf cohort, with a significant interaction term (table
11). The effect persisted after control for receipt of
biological warfare vaccines (table 12). Stratification by use
of records to control for recall bias did not affect the
association (table 13). The same analyses were repeated
for the other five main outcomes. For each of these
outcomes, multiple vaccinations were associated with
poorer health after control for deployment. The
interaction term between deployment and multiple
vaccinations was significant for only two of these
outcomes—health perception and physical health. There
was no interaction between pyridostigmine bromide
ingestion and multiple vaccinations (p=0·7).
We repeated the analyses to find out whether sideeffects experienced at the time of vaccinations were
associated with the outcome. Veterans who recalled
experiencing side-effects were more likely to have current
symptoms (Gulf War cohort 2·8 [2·4–3·3]; Bosnia cohort
2·2 [1·6–3·1]). Analyses including reporting side-effects in
the model, for the variables shown in table 11, showed
only one significant association between tetanus
vaccination and ill health in the Gulf War cohort (1·2
[1·0–1·4]). After control for reported side-effects the
association between all vaccinations and illness was
weakened, but remained significant (table 13). The relation
between multiple vaccinations and outcome was almost
unchanged in servicemen who had vaccination records.
Discussion
UK veterans of the Gulf War report higher rates of many
symptoms and disorders and have a decreased perception
of well being than servicemen who were not deployed to
the Gulf War, despite no evidence of increased frequencies
and no excess of objective outcomes, such as birth defects,
cancers, or death.1,2,4 By contrast, we report that servicemen in the Gulf were about three times more likely to fulfil
criteria for chronic fatigue, post-traumatic stress reaction,
or the CDC multisymptom syndrome criteria than those in
the control cohorts, even after adjustment for confounders.
These participants were at least twice as likely to
experience similar outcomes as those deployed to Bosnia.
Despite these findings, disability was not severe, and there is
no evidence of an increased rate of adverse outcomes such
as unemployment or marital breakdown. Nevertheless, we
believe that our data constitute firm evidence that service in
the Gulf War has affected the health of servicemen.
ARTICLES
THE LANCET • Vol 353 • January 16, 1999 175
Gulf War Bosnia Era
SF-36 physical functioning
Diesel or petrochemical fumes 1·4 (1·2–1·7) 1·4 (1·0–1·8) 1·8 (1·5–2·2)
NBC suits 1·5 (1·3–1·8) 1·5 (0·8–2·7) 1·4 (0·9–2·3)
Pyridostigmine bromide 1·3 (1·1–1·5) 1·7 (0·8–3·5) 1·1 (0·8–1·7)
Exhaust from heaters of generators 1·4 (1·2–1·7) 1·4 (1·1–1·9) 1·7 (1·4–2·0)
Smoke from oil-well fires 1·2 (0·99–1·3) 0·7 (0·4–1·3) 1·2 (0·7–2·0)
Hear chemical alarms sounding 1·5 (1·3–1·8) 1·5 (0·7–2·8) 1·5 (1·0–2·0)
Personal pesticides 1·5 (1·3–1·8) 1·4 (1·1–1·8) 1·5 (1·2–1·8)
Local food* 1·0 (0·9–1·2) 1·3 (1·0–1·7) . .
Burning rubbish or faeces 1·2 (1·0–1·4) 1·0 (0·8–1·2) 1·3 (1·1–1·6)
Diesel or petrochemical fuel on skin 1·4 (1·2–1·6) 1·2 (0·9–1·5) 1·5 (1·3–1·8)
Dismembered bodies 1·3 (1·2–1·5) 1·3 (1·0–1·6) 1·3 (1·0–1·5)
Other paints or solvents 1·4 (1·2–1·6) 1·3 (1·0–1·7) 1·6 (1·3–1·9)
Dead animals 1·2 (1·1–1·4) 1·2 (0·9–1·5) 1·2 (0·9–1·4)
Handled prisoners of war 1·1 (0·9–1·3) 1·3 (1·0–1·6) 1·0 (0·7–1·3)
Maimed soldiers 1·2 (1·0–1·4) 1·3 (1·0–1·6) 1·3 (1·1–1·6)
Pesticides on clothing or bedding 1·4 (1·2–1·6) 1·5 (1·4–1·9) 1·6 (1·2–1·9)
Other exposures of interest
Chemical or nerve gas attack 2·2 (1·7–2·9) 9·5 (1·9–47·1) 1·5 (0·8–2·9)
Mustard gas 1·8 (1·2–2·9) 1·2 (0·3–4·4) 1·7 (0·6–4·5)
Combat-related injury 1·8 (1·4–2·4) 1·6 (1·1–2·4) 2·1 (1·5–2·9)
Witness anyone dying 1·4 (1·2–1·7) 1·5 (1·2–2·0) 1·3 (1·0–1·5)
SCUD missile explosion within 1·5 (1·3–1·8) 3·1 (1·0–9·7) 1·3 (0·5–3·6)
1 mile
Come under small-arms fire 1·1 (0·9–1·3) 1·8 (0·9–1·5) 1·3 (1·1–1·6)
Artillery close by 1·4 (1·2–1·6) 1·2 (0·9–1·5) 1·2 (0·9–1·5)
CDC syndrome
Diesel or petrochemical fumes 2·1 (1·7–2·5) 1·8 (1·4–2·3) 2·4 (1·9–2·9)
NBC suits 2·7 (2·3–3·3) 2·7 (1·6–4·8) 2·3 (1·5–3·7)
Pyridostigmine bromide 2·6 (2·2–3·1) 3·4 (1·7–6·8) 1·9 (1·4–2·8)
Exhaust from heaters or generators 1·9 (1·6–2·2) 2·8 (2·1–3·7) 2·4 (1·9–2·8)
Smoke from oil-well fires 1·8 (1·5–2·1) 1·4 (0·8–2·3) 1·8 (1·1–2·9)
Hear chemical alarms sounding 2·2 (1·9–2·6) 2·5 (1·4–4·5) 2·3 (1·7–3·2)
Personal pesticides 2·2 (1·9–2·6) 1·8 (1·5–2·2) 1·8 (1·5–2·2)
Local food* 1·1 (0·9–1·3) 1·8 (1·5–2·3) . .
Burning rubbish or faeces 1·9 (1·6–2·2) 1·9 (1·6–2·3) 1·8 (1·5–2·1)
Diesel or petrochemical fuel on skin 1·8 (1·5–2·1) 1·8 (1·5–2·2) 2·0 (1·7–2·4)
Dismembered bodies 2·0 (1·7–2·3) 2·0 (1·6–2·4) 1·9 (1·5–2·3)
Other paints or solvents 1·7 (1·5–2·0) 1·9 (1·5–2·3) 1·9 (1·6–2·3)
Dead animals 1·8 (1·5–2·0) 2·4 (1·9–2·9) 2·3 (1·9–2·8)
Handled prisoners of war 1·7 (1·5–1·9) 2·2 (1·8–2·7) 1·9 (1·5–2·5)
Maimed soldiers 1·7 (1·5–2·0) 2·0 (1·6–2·5) 1·8 (1·5–2·2)
Pesticides on clothing or bedding 1·9 (1·6–2·2) 1·7 (1·4–2·2) 1·9 (1·5–2·3)
Other exposures of interest
Chemical or nerve gas attack 2·6 (1·9–3·5) 6·0 (1·2–29·0) 2·2 (1·2–4·2)
Mustard gas 1·9 (1·2–3·3) 7·7 (1·6–35·9) 3·2 (1·2–8·7)
Combat-related injury 2·9 (2·1–4·2) 2·4 (1·7–3·6) 3·1 (2·2–4·2)
Witness anyone dying 1·6 (1·4–1·9) 2·0 (1·6–2·6) 1·8 (1·4–2·1)
SCUD missile explosion within 1·6 (1·4–1·9) 2·4 (0·8–7·5) 2·2 (0·8–6·0)
1 mile
Come under small-arms fire 1·5 (1·3–1·7) 1·7 (1·4–2·1) 1·6 (1·4–1·9)
Artillery close by 1·9 (1·6–2·2) 1·8 (1·4–2·2) 1·6 (1·3–2·0)
Post-traumatic stress reaction
Diesel or petrochemical fumes 2·5 (1·7–3·6) 3·2 (1·5–6·7) 1·9 (1·1–3·1)
NBC suits 3·0 (2·1–4·4) 2·0 (0·8–5·3) 3·3 (1·6–6·7)
Pyridostigmine bromide 3·1 (2·1–4·4) 1·9 (0·6–6·4) 2·1 (1·1–4·2)
Exhaust from heaters or generators 2·3 (1·7–3·1) 4·4 (1·8–11·0) 2·6 (1·6–4·2)
Smoke from oil-well fires 2·3 (1·7–2·9) 3·2 (1·6–6·8) 3·0 (1·4–6·5)
Hear chemical alarms sounding 2·1 (1·6–2·8) 1·4 (0·4–4·5) 1·8 (0·9–3·5)
Personal pesticides 2·3 (1·7–2·9) 1·8 (1·1–2·8) 1·8 (1·2–2·8)
Local food* 0·8 (0·6–0·9) 2·1 (1·2–3·7) . .
Burning rubbish or faeces 2·0 (1·5–2·5) 3·5 (1·9–6·1) 2·8 (1·8–4·2)
Diesel or petrochemical fuel on skin 2·0 (1·6–2·6) 2·1 (1·2–3·4) 2·0 (1·3–3·0)
Dismembered bodies 2·7 (2·1–3·5) 3·9 (2·4–6·3) 3·7 (2·5–5·5)
Other paints or solvents 1·4 (1·1–1·7) 2·2 (1·3–3·5) 3·3 (2·0–5·4)
Dead animals 1·6 (1·3–1·9) 3·9 (1·9–5·9) 2·9 (1·9–4·3)
Handled prisoners of war 2·3 (1·8–2·8) 4·0 (2·6–6·3) 1·5 (0·9–2·7)
Maimed soldiers 2·8 (2·3–3·5) 3·8 (2·4–6·0) 3·7 (2·5–5·5)
Pesticides on clothing or bedding 2·4 (1·9–2·9) 1·9 (1·2–3·0) 2·9 (1·9–4·5)
Other exposures of interest
Chemical or nerve gas attack 3·1 (2·3–4·1) 2·4 (0·3–19·7) 1·2 (0·3–4·9)
Mustard gas† 2·1 (1·2–3·6) · · 1·4 (0·2–11·0)
Combat-related injury 2·4 (1·8–3·3) 2·4 (1·3–4·6) 5·0 (3·1–8·2)
Witness anyone dying 2·2 (1·8–2·7) 2·5 (1·6–3·9) 2·8 (1·9–4·2)
SCUD missile explosion within 1·7 (1·4–2·1) 3·3 (0·7–14·9) 3·9 (0·9–18·3)
1 mile
Come under small-arms fire 2·0 (1·6–2·5) 2·9 (1·8–4·8) 3·9 (2·6–5·9)
Artillery close by 2·4 (1·9–2·9) 2·3 (1·5–3·6) 3·8 (2·5–5·7)
*Not asked in Era group. †Statistic for Bosnia not calculated due to empty cell. Odds
ratio (95% CI).
Table 9: Association of 15 most frequent exposures and
exposures of interest with principal health outcomes
Gulf (%) Bosnia (%)
All Record No record All Record No record
(n=940) (n=2242) (n=1127) (n=1718)
Biological warfare
vaccine
Anthrax 57·2 69·3 55·1 2·6 2·9 2·5
Plague 25·7 34·1 23·3 0·2 0·4 0
Pertussis 12·2 36·2 2·8 0·1 0·3 0
Any biological 58·4 69·7 56·4 2·9 3·5 2·5
Routine vaccines
Hepatitis A 6·3 7·8 6·1 23·8 37·2 14·2
Hepatitis B 7·2 10·6 6·1 12·3 17·8 8·6
Yellow fever 14·0 15·8 13·9 13·4 19·3 9·5
Typhoid 12·5 25·4 7·6 15·9 27·7 7·4
Poliomyelitis 13·7 15·9 12·8 14·7 20·0 11·2
Cholera 13·7 31·5 6·2 2·1 2·7 1·6
Tetanus 33·8 34·3 32·3 29·3 39·5 22·2
Any routine 48·1 62·4 42·0 45·6 61·8 33·3
vaccination
Table 10: Frequency of reported vaccines by theatre of war
and vaccine records
ARTICLES
Study limitations
As in similar studies, the most important factor for
participation in the survey was our ability to find accurate
addresses.5,6,13,14 The second factor influencing response
was demography. Young men generally change addresses
frequently and are not inclined to respond to lengthy
questionnaire surveys,15 which has been experienced in
previous studies of Gulf War veterans.
A key question is whether or not participation was
biased towards those with health complaints. Responders
were more likely to still be in service, but did not differ
from non-responders on various relevant health outcomes,
including the proportion of those given medical
discharges. There was no suggestion that veterans with
worse health outcomes were more or less likely to respond
at the earliest opportunity, although those with more
symptoms responded earlier and proportionally more
responders attended the medical assessment programme.
An identical pattern of response was reported in the US
study most comparable with our own.14 By contrast,
servicemen traced by intensive follow-up, who were
assumed to represent non-responders to the main study,
had worse health perception than responders. The
difference was not significant, did not differ by cohort, and
was not accompanied by a similar decline in self-reported
physical functioning. We conclude that the pattern that
those who had more symptoms responded earlier was in
keeping with other large surveys. A few veterans probably
had worse health and were also non-responders, which has
been shown in individuals who attribute poor health to
living close to hazardous waste sites.16 We suspect that few
of the persistently non-responding veterans may feel
distrust for and alienation from “authority”, a
phenomenon reported previously in soldiers returning
from war.17,18 The most important conclusion is that
differential non-response between the three cohorts does
not explain the observed results.
There has been dispute about the choice of controls in
Gulf War studies. Some argue that deployed veterans may
be healthier than servicemen who are not deployed, which
would lead to a “healthy warrior” bias,3 and which could
have obscured an increase in adverse outcomes in those
deployed. The issue is unresolved,19 but cannot account
for our findings. The associations between the Gulf War
and Era cohorts were only slightly more robust than those
between the Gulf War and Bosnia cohorts, which suggests
that the “healthy warrior” effect was not strong. We
controlled for predeployment fitness, a proxy for general
health. Given the robust increases in ill health reported by
Gulf War veterans, any “healthy warrior” effect would add
to the strength of our findings.
All the chosen outcomes are questionnaire-based and
relied on self-report. We have not reported the frequency
of disorders such as asthma, neuropathy, major
depression, chronic fatigue syndrome, or post-traumatic
stress disorder, which require a clinical interview and
examination for diagnosis. Instead our chosen outcomes
should be interpreted as indicating that the responder was
more likely to have a disorder but not as being diagnostic.
The differential patterns between the three cohorts
therefore show more than the absolute numbers for each
classification.
We did not do physical examinations. Previous studies
of selected and randomly chosen Gulf War veterans have
shown an absence of unexpected abnormal findings.1,5,20,21
Routine surveillance of Gulf War veterans for infectious
disease has generally been negative.5 In addition, Gulf War
veterans seem to have no increased rates of defined
physical disorders that might explain increased symptom
reporting.4 Likewise, whereas Vietnam veterans complain
176 THE LANCET • Vol 353 • January 16, 1999
Total vaccinations Control for biological warfare Control for experience of
vaccines side-effects after vaccination
All Records only All Records only
0* · · · · · · · ·
1–2 0·8 (0·6–1·0) 0·9 (0·6–1·5) 0·8 (0·6–1·1) 1·3 (0·7–2·2)
3–6 1·0 (0·6–1·0) 1·1 (0·8–1·5) 1·0 (0·8–1·2) 1·1 (0·8–1·6)
Ä7 1·5 (1·2–1·9) 1·7 (1·2–2·4) 1·3 (1·0–1·6) 1·7 (1·1–2·5)
p 0·0005 0·008 0·05 0·01
*Reference.
Table 13: Associations between multiple vaccination and CDC
syndrome, controlled for experience of side-effects and
biological warfare vaccine, Gulf only
Gulf Bosnia
Odds ratio for all With records Without records Odds ratio for all With records Without records
odds ratio odds ratio odds ratio odds ratio
Biological warfare vaccine
Anthrax 1·5 (1·3–1·7) 1·4 (1·0–1·8) 1·4 (1·2–1·7) 1·5 (0·7–2·9) 2·6 (0·9–7·4) 0·9 (0·4–2·3)
Plague* 1·3 (1·1–1·6) 1·1 (0·9–1·5) 1·4 (1·1–1·7) · · · · · ·
Pertussis* 1·1 (0·9–1·4) 1·3 (1·0–1·7) 0·9 (0·5–1·6) · · · · · ·
Any biological 1·5 (1·3–1·7) 1·4 (1·1–1·9) 1·5 (1·2–1·8) 1·5 (0·8–2·8) 2·5 (0·9–6·6) 0·9 (0·4–2·3)
Routine vaccines
Hepatitis A 1·1 (0·8–1·5) 1·1 (0·7–1·9) 1·0 (0·7–1·5) 1·1 (0·8–1·4) 1·1 (0·7–1·5) 1·1 (0·7–1·6)
Hepatitis B 1·0 (0·8–1·3) 1·0 (0·7–1·6) 0·9 (0·6–1·3) 1·2 (0·9–1·7) 1·2 (0·8–1·9) 1·2 (0·7–2·1)
Yellow fever 1·3 (1·1–1·7) 1·4 (0·9–2·0) 1·3 (0·9–1·6) 1·0 (0·7–1·4) 0·8 (0·5–1·2) 1·2 (0·7–1·9)
Typhoid 1·0 (0·8–1·3) 1·0 (0·7–1·4) 1·1 (0·8–1·5) 1·1 (0·8–1·5) 1·1 (0·7–1·6) 1·1 (0·7–1·9)
Poliomyelitis 1·2 (0·96–1·5) 0·9 (0·8–1·4) 1·3 (1·0–1·8) 1·2 (0·9–1·7) 0·9 (0·6–1·4) 1·6 (1·1–2·5)
Cholera 1·1 (0·9–1·4) 1·1 (0·8–1·4) 1·3 (0·9–1·9) 0·8 (0·3–2·1 ) 0·5 (0·1–2·3) 1·1 (0·3–4·0)
Tetanus 1·3 (1·1–1·5) 1·1 (0·8–1·4) 1·3 (1·1–1·6) 1·0 (0·8–1·3) 1·0 (0·7–1·3) 1·1 (0·8–1·5)
Any routine 1·2 (1·1–1·4) 1·0 (0·7–1·3) 1·3 (1·1–1·5) 1·1 (0·9–1·3) 1·0 (0·7–1·3) 1·2 (0·9–1·6)
*Odds ratios not calculated for Bosnia because of empty cells.
Table 11: Associations between reported vaccinations and CDC syndrome, stratified by theatre of war and whether respondent had
vaccination record
Total All (Gulf Gulf Bosnia
vaccina- and Bosnia)
All With All With
tions
records records records records
0* · · · · · · · · · ·
1–2 0·9 (0·8–1·1) 0·9 (0·7–1·2) 1·2 (0·7–2·0) 1·0 (0·8–1·3) 1·0 (0·7–1·4)
3–6 1·4 (1·2–1·6) 1·2 (1·0–1·4) 1·1 (0·8–1·6) 1·1 (0·8–1·4) 0·8 (0·6–1·2)
Ä7 2·6 (2·2–3·1) 1·8 (1·5–2·2) 1·9 (1·3–2·8) 1·1 (0·4–3·4) 1·2 (0·3–5·5)
p <0·0001 <0·0001 0·001 0·6 0·5
Interaction term vaccinations by theatre of war x2 4·6 (p=0·03).
*Reference.
Table 12: Associations between multiple vaccination and CDC
syndrome
of a range of self-reported symptoms and disorders, these
were rarely diagnosed on physical examination or
investigation.22 A few veterans may have undetected
physical disease, but this possibility would not affect the
pattern of our results. We intend to do further studies that
include detailed physical, neurophysiological, and
neuropsychological examinations of veterans who report
symptoms and of controls.
Implications
The finding that active military service has led to longterm adverse health effects is not new and has been
reported in US and Australian Vietnam veterans,22,23 and
inferred after earlier conflicts.24 Furthermore, the US study
of Gulf veterans most comparable to ours reported a
similar decline in self-reported health status and higher
rates of various symptoms and disorders.6
The most obvious explanation for this increase in
symptoms in the Gulf War veterans is that it relates to
different experiences of hazardous exposures. The
differences in many self-reported exposures between Gulf
veterans and controls was not substantial. For example,
although reported use of pesticides was common among
UK Gulf veterans (more so than US servicemen6), it was
also frequently reported in the Bosnia and Era cohorts.
Three types of self-reported exposures did differ
substantially between the Gulf War veterans and the
comparison cohorts: exposure to the smoke of burning oil
wells, vaccinations against biological warfare, and
measures to protect against, and possible exposure to,
chemical warfare.
All service personnel deployed abroad are routinely
vaccinated against several infective agents. Some personnel
received booster doses of one or more of these
vaccinations before deployment. At the time of the Gulf
War, two new vaccination programmes were started to
protect troops against plague and anthrax. Pertussis
vaccine was administered with the anthrax vaccine as an
adjuvant, to speed the immunological response.
Servicemen who received vaccinations against biological
warfare agents were more likely to report long-term
symptoms. Those who received routine vaccinations were
generally not at increased risk. Receipt of multiple nonbiological warfare vaccinations was, however, associated
with an increased risk of illness, but only among Gulf War
veterans, even though Bosnia veterans also received
multiple vaccinations. This finding was not explained by
simultaneous exposure to biological warfare vaccines. A
striking relation between retrospective recollection of sideeffects of vaccines at the time and later illness seemed to
explain the association between individual vaccines and
illness, but not multiple vaccines and illness.
The association between receipt of any routine
vaccinations and adverse outcomes was significant only in
servicemen who had not used their vaccination records,
which suggests some recall bias. However, servicemen who
had used their records were more likely to report biological
warfare vaccination, which suggests that some had
forgotten that they had received biological warfare
vaccines. Slight positive and negative recall biases were,
therefore, present, but our main findings on the long-term
outcome of biological vaccines and multiple vaccines in
the Gulf War was unlikely to be because of recall bias. The
association persisted in servicemen who had their records,
which were generally used when completing the
questionnaire.
We cannot explain the vaccine findings. Multiple
vaccinations in a short period of time have been suggested
to produce a shift in the cytokine profile from Th1 to
Th2.25 We hope to be able to test this hypothesis directly.
Likewise, there may be an interaction between stress and
response to vaccination,25 as has been suggested for
pyridostigmine ingestion in experimental animal models.26
We found no interactions between exposures such as
immunisations and pyridostigmine bromide. Finally,
psychological mechanisms should be taken into account
that are consistent with our data; for example, symptoms
experienced acutely after vaccination could generate health
anxiety and prime recipients to detect similar generalised
symptoms occurring later. Given the results of our
accompanying paper (pages 179–82), multiple or
biological warfare vaccination may be a further nonspecific trigger for later symptoms.
The third factor specific to the Gulf conflict was the
realistic threat of chemical warfare. Nearly 70% of US
personnel surveyed just before the active conflict reported
that anticipation of attack by chemical weapons, biological
weapons, or both was their most common fear.27 7 years
later we found that nearly all Gulf veterans remember
wearing nuclear-biological-chemical suits and hearing
chemical alerts, 26% reported a SCUD missile explosion
nearby, and 9% believed that they had been exposed to
chemical attack.
Gulf and Bosnia veterans differed in their experience of
needing to protect themselves against chemical attack,
their perception that such attack might be imminent, and
the belief that such an attack had taken place. Whether or
not such attack occurred is uncertain, although an
accidental discharge of chemical agents did take place after
the war (the Khamisiyah incident28). Irrespective of
whether actual exposure took place, the threat of such
exposure was real to the servicemen and may be a risk
factor for development of the adverse outcomes we report.
Previous attempts to give at least a part explanation of
the health difficulties of US veterans have drawn specific
analogies with combat stress and subsequent posttraumatic stress disorder. Classic traumatic events, such as
seeing dismembered bodies, maimed soldiers, or
witnessing death were associated with Gulf War service,
but were not unique to that deployment. Combat-related
injury, one of the most robust associations of posttraumatic stress,29 was one of the strongest associations of
all the outcomes, but did not differ between the cohorts.
Adjustment for psychological distress did not alter the
pattern of results. Although clinically diagnosed posttraumatic stress disorder has been associated with
increased experience of physical symptoms,30,31 narrowly
defined post-traumatic stress pathways can only partly
explain the pattern of results. Likewise, war trauma,
although important, is not by itself sufficient explanation
for our findings. We prefer to broaden the definition of
stress to include environmental as well as direct battle
traumas, as noted in the Vietnam War32 and in civilian
life.33
Our findings suggest that general mechanisms link
adversity and health outcomes. These mechanisms include
the general effect of conflict on self-reported health and
the general association between all potentially adverse
exposures and health.6 Therefore, although some of the
exposures were unique to the Gulf War, the mechanisms
linking them to ill health might not be specific. One
pathway could involve perceived risk and later ill health.
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ARTICLES
We suspect that the threat of chemical attack was one such
exposure, analogous to previous observations that link selfreported exposure to herbicide (“Agent Orange”) and
various similar outcomes.34 Recall bias in which
servicemen with more symptoms recall more exposures
may be a further general link, as seen in assessment of
possible toxic hazards several years after exposure.35 The
increase in symptoms, for whatever reason, leads to lower
health perception, and an increased probability of
endorsing any specified medical disorder.
Finally, we cannot exclude possible unique biological
mechanisms that link Gulf War service and later ill health.
We have shown an adverse effect of multiple vaccination
specific to the Gulf War and aim to confirm this finding in
further studies. We cannot make recommendations about
the medical preparation for future military conflicts from
our findings.
A fuller understanding of why service in the Persian
Gulf War was associated with a definite decline in general
well-being will come from assessment of the effects of true
and perceived exposure to physical and psychological
adversity, and the interaction between the two.
Contributors
Catherine Unwin coordinated the study, and was involved in analysis and
the writing of the paper. Nick Blatchley gave statistical support and created
the study cohorts. William Coker and Ian Palmer are grant holders, and
provided military advice and liaison. Lisa Hull traced veterans and
coordinated the study and follow-up. Khalida Ismail did the follow-up
study, and was involved in the analysis and the writing of the paper.
Susan Ferry was the initial study coordinator. Matthew Hotopf gave
epidemiological advice and was involved in the analysis and the writing of
the paper. Anthony David and Simon Wessely were the principal
investigators and planned, designed, and supervised the study, as well as
drafting the paper.
Acknowledgments
This study was funded by the US Department of Defence. Neither the US
Department of Defence nor the UK Ministry of Defence has had any input
into the design, analysis, and reporting of the study. The views expressed
here are ours and not those of any US or UK governmental organisation.
We thank the Ministry of Defence for assistance in identifying and tracing
the participants. NB was seconded to the Ministry of Defence from the
Office of National Statistics. We thank Terry English, Royal British Legion,
and his staff, the Gulf veterans’ organisations, and the veterans who gave
advice and encouragement and who continue to serve on our advisory
board. We thank our colleagues in the other research teams at the London
School of Hygiene and Tropical Medicine and the University of
Manchester for their cooperation, and Margo Pellerin for providing
supportive counselling to distressed veterans or their relatives.
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