Gulf War syndrome

Gulf War syndrome (GWS) or Gulf War illness (GWI) is an illness reported by combat veterans of the 1991 Persian Gulf War typified by symptoms including immune system disorders and birth defects. It has not always been clear whether these symptoms were related to Gulf War service or the occurrence of illnesses in Gulf War veterans is higher than comparable populations.

Symptoms attributed to this syndrome have been wide-ranging, including chronic fatigue, loss of muscle control, headaches, dizziness and loss of balance, memory problems, muscle and joint pain, indigestion, skin problems, shortness of breath, and even insulin resistance. Brain cancer deaths, amyotrophic lateral sclerosis (also known as Lou Gehrig's disease, or motoneurone disease) and fibromyalgia are now recognized by the Defense and Veterans Affairs departments as potentially connected to service during the Gulf War.[1]

Since the end of the Gulf War, the U.S. Department of Veterans Affairs (VA) and the British Ministry of Defense have conducted numerous studies on Gulf War Veterans. The latest studies have determined that while the physical health of deployed veterans is similar to that of non-deployed veterans, there is an increase in 4 out of the 12 medical conditions reportedly associated with Gulf War syndrome (fibromyalgia, chronic fatigue syndrome, eczema, and dyspepsia).[2] They have also concluded that while mortality was significantly higher in deployed veterans, most of the increase was due to automobile accidents.

In 2008, the U.S. National Academy of Sciences published evidence suggesting that excess illnesses in Gulf War veterans can be explained in part by their exposure to acetylcholinesterase inhibitors.[3] On November 17, 2008, the federally mandated Research Advisory Committee on Gulf War Veterans' Illnesses produced a 452-page report,[4] indicating that roughly 1 in 4 of the 697,000 veterans who served in the first Gulf War are afflicted with the disorder. Exposure to toxic chemicals was identified as the cause of the illness. The report states that "scientific evidence leaves no question that Gulf War illness is a real condition with real causes and serious consequences for affected veterans."[5]

Contents

Medical problems by soldier nationality

Summary of the Operation Desert Storm offensive ground campaign, February 24-28, 1991, by nationality (click for detail).

About 30 percent of the 700,000 U.S. servicemen and women in the first Persian Gulf War have registered in the Gulf War Illness database set up by the American Legion. Some still suffer a baffling array of serious health impairing symptoms.[6] The tables below apply only to coalition forces involved in combat. Since each nation's soldiers generally served in different geographic regions, epidemiologists are using these statistics to correlate effects with exposure to the different suspected causes.

U.S. and UK, with the highest rates of excess illness, are distinguished from the other nations by higher rates of pesticide use, use of anthrax vaccine, and somewhat higher rates of exposures to oil fire smoke and reported chemical alerts. France, with possibly the lowest illness rates, had lower rates of pesticide use, and no use of anthrax vaccine.[7] French troops also served to the North and West of all other combat troops,[8] away and upwind of major combat engagements.

Excess prevalence of general symptoms[9]
Symptom U.S. UK Australia Denmark
Fatigue 23% 23% 10% 16%
Headache 17% 18% 7% 13%
Memory problems 32% 28% 12% 23%
Muscle/joint pain 18% 17% 5% 2% (<2%)
Diarrhoea 16% 9% 13%
Dyspepsia/indigestion 12% 5% 9%
Neurological problems 16% 8% 12%
Terminal tumours 33% 9% 11%
Excess prevalence of recognized medical conditions[10]
Condition U.S. UK Canada Australia
Skin conditions 20-21% 21% 4-7% 4%
Arthritis/joint problems 6-11% 10% (-1)-3% 2%
Gastro-intestinal (GI) problems 15% 5-7% 1%
Respiratory problem 4-7% 2% 2-5% 1%
Chronic fatigue syndrome 1-4% 3% 0%
Post-traumatic stress disorder 2-6% 9% 6% 3%
Chronic multi symptom illness 13-25% 26%

Possible causes

Graph showing the rate per 1,000 births of congenital malformations observed at Basra University Hospital, Iraq[11]

In 2008, Beatrice Golomb found evidence suggesting excess illnesses in Gulf War veterans can be explained in part by their exposure to organophosphate and carbamate acetylcholinesterase inhibitors.[3] A federal report released in November, 2008, states that exposure to two neurotoxic agents "are causally associated with Gulf War illness":[12]

Chemical weapons such as nerve gas and mustard gas are usually also acetylcholinesterase inhibitors. The report does not establish a clear connection between other possible contributing factors such as smoke from oil well fires and anthrax vaccine but does not eliminate them either. During the war, many oil wells were set on fire, and the smoke from those fires was inhaled by large numbers of soldiers, many of whom suffered acute pulmonary and other chronic effects, including asthma and bronchitis. However, none of the firefighters who were assigned to the oil well fires encountering the smoke, and who didn't take part in combat, have had any GWI symptoms.[14] The 2008 study said that Gulf War illness is not the result of combat or other stressors, and that Gulf War veterans have lower rates of posttraumatic stress disorder than veterans of other wars.[15] The report said that exposure to depleted uranium munitions is not likely a primary cause of Gulf War illness, but that questions remain about long-term health effects of DU, particularly in relation to other health outcomes.[16]

Anthrax vaccine

During Operation Desert Storm, 41% of U.S. combat soldiers and 57-75% of UK combat soldiers were vaccinated against anthrax.[17] The early 1990s version of the anthrax vaccine was a source of several serious side effects including GWI symptoms. Like all vaccines, it often caused local skin reactions, some lasting for weeks or months.[18] While the Food and Drug Administration (FDA) approved the vaccine, it never went through large scale clinical trials, unlike almost all other vaccines in the United States.[19]

One study found that deployed Gulf War Syndrome patients are significantly more likely to have antibodies to the experimental vaccine adjuvant squalene (95 percent) than asymptomatic Gulf War veterans (0 percent; p<.001), [20] which raises the possibility that squalene was used experimentally (squalene is not approved for use as an adjuvant in the United States[21]) in the Anthrax vaccine given to soldiers prior to deployment in the Gulf War to better induce immunity. The potential implication that the Anthrax vaccine given to soldiers immediately prior to the Gulf War was correlated with Gulf War Syndrome prompted the Department of Defense to task the Armed Forces Epidemiological Board (AFEB) to review Asa, Cao, & Garry's methods. The AFEB found several shortcomings that called into question the validity of the results; namely questionable positive controls, the unproven specificity of the ASA assay, and the potential that the researchers were not blind in their knowledge of patient illness/wellness. [22]

Research into the vaccine used after 1997 suggests that specific vaccine lots used in immunization during the Anthrax Vaccine Immunization Program program initiated in 1997 likely contain squalene because " the incidence of [anti-squalene antibodies] in personnel in the blinded study receiving these lots was 47% (8/17) compared to an incidence of 0% (0/8; P < 0.025) of the AVIP participants receiving other lots of vaccine."[23]

Even after the war, troops that had never been deployed overseas, after receiving the anthrax vaccine, developed symptoms similar to those of Gulf War Syndrome. The Pentagon failed to report to Congress 20,000 cases where soldiers were hospitalized after receiving the vaccine between 1998 and 2000.[24] Despite repeated assurances that the vaccine was safe and necessary, a U.S. Federal Judge ruled that there was good cause to believe it was harmful, and he ordered the Pentagon to stop administering it in October 2004.[25] The ban was lifted in February 2008 after the FDA re-examined and approved the drug again. Anthrax vaccine is the only substance suspected in Gulf War syndrome to which forced exposure has since been banned to protect troops from it.[26]

On December 15, 2005, the Food and Drug Administration, released a Final Order finding that anthrax vaccine is safe and effective.[27][28][29] Women who receive the vaccine get pregnant and deliver children at the same rates as unvaccinated women.[30] Anthrax vaccination has no effect on pregnancy and birth rates or adverse birth outcomes.[31] however the anthrax vaccine currently used is not the same vaccine that was issued during the First Gulf War.[32]

Chemical weapons

Iraq-gwi-map.jpg

Many of the symptoms, other than low cancer incidence rates, of Gulf War syndrome are similar to the symptoms of organophosphate, mustard gas, and nerve gas poisoning.[33][34] Gulf War veterans were exposed to a number of sources of these compounds, including nerve gas and pesticides.[35]

Over 125,000 U.S. troops and 9,000 UK troops were exposed to nerve gas and mustard gas when an Iraqi depot in Khamisiyah, Iraq was bombed in 1991.

One of the most unusual events during the build-up and deployment of British forces into the desert of Saudi Arabia was the constant alarms from the NIAD detection systems deployed by all British forces in theatre. The NIAD is a chemical and biological detection system that is set-up some distance away from a deployed unit, and will set off an alarm automatically if an agent is detected. During the troop build-up, these detectors were set off on a large number of occasions, making the soldiers don their respirators. Many reasons were given for the alarms, ranging from fumes from helicopters, fumes from passing jeeps, cigarette smoke and even deodorant worn by troops manning the NIAD posts. Although the NIAD had been deployed countless times in peacetime exercises in the years before the Gulf War, the large number of alarms was, to say the least, very unusual, and the reasons given were something of a joke among the troops.[36]

The Riegle Report said that chemical alarms went off 18,000 times during the Gulf War. The United States did not have any biological agent detection capability during the Gulf War. After the air war started on January 16, 1991, coalition forces were chronically exposed to low (nonlethal) levels of chemical and biological agents released primarily by direct Iraqi attack via missiles, rockets, artillery, or aircraft munitions and by fallout from allied bombings of Iraqi chemical warfare munitions facilities. Chemical detection units from the Czech Republic, France, and Britain confirmed chemical agents. French detection units detected chemical agents. Both Czech and French forces reported detections immediately to U.S. forces. U.S. forces detected, confirmed, and reported chemical agents; and U.S. soldiers were awarded medals for detecting chemical agents.[37]

Some, including Richard Guthrie, an expert in chemical warfare at Sussex University, have argued that a likely cause for the increase in birth defects was the Iraqi Army’s use of teratogenic mustard agents. Plaintiffs in a long-running class action lawsuit continue to assert that sulphur mustards might be responsible.[38] Both chemical agents, at the exposure levels required to cause such birth defects, would be likely to produce elevated levels of cancer not seen in Gulf War veterans.[33]

In 1997, the US Government released an unclassified report that stated, "The US Intelligence Community (IC) has assessed that Iraq did not use chemical weapons during the Gulf war. However, based on a comprehensive review of intelligence information and relevant information made available by the United Nations Special Commission (UNSCOM), we conclude that chemical warfare (CW) agent was released as a result of US postwar demolition of rockets with chemical warheads in a bunker (called Bunker 73 by Iraq) and a pit in an area known as Khamisiyah." See Khamisiyah: A Historical Perspective on Related Intelligence by the Persian Gulf War Illnesses Task Force (9 April 1997)[39] Khanisiya was the location of an Iraqi chemical weapons storage facility bombed during the first Gulf War.

There is also speculation that residual chemical agents from the Iran-Iraq war caused environmental contamination and chronic exposure amongst the troops, consistent with the increased observation of birth defects amongst the Iraqis bracketing the period of the Gulf War.

Depleted uranium

Approximate area and major clashes in which DU rounds were used.

Depleted uranium (DU) was used in tank kinetic energy penetrator and autocannon rounds on a large scale for the first time in the Gulf War. DU munitions often burn when they impact a hard target, producing toxic combustion products.[40] The toxicity, effects, distribution, and exposure involved have all been the subject of a lengthy and complex debate.

Because uranium is a heavy metal and chemical toxicant with nephrotoxic (kidney-damaging),[41] teratogenic(birth defect-causing),[42][43] and potentially carcinogenic[44] properties, uranium exposure is associated with a variety of illnesses.[45] The chemical toxicological hazard posed by uranium dwarfs its radiological hazard because it is only weakly radioactive, and depleted uranium even less so.

Early studies of depleted uranium aerosol exposure assumed that uranium combustion product particles would quickly settle out of the air[46] and thus could not affect populations more than a few kilometers from target areas,[47] and that such particles, if inhaled, would remain undissolved in the lung for a great length of time and thus could be detected in urine.[48] Uranyl ion contamination has been found on and around depleted uranium targets.[49]

DU has recently been recognized as a neurotoxin.[50] In 2005, depleted uranium was shown to be a neurotoxin in rats.[51]

In 2001, a study was published in Military Medicine that found DU in the urine of Gulf War veterans.[52] Another study, published by Health Physics in 2004, also showed DU in the urine of Gulf War veterans.[53] A study of UK veterans who thought they might have been exposed to DU showed aberrations in their white blood cell chromosomes.[54] Mice immune cells exposed to uranium exhibit abnormalities.[55]

A 2001 study of 15,000 February 1991 U.S. Gulf War combat veterans and 15,000 control veterans found that the Gulf War veterans were 1.8 (fathers) to 2.8 (mothers) times more likely to have children with birth defects.[56] After examination of children's medical records two years later, the birth defect rate increased by more than 20%:

"Dr. Kang found that male Gulf War veterans reported having infants with likely birth defects at twice the rate of non-veterans. Furthermore, female Gulf War veterans were almost three times more likely to report children with birth defects than their non-Gulf counterparts. The numbers changed somewhat with medical records verification. However, Dr. Kang and his colleagues concluded that the risk of birth defects in children of deployed male veterans still was about 2.2 times that of non-deployed veterans."[57]

In a study of U.K. troops, "Overall, the risk of any malformation among pregnancies reported by men was 50% higher in Gulf War Veterans (GWV) compared with Non-GWVs."[58]

In 2005, uranium metalworkers at a Bethlehem plant near Buffalo, New York, exposed to frequent occupational uranium inhalation risks, were alleged by non-scientific sources to have the same patterns of symptoms and illness as Gulf War Syndrome victims.[59]

In the Balkans war zone where depleted uranium was also used, an absence of problems is seen by some as evidence of DU munitions' safety. "Independent investigations by the World Health Organization, European Commission, European Parliament, United Nations Environment Programme, United Kingdom Royal Society, and the Health Council of the Netherlands all discounted any association between depleted uranium and leukemia or other medical problems."[40] In Italy, controversy over the health risks associated with the use of DU continues, with a Senate investigation committee due to release its report into 'Balkan Syndrome' by the end of 2007.[60] Since then, there has been a resurgence of interest in the health effects of depleted uranium, especially since it has recently been linked with neurotoxicity.[50]

Infectious diseases

Along with possible confounding problems caused by exposure to more than one of the substances listed above, comorbidities with infectious diseases have also not been ruled out.[32] Suspected diseases include leishmaniasis, from sandfly bites, and fungal mycoplasma parasites.

There are some who believe that Gulf War Syndrome is the result of a contagious bacteria. There are anecdotal reports of improvement in some victims when treated with antibiotics.[61]

Controversy

There has been considerable controversy over whether or not Gulf War syndrome is a physical medical condition related to sufferers' Gulf War service (or relation to a Gulf War veteran). The following graphs illustrate the state of the controversy in 1998. Since then, as shown by the statistics above, the extent of the problem has become more pronounced.[62]

Evidence for

United States Veterans Affairs Secretary Anthony Principi's panel found that pre-2005 studies suggested the veterans' illnesses are neurological and apparently are linked to exposure to neurotoxins, such as the nerve gas sarin, the anti-nerve gas drug pyridostigmine bromide, and pesticides that affect the nervous system.

"Research studies conducted since the war have consistently indicated that psychiatric illness, combat experience or other deployment-related stressors do not explain Gulf War veterans illnesses in the large majority of ill veterans," the review committee said.

In November, 2004, the anonymously-funded British inquiry headed by Lord Lloyd[64] concluded, for the first time, that thousands of UK and US Gulf War veterans were made ill by their service. The report claimed that Gulf veterans were twice as likely to suffer from ill health than if they had been deployed elsewhere, and that the illnesses suffered were the result of a combination of causes. These included multiple injections of vaccines, the use of organophosphate pesticides to spray tents, low level exposure to nerve gas, and the inhalation of depleted uranium dust.[65] The report was the first to suggest a direct link between military service in the Persian Gulf and illnesses suffered by veterans of that war and directly contradicts other theories which have suggested GWI is not a physical illness, but a response to the stresses of war.

Increases in the rate of birth defects for children born to Gulf War veterans have been reported. A 2001 survey of 15,000 U.S. Gulf War combat veterans and 15,000 control veterans found that the Gulf War veterans were 1.8 (fathers) to 2.8 (mothers) times as likely to report having children with birth defects.[66]

Although not identifying Gulf War syndrome by name, in June 2003 the High Court of England and Wales upheld a claim by Shaun Rusling that the depression, eczema, fatigue, nausea and breathing problems that he experienced after returning from the Gulf War were attributed to his military service.

A 2004 British study comparing 24,000 Gulf War veterans to a control group of 18,000 men found that those who had taken part in the Gulf war have lower fertility and are 40 to 50% more likely to be unable to start a pregnancy. Among Gulf war soldiers, failure to conceive was 2.5% vs. 1.7% in the control group, and the rate of miscarriage was 3.4% vs. 2.3%. These differences are small but statistically significant.[67]

In January 2006, a study led by Melvin Blanchard and published by the Journal of Epidemiology, part of the "National Health Survey of Gulf War-Era Veterans and Their Families", stated that veterans deployed in the Persian Gulf War had nearly twice the prevalence of chronic multisymptom illness (CMI), a cluster of symptoms similar to a set of conditions often called Gulf War Syndrome.[68]

On November 17, 2008 a congressionally appointed committee called the Research Advisory Committee on Gulf War Veterans' Illnesses, staffed with independent scientists and veterans appointed by the Department of Veterans Affairs, announced that the syndrome is a distinct physical condition. The committee stated that the condition was likely caused by a drug given to troops to protect against nerve gas, known as pyridostigmine bromide, and pesticides that were used heavily during the war. It said other possible causes could not be ruled out. The committee recommended that Congress increase funding for research on Gulf War veterans' health to at least $60 million per year.[69]

Evidence against

Similar syndromes have been seen as an after effect of other conflicts — for example, 'shell shock' after World War I, and post-traumatic stress disorder (PTSD) after the Vietnam War. A review of the medical records of 15,000 American Civil War soldiers showed that "those who lost at least 5% of their company had a 51% increased risk of later development of cardiac, gastrointestinal, or nervous disease."[70]

A November 1996 article in the New England Journal of Medicine found no difference in death rates, hospitalization rates or self-reported symptoms between Persian Gulf veterans and non-Persian Gulf veterans. This article was a compilation of dozens of individual studies involving tens of thousands of veterans. The studies did find a statistically significant elevation in the number of traffic accidents suffered by Persian Gulf vets vs. non-Persian Gulf vets.

An April, 1998 article in Emerging Infectious Diseases found no increased rate of hospitalization and better health overall for veterans of the Persian Gulf War vs. Veterans who stayed home. James D. Knoke and Gregory C. Gray, Naval Health Research Center, San Diego, California, USA, Emerging Infectious Diseases 1998 Oct-Dec;4(4):707-9, Hospitalizations for unexplained illnesses among U.S. veterans of the Persian Gulf War.[71]

The US Institute of Medicine, released their conclusions in a September 2006 report further casting doubts on the validity of Gulf War Syndrome, writing that although roughly 30% of service men and women who served either have suffered or still suffer from symptoms,[72] no single cluster of symptoms that constitute a syndrome unique to Gulf War veterans has been identified.[73]

While an increase in birth defects has also been attributed to Gulf War Syndrome, a study on members of the Mississippi National Guard deployed to the Persian Gulf, conducted in 1996 found that of a total of 55 births, five children were born with birth defects. The study concluded that “The rate of birth defects of all types in children born to this group of veterans is similar to that expected for the general population.”[74] In another study of 75,000 births conducted by the New England Journal of Medicine, 7.45% of the Gulf War veteran children were born with birth defects, compared to 7.59% for children of veterans not deployed in the Gulf[75]

Iraq War

Many U.S. veterans of the 2003 Iraq War have reported a range of serious health issues, including tumors, daily blood in urine and stool, sexual dysfunction, migraines, frequent muscle spasms, and other symptoms similar to the debilitating symptoms of "Gulf War Syndrome" reported by many veterans of the 1991 Gulf War, which some believe is related to the continued United States' use of radioactive depleted uranium.[76]

New research from the United Kingdom, published in the medical journal the Lancet compared the health of thousands of service personnel who served in Iraq with the health of thousands who did not, stated:

"If we had found an increase in morbidity after the Iraq war equivalent to that after the Gulf war we could say that these changes were not related to the occurrence of symptoms; all we can now say at this stage is that our new data add to the evidence that there was some relation between the specific pattern of medical countermeasures used in 1991 and ill health."[77]

After 10 years of research worldwide, overseen by the veterans' lawyers and funded by the UK's Legal Services Commission, no evidence was found which established any specific cause for the range of the health problems of over 2,000 British troops who were seeking disability pensions for Gulf War Syndrome.[78]

See also

References

  1. ↑ First Gulf War still claims lives. Seattle Post-Intelligencer. January 16, 2006
  2. ↑ Annals of Internal Medicine. Gulf War Veterans' Health: Medical Evaluation of a U.S. Cohort. June 7, 2005
  3. ↑ 3.0 3.1 Golomb, B. (2008) "Acetylcholinesterase inhibitors and Gulf War illnesses" Proc Natl Acad Sci; Reuters; MedPageToday.com
  4. ↑ Gulf War Illness and Health of Gulf War Veterans [http://sph.bu.edu/insider/images/stories/resources/annual_reports/GWI%20and%20Health%20of%20GW%20Veterans_RAC-GWVI%20Report_2008.pdf
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  6. ↑ (Associated Press, August 12, 2006, free archived copy at: http://www.commondreams.org/headlines06/0812-06.htm Retrieved June 7, 2007)
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  8. ↑ Research Advisory Committee on Gulf War Veterans’ Illnesses December 12-13, 2005 Committee Meeting Minutes (page 68)
  9. ↑ Research Advisory Committee on Gulf War Veterans’ Illnesses December 12-13, 2005 Committee Meeting Minutes (page 70)
  10. ↑ Research Advisory Committee on Gulf War Veterans’ Illnesses December 12-13, 2005 Committee Meeting Minutes (page 71)
  11. ↑ I. Al-Sadoon, et al., writing in the Medical Journal of Basrah University, (see Table 1 here). This version from data by same author(s) in Wilcock, A.R., ed. (2004) "Uranium in the Wind" (Ontario: Pandora Press) ISBN 097361532X
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  18. ↑ GAO-01-92T Anthrax Vaccine: Preliminary Results of GAO's Survey of Guard/Reserve Pilots and Aircrew Members
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  25. ↑ Marine Corps Times - News - More News
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  30. ↑ [2]
  31. ↑ Relationship between prepregnancy anthrax vaccinat...[JAMA. 2002] - PubMed Result
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  34. ↑ Spektor, Dalia M.; Richard A. Rettig, Lee H. Hilborne, Beatrice Alexandra Golomb, Grant N. Marshall, L. M. Davis, Cathy Donald Sherbourne, Naomi H. Harley, William S. Augerson, Gary Cecchine, United States Dept. of Defense (1998). A Review of the Scientific Literature as it Pertains to Gulf War Illnesses. Rand Corporation. ISBN 0833026801. 
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  36. ↑ BBC NEWS | Health | Sarin 'Gulf war syndrome cause'
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  38. ↑ Pitts & Associates - GulfWarVetLawsuit.com - Index
  39. ↑ Khamisiyah: A Historical Perspective on Related Intelligence
  40. ↑ 40.0 40.1 Depleted Uranium
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  43. ↑ Arfsten D, Still K, Ritchie G (2001). "A review of the effects of uranium and depleted uranium exposure on reproduction and fetal development". Toxicol Ind Health 17 (5-10): 180–91. doi:10.1191/0748233701th111oa. PMID 12539863. 
  44. ↑ [6]
  45. ↑ ATSDR - Toxicological Profile: Uranium
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  48. ↑ Horan P, Dietz L, Durakovic A (2002). "The quantitative analysis of depleted uranium isotopes in British, Canadian, and U.S. Gulf War veterans". Mil Med 167 (8): 620–7. PMID 12188230. 
  49. ↑ Salbu B, Janssens K, Lind O, Proost K, Gijsels L, Danesi P (2005). "Oxidation states of uranium in depleted uranium particles from Kuwait". J Environ Radioact 78 (2): 125–35. doi:10.1016/j.jenvrad.2004.04.001. PMID 15511555. 
  50. ↑ 50.0 50.1 Jiang G, Aschner M (2006). "Neurotoxicity of depleted uranium: reasons for increased concern". Biol Trace Elem Res 110 (1): 1–17. doi:10.1385/BTER:110:1:1. PMID 16679544. 
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  53. ↑ Gwiazda R, Squibb K, McDiarmid M, Smith D (2004). "Detection of depleted uranium in urine of veterans from the 1991 Gulf War". Health Phys 86 (1): 12–8. doi:10.1097/00004032-200401000-00004. PMID 14695004. 
  54. ↑ http://www.cerrie.org/committee_papers/INFO_9-H.pdf
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  56. ↑ Kang, H., et al.' (2001). "Pregnancy Outcomes Among U.S. Gulf War Veterans: A Population-Based Survey of 30,000 Veterans". Annals of Epidemiology 11 (7): 504–511. doi:10.1016/S1047-2797(01)00245-9. PMID 11557183. http://www.annalsofepidemiology.org/article/PIIS1047279701002459/abstract. 
  57. ↑ Department of Veterans Affairs (2003) "Q's & A's - New Information Regarding Birth Defects," Gulf War Review 12(1), p. 10.
  58. ↑ Doyle, P., et al. (2004) "Miscarriage, stillbirth and congenital malformation in the offspring of UK veterans of the first Gulf war," International Journal of Epidemiology, 33(1), pp. 74-86; PMID 15075150.
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  63. ↑ 63.0 63.1 "Hospitalizations for Unexplained Illnesses among U.S. Veterans of the Persian Gulf War"
  64. ↑ Gulf War Illness Public Inquiry
  65. ↑ [12][13]
  66. ↑ Kang H, Magee C, Mahan C, Lee K, Murphy F, Jackson L, Matanoski G (2001). "Pregnancy outcomes among U.S. Gulf War veterans: a population-based survey of 30,000 veterans". Ann Epidemiol 11 (7): 504–11. doi:10.1016/S1047-2797(01)00245-9. PMID 11557183. 
  67. ↑ Gulf war veterans have fertility problems - 14 July 2004 - New Scientist
  68. ↑ Record: Study finds multisymptom condition is more prevalent among Persian Gulf vets
  69. ↑ News Services, "Gulf War Syndrome Is Real, Panel Concludes", Washington Post, November 18, 2008, p. 14.
  70. ↑ http://www.sciencemag.org/content/vol311/issue5763/r-samples.dtl#311/5763/927b
  71. ↑ EID Vol. 4 No. 2: Hospitalizations for Unexplained Illnesses among U.S. Veterans of the Persian Gulf War
  72. ↑ Study: Gulf War syndrome doesn't exist - More health news - MSNBC.com
  73. ↑ Gulf War and Health: Volume 4. Health Effects of Serving in the Gulf War - Institute of Medicine
  74. ↑ Committee to Review the Health Consequences of Services During the Persian War, Medical Follow-up Agency, Institute of Medicine, National Academy Press, Washington, DC, 1996
  75. ↑ Cowan, D. N., R. F. DeFraites, G.C. Gray, M.B. Goldenbaum, and S.M. Wishik, “The Risk of Birth Defects Among Children of Persian Gulf War Veterans,” New England Journal of Medicine 336 23, 1997
  76. ↑ Is an Armament Sickening U.S. Soldiers?
  77. ↑ Is there an Iraq war syndrome? Comparison of the health of UK service personnel after the Gulf and Iraq wars. The Lancet, May 16, 2006
  78. ↑ Gulf war syndrome: the legal case collapses

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