Original Research

Improving Health Care for Veterans With Gulf War Illness

Physicians need to recognize and manage Gulf War illness and similar postdeployment, chronic, multisymptom diseases among veterans of recent military operations.

Fed Pract. 2019 May;36(5):212-219

Author(s):

Nicole Baldwin

Rebecca R. Rudquist

Susan Lava-Parmele, MD

Janeen H. Trembley, PhD

Tammy A. Butterick, PhD

Ronald R. Bach, PhD

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References

1. US Department of Veterans Affairs. Research Advisory Committee on Gulf War Veterans’ Illnesses. Gulf War Illness and the Health of Gulf War Veterans: Scientific Findings and Recommendations. https://www.va.gov/RAC-GWVI/docs/Committee_Documents/GWIandHealthofGWVeterans_RAC-GWVIReport_2008.pdf. Published November 2008. Accessed April 16, 2019.

2. Institute of Medicine. Gulf War and Health. Update of Health Effects of Serving in the Gulf War. Vol 8. Washington, DC: National Academies Press; 2009.

3. Fukuda K, Nisenbaum R, Stewart G, et al. Chronic multisymptom illness affecting Air Force veterans of the Gulf War. JAMA. 1998;280(11):981-988.

4. Steele L. Prevalence and patterns of Gulf War illness in Kansas veterans: association of symptoms with characteristics of person, place, and time of military service. Am J Epidemiol. 2000;152(10):992-1002.

5. Kang HK, Mahan CM, Lee KY, Magee CA, Murphy FM. Illnesses among United States veterans of the Gulf War: a population-based survey of 30,000 veterans. J Occup Environ Med. 2000;42(5):491-501.

6. Kang HK, Li B, Mahan CM, Eisen SA, Engel CC. Health of US veterans of 1991 Gulf War: a follow-up survey in 10 years. J Occup Environ Med. 2009;51(4):401-410.

7. Dursa EK, Barth SK, Schneiderman AI, Bossarte RM. Physical and mental health status of Gulf War and Gulf era veterans: results from a large population-based epidemiological study. J Occup Environ Med. 2016;58(1):41-46.

8. Institute of Medicine. Gulf War and Health: Treatment for Chronic Multisymptom Illness. Washington, DC: National Academies Press; 2013.

9. Institute of Medicine. Chronic Multisymptom Illness in Gulf War Veterans: Case Definitions Reexamined. Washington, DC: National Academies Press; 2014.

10. United States Government Accountability Office. Gulf War illness: improvements needed for VA to better understand, process, and communicate decisions on claims. https://www.gao.gov/assets/690/685562.pdf. Published June 2017. Accessed April 16, 2019.

11. Johnson GJ, Slater BC, Leis LA, Rector TS, Bach RR. Blood biomarkers of chronic inflammation in Gulf War illness. PLoS One. 2016;11(6):e0157855.

12. Reno J. Gulf War veterans still fighting serious health problems. https://www.healthline.com/health-news/gulf-war-veterans-still-fighting-serious-health-problems#1. Published June 17, 2016. Accessed April 16, 2019.

13. McAndrew LM, Helmer DA, Phillips LA, Chandler HK, Ray K, Quigley KS. Iraq and Afghanistan veterans report symptoms consistent with chronic multisymptom illness one year after deployment. J Rehabil Res Dev. 2016;53(1):59-70.

14. Steele L, Sastre A, Gerkovich MM, Cook MR. Complex factors in the etiology of Gulf War illness: wartime exposures and risk factors in veteran subgroups. Environ Health Perspect. 2012;120(1):112-118.

15. US Department of Veterans Affairs. VA/DoD Clinical Practice Guideline for the Management of Chronic Multisymptom Illness. Version 2.0. https://www.healthquality.va.gov/guidelines/MR/cmi/VADoDCMICPG2014.pdf. Published October 2014. Accessed April 22, 2019.

16. Koslik HJ, Hamilton G, Golomb BA. Mitochondrial dysfunction in Gulf War illness revealed by 31phosphorus magnetic resonance spectroscopy: a case-control study. PLoS One. 2014;9(3):e92887.

17. Brewer KL, Mainhart A, Meggs WJ. Double-blinded placebo-controlled cross-over pilot trial of naltrexone to treat Gulf War illness. Fatigue: Biomed Health Behav. 2018;6(3):132-140.

18. Golomb BA, Allison M, Koperski S, Koslik HJ, Devaraj S, Ritchie JB. Coenzyme Q10 benefits symptoms in Gulf War veterans: results of a randomized double-blind study. Neural Comput. 2014;26(11):2594-2651.

19. Weiduschat N, Mao X, Vu D, et al. N-acetylcysteine alleviates cortical glutathione deficit and improves symptoms in CFS: an in vivo validation study using proton magnetic resonance spectroscopy. In: Proceedings from the IACFS/ME 12th Biennial Conference; October 27-30, 2016; Fort Lauderdale, FL. Abstract. http://iacfsme.org/ME-CFS-Primer-Education/News/IACFSME-2016-Program.aspx. Accessed April 22, 2019.

20. White RF, Steele L, O’Callaghan JP, et al. Recent research on Gulf War illness and other health problems in veterans of the 1991 Gulf War: effects of toxicant exposures during deployment. Cortex. 2016;74:449-475.

21. US Department of Veterans Affairs. Caring for Gulf War I Veterans. http://www.ngwrc.net/PDF%20Files/caring-for-gulf-war.pdf. Published July 2011. Accessed April 15, 2019.

22. National Academies of Sciences, Engineering, and Medicine. Gulf War and Health. Update of Serving in the Gulf War. Vol 10. Washington, DC: National Academies Press; 2016.

23. US Department of Veterans Affairs. War-Related Illness and Injury Study Center. Gulf War illness: a guide for veteran health care providers. https://www.warrelatedillness.va.gov/education/factsheets/gulf-war-illness-for-providers.pdf. Updated October 2018. Accessed April 16, 2019.

Many veterans of the Gulf War are experiencing deployment-related chronic illness, known as Gulf War illness (GWI). Symptoms of GWI include cognitive impairments (mood and memory), chronic fatigue, musculoskeletal pain, gastrointestinal (GI) disorders, respiratory problems, and skin rashes.^1-4 Three survey studies of the physical and mental health of a large cohort of Gulf War and Gulf era veterans, conducted by the US Department of Veterans Affairs (VA) Office of Public Health, established the increased prevalence of GWI in the decades that followed the end of the conflict.^5-7 Thus, GWI has become the signature adverse health-related outcome of the Gulf War. Quality improvement (QI) within the Veterans Health Administration (VHA) is needed in the diagnosis and treatment of GWI.

Background

GWI was first termed chronic multisymptom illness (CMI) by the Centers for Disease Control and Prevention (CDC). According to the CDC-10 case definition, CMI in veterans of the 1990-1991 Gulf War is defined as having ≥ 1 symptoms lasting ≥ 6 months in at least 2 of 3 categories: fatigue, depressed mood and altered cognition, and musculoskeletal pain.³ The Kansas case definition of GWI is more specific and is defined as having moderate-to-severe symptoms that are unexplained by any other diagnosis, in at least 3 of 6 categories: fatigue/sleep, somatic pain, neurologic/cognition/mood, GI, respiratory, and skin.⁴ Although chronic unexplained symptoms have occurred after other modern conflicts, the prevalence of GWI among Gulf War veterans has proven higher than those of prior conflicts.⁸

The Persian Gulf War Veterans Act of 1998 and the Veterans Programs Enhancement Act of 1998 mandated studies by the Institute of Medicine (IOM) on the biologic and chemical exposures that may have contributed to illness in the Kuwaiti theater of operations.⁹ However, elucidating the etiology and underlying pathophysiology of GWI has been a major research challenge. In the absence of objective diagnostic measures, an understanding of the fundamental pathophysiology, evidence-based treatments, a single case definition, and definitive guidelines for health care providers (HCPs) for the diagnosis and management of GWI has not been produced. As a result, veterans with GWI have struggled for nearly 3 decades to find a consistent diagnosis of and an effective treatment for their condition.

According to a report by the Government Accountability Office (GAO), the VA approved only 17% of claims for compensation for veterans with GWI from 2011 to 2015, about one-third the level of approval for all other claimed disabilities.¹⁰ Although the VA applied GAO recommendations to improve the compensation process, many veterans consider that their illness is treated as psychosomatic in clinical practice, despite emerging evidence of GWI-associated biomarkers.¹¹ Others think they have been forgotten due to their short 1-year period of service in the Gulf War.¹² To realign research, guidelines, clinical care, and the health care experience of veterans with GWI, focused QI within VHA is urgently needed.

Veterans of Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND) are experiencing similar CMI symptoms. A study of US Army Reserve OEF/OIF veterans found that > 60% met the CDC-10 case definition for GWI 1-year postdeployment.¹³ Thus, CMI is emerging as a serious health problem for post-9/11 veterans. The evidence of postdeployment CMI among veterans of recent conflicts underscores the need to increase efforts at a national level, beginning with the VHA. This report includes a summary of Gulf War veterans’ experiences at the Minneapolis VA Health Care System (MVAHCS) and a proposal for QI of MVAHCS processes focused on HCP education and clinical care.