Gulf War Illnesses: Similarities and Differences Among Countries 
in Chemical and Biological Threat Assessment and Veterans' Health
Status (24-JAN-02, GAO-02-359T).				 
								 
This testimony discusses GAO's findings on differences among the 
French, United Kingdom, and the United States forces concerning  
the assessment of Iraqi chemical and biological threats and the  
use of various countermeasures. Also, GAO discusses the extent of
illness, as well as exposure, reported by each country's	 
veterans, focusing on the results of population-based surveys of 
Gulf War veterans' exposure to chemicals, as well as drugs and	 
vaccines to guard against warfare agents. This testimony	 
summarized the April, 2001 report, (GAO-01-13). 		 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-02-359T					        
    ACCNO:   A02700						        
  TITLE:     Gulf War Illnesses: Similarities and Differences Among   
Countries in Chemical and Biological Threat Assessment and	 
Veterans' Health Status 					 
     DATE:   01/24/2002 
  SUBJECT:   Biological warfare 				 
	     Chemical warfare					 
	     Comparative analysis				 
	     Defense contingency planning			 
	     Emergency preparedness				 
	     Foreign governments				 
	     Immunization programs				 
	     International relations				 
	     Radiological warfare				 
	     Veterans						 
	     France						 
	     Iraq						 
	     Persian Gulf War					 
	     United Kingdom					 

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GAO-02-359T
     
United States General Accounting Office

GAO Before the Subcommittee on National Security, Veterans' Affairs, and
International Relations, Committee on Government Reform, House of
Representatives

For Release on Delivery Expected at 10:00 a.m. EDT

Thursday, January 24, 2002

GULF WAR ILLNESSES

Similarities and Differences Among Countries in Chemical and Biological
Threat Assessment and Veterans' Health Status

Statement of Nancy Kingsbury, Ph.D., Managing Director, Applied Research and
Methods

GAO-02-359T

Mr. Chairman and Members of the Subcommittee:

We are pleased to participate in this international hearing by presenting
our findings on differences in illnesses, as well as exposure, among the
Allied Forces-France, the United Kingdom (U.K.), and the United States
(U.S.)-that served in the Persian Gulf War, which began in 1990. My
statement is based on on our report entitled Coalition Warfare: Gulf War
Allies Differed in Chemical and Biological Threats Identified and in Use of
Defensive Measures, which we issued on April 24, 2001, and subsequent work
that we conducted at your request.1

As you know, shortly after the war, some veterans began reporting illnesses
that they believed might be due to exposure to chemicals; to medical
countermeasures, such as drugs and vaccines, to guard against chemical and
biological warfare agents; and to other potentially hazardous substances
used during the war. In the United Kingdom (U.K.) and the United States
(U.S.), such exposure has been evaluated as a possible cause of illnesses
among veterans. In France, the legislature has recently completed an inquiry
into the health of French veterans of the Gulf War. Consequently, the French
government has decided to study this issue systematically.

In our testimony today, we will present our findings on differences among
the French, U.K., and U.S. forces concerning the assessment of Iraqi
chemical and biological threats and the use of various medical
countermeasures. We will also report on the extent of illness, as well as
exposure, reported by each country's veterans. In particular, we will focus
on the results of population-based surveys of Gulf War veterans' exposure to
chemicals, as well as drugs and vaccines to guard against warfare agents.
For a discussion of our scope and methodology, see appendix I. For a list of
the organizations we contacted in France and the United Kingdom, see
appendix II.

Background Following the Iraqi invasion of Kuwait on August 2, 1990, the
United Nations (U.N.) set a deadline of January 15, 1991, for Iraqi
withdrawal from Kuwait and authorized military action to enforce this
deadline. These U.N. resolutions formed the legal canopy for the Persian
Gulf War, which

1 Coalition Warfare:  Gulf War  Allies Differed  in Chemical  and Biological
Threats  Identified and in Use  of Defensive Measures ( GAO-01-13, April 24,
2001).

included the largest international military coalition in combat since World
War II. The size of the coalition forces varied greatly, as did location in
the theater: French ground forces were on the western flank; U.S. forces
were spread across the theater; and U.K. forces were concentrated closer to
the Saudi-Kuwaiti border. It has been reported that during this deployment,
many troops had known or potential exposure to a variety of substances with
known or suspected health effects, including chemicals (for example,
organophosphate pesticides), drugs (for example, pyridostigmine bromide),
and vaccines (for example, the vaccine against anthrax).

The coalition countries drew different conclusions about the threats posed
by Iraq. As shown in table 1, during the Gulf War, both the United Kingdom
and the United States considered biological warfare a possible threat, but
France did not. Specifically, the United Kingdom and the United States
jointly concluded that use of anthrax or botulinum toxin was possible. The
United Kingdom alone concluded that plague was a threat.

Differences in Threat Assessment

Table 1: Differences in Threat Assessment by Country

Country Biological warfare Chemical warfare Nuclear/radiation

France No Yes No

United Kingdom Yes Yes No

United States Yes Yes Limited

Although the coalition countries agreed that chemical warfare was a threat,
they did not agree about the specific types of chemical agents that might be
used. Both the U.K. and U.S. assessments found that Iraq had weapons capable
of delivering blister and nerve agents. Immediately before the war, the U.K.
found Iraq's chemical weapon capability to include nerve agents, blister
agents, and, probably, a blood agent, hydrogen cyanide. Similarly, at the
time of the war, the U.S. military found that Iraq had weapons capable of
delivering nerve agents - including sarin, soman, and VX - and the blister
agent, mustard.2 In November 1990, the U.K. specifically concluded that the
Iraqis had dust impregnated with

2 Final  Report,  Presidential  Advisory  Committee on  Gulf  War Veterans '
Illnesses (Washington, D.C.: Dec. 1996), p. 107.

Differences in Medical Countermeasures- Drug and Vaccines- Against Chemical
and Biological Threats

sulfur mustard, commonly known as "dusty mustard."3 In contrast to this U.K.
assessment, French officials did not believe agents in dust form were
present before, during, or after the war.

France, the United Kingdom, and the United States adopted varied
combinations of protective drugs and vaccines for protection against the
threat of chemical or biological exposure; each country employed these drugs
and vaccines to a different extent. Some of the differences could be
attributed to each country's having identified different threats. For
example, as shown in table 2, France, which did not identify a biological
threat, did not use vaccines to protect against biological threats and
reportedly relied more on protective gear than did either the U.S. or the
U.K. Similarly, the U.S. did not identify plague as a threat, although the
U.K. did; therefore, the U.S. did not require forces to receive plague
immunization.

Table  2: Differences  in  Medical Countermeasures  Used Against  Biological
Threats by Country

In addition, some
differences occurred in
the use or selection of
medical countermeasures
even when the same threat
had been identified. For
example, botulinum toxin was identified as a threat by both the United
States and the United Kingdom. But the United Kingdom addressed it with
antitoxin to be given post-exposure; the United States addressed it with
investigational botulinum toxoid vaccine, to be administered before
exposure. Similarly, the countries took different approaches to managing the
mismatch between the standard schedules for immunization and the time
available to prepare for war. The U.K. used pertussis vaccine as an adjuvant
for anthrax vaccine, in the belief that this would help soldiers

3In addition, U.K. analyses of Gulf War decision making state that it was
known that Iraq had been provided information on the nerve agent soman, the
choking agent phosgene, the psychochemical BZ, and the vomiting agent
adamsite.

achieve adequate immunity by the projected onset of the war.4 All three
countries employed a drug, pyridostigmine bromide, to enhance the
effectiveness of post-attack therapy for exposure to the nerve agents, such
as soman, but the extent and duration of its use differed somewhat across
the coalition countries.

Finally, the use of medical countermeasures for biological and chemical
threats varied within, as well as across, national commands. For example,
based on official report and survey data, the U. S. administered botulinum
toxoid vaccine to only a small portion of its forces. Similarly, the U.K.
reported that it administered the first anthrax injection to over 75 percent
of its deployed forces, with some units fully vaccinated.

Differences in Extent of Illness Reported by Veterans

To date, French veterans of the Gulf War have not reported as many illnesses
since the conflict as their counterparts from the U.K. and U.S. Since the
war, the U.K. and the U.S. veterans have reported illnesses at rates that
are significantly higher than veterans who were not deployed or deployed
elsewhere.5 Across several studies of U.K. and U.S. veterans, the rates of
illnesses reported by those deployed to the Gulf War have consistently been
between 25 and 30 percent greater than the rate reported by comparison
groups of veterans.

In the U.K., researchers surveyed three groups of veterans: U.K. Gulf War
veterans, U.K. veterans deployed to Bosnia, and U.K. veterans deployed
elsewhere during the Gulf War. Illnesses-including symptoms and
disorders-were reported significantly more frequently by the Gulf War
veterans than by the other two groups of veterans. Even after adjusting for
various factors, reporting of illness was significantly higher among Gulf
War veterans than among others. In particular, Gulf War veterans were more
likely to report substantial fatigue and symptoms of post-traumatic

4An adjuvant is a substance incorporated in a vaccine to accelerate,
enhance, or prolong a specific immune response.

5See Iowa Persian Gulf Study Group, "Self-reported Illness and Health Status
Among Gulf War Veterans: A Population-Based Study," Journal of the American
Medical Association, 277 (3), (1997), pp. 238-245. K. Fukuda et al.,
"Chronic Multisymptom Illness Affecting Air Force Veterans of the Gulf War,"
Journal of the American Medical Association, 280, (Sep. 16, 1998), pp.
981-88; C. Unwin et al., "Health of U.K. Servicemen Who Served in the
Persian Gulf War," Lancet, 353, (Jan. 16, 1999), pp. 169-178; and P. Pierce,
"Physical and Emotional Health of Gulf War Veteran Women," Aviation, Space
and Environmental Medicine, 68, (Apr. 1997), pp. 317-21.

stress and psychological stress. These symptoms were consistent with a
working case definition of Gulf War illness developed by the Centers for
Disease Control.6

According to a survey of U.S. veterans, the Gulf War veterans reported
significantly higher rates of illnesses than did veterans who were deployed
elsewhere during the same time period. U.S. Gulf War veterans, compared with
non-Gulf War veterans, reported a rate of functional impairment twice as
high.7 In addition, according to a recent study of Kansas veterans, the
probability of reporting a specific set of symptoms, among Gulf War
veterans, was highest among those who served in Iraq or Kuwait; the
probability, among those who served elsewhere in the region, increased with
the length of stay in the region after the war.8

The French government has not conducted any survey of Gulf War veterans'
health status, although plans for an epidemiological study have recently
been put in place.9 When we visited in 1998, we did not find any reports of
Gulf War-related illnesses among French veterans, although we spoke with
medical staff at a military hospital, multiple French veterans'
organizations, a French military writer, and many French military officials.
The leader of a French veterans' organization cited only a few cases of
psychological problems and a handful of veterans affected by Gulf
War-related traffic accidents, accidental atropine injection, and
unexplained hair loss (two cases). Veterans from the U.K. and U.S., however,
had long reported a variety of symptoms, including fatigue, weakness, and
muscle pain.

The relative absence of reports of illnesses among French veterans could
not, even at that time, be attributed to a lack of publicity within France
as to the illnesses of U.K. and U.S. veterans. Such illnesses had been

6C. Unwin et  al., "Health of U.K. Servicemen Who Served in the Persian Gulf
War," The Lancet, 353 (9148), Jan. 16, 1999.

7Han  K. Kang et  al., "Illnesses  Among United States Veterans  of the Gulf
War: A Population-based  Survey of 30,000 Veterans," Journal of Occupational
and Environmental Medicine, 42 (5), May 2000, 491-501.

8L. Steele, "Prevalence and Patterns of Gulf War Illness in Kansas Veterans:
Association of  Symptoms with Characteristics of  Person, Place, and Time of
Military Service, "  American Journal  of Epidemiology,  152 (10), 992-1002,
Dec. 2000.

9See " Syndrome de la guerre du Golfe: vers une  ï¿½tude ï¿½pidï¿½miologique [Gulf
War Syndrome: Towards an Epidemiological Study]," Le Monde, Sep. 1, 2000, p.
26.

discussed in articles and broadcasts in mainstream French media.10 The
apparently low rates of reported illnesses persisted even in the presence of
outreach by French veterans' organizations and the publicized existence of
veterans' benefits. More recently, 140 among the 25,000 French veterans of
the Gulf War have come forward with illnesses they link to the war; a new
group (Avigolfe), specifically representing ill Gulf War veterans, has been
formed; and the French legislature has held a series of hearings to review
the matter.11 However, as recently as June 2000, no case of Gulf War
illness, French military authorities state, has been identified among the
25,000 French veterans of the war.12 Only 300 requests for compensation have
been made, officials reported, of which 120 had been granted based on proof
of connection to Gulf War service.

The apparently lower rate of illness reported by French Gulf War veterans
does not clearly point to any particular cause for Gulf War veterans'
illnesses; there were, in fact, several differences in French veterans'
experience. For example, French officials reported, apart from the
differences in force location already mentioned, French forces did not,
unlike certain U.S. and U.K. forces, make use of vaccines to protect against
chemical and biological warfare agents. French forces also made no use of
organophosphate pesticides, unlike the U.S. and U.K. forces, and relied on
bottled water. In addition, French forces had greater access to forms of
collective protection, such as specially ventilated truck cabs and shelters;
in addition, they employed protective gear that was less bulky than that of
the United States and the United Kingdom and, consequently, were reported to
have used the gear more often.

In contrast, population-based studies have consistently shown that Gulf War
veterans from the U.K. and U.S. have unexpected levels of illnesses,

10See, for example, Nathalie Mattheiem, "Dix mille soldats amï¿½ricans de la
"Tempï¿½te du dï¿½sert" atteints Enquï¿½tes en chaï¿½ne sur le "syndrome du Golfe
[Ten thousand American soldiers from Desert Storm wait for investigations in
process on `Gulf War Syndrome']," Le Soir (May 27, 1994), p. 6; and Naima
Lefkir-Laffitte and Roland Laffitte, "Armes radioactives contre l'"ennemi
irakien" [Radioactive arms against the "Iraqi Enemy"] Le Monde Diplomatique
(April 1995), p. 2.

11See B. Cazeneuve, M. Rivasi, and C. Lanfranca, Guerre du Golfe: Vï¿½ritï¿½ sur
un conflit, vols. 1 (report) and 2 (hearing transcripts), Paris: Assemblï¿½e
Nationale, 2001 (number 3055).

12"La polï¿½mique sur le `syndrome du Golfe' atteint l'armï¿½e franï¿½aise: Aucun
cas, selon les autoritï¿½s militaires" ["The debate on Gulf War syndrome
reaches the French Army: Not one case, according to military authorities.],
Le Monde, June 7, 2000, p. 12.

as characterized by self-reported symptoms and diagnosed medical and
psychiatric conditions. Overall, the types of symptoms reported by different
veterans' groups in the U.S. and U.K. are strikingly similar, even though
veterans in these studies come from different countries and served in
different locations in the Gulf War theater.

Among Gulf War veterans, the prevalence of symptoms is frequently associated
with specific self-reported wartime exposures.13 For example, veterans in
both the U.K. and U.S. who reported receiving biological warfare vaccine or
exposure to specific types of chemical agents were found to have higher
rates of illnesses. According to studies in both the U.K. and the U.S.,
veterans of the Gulf War who reported receiving biological warfare
inoculations-for anthrax or other threats- were more likely to report a
number of symptoms than non-Gulf War veterans who did not report receiving
such inoculations. This pattern was observed in data collected in the United
Kingdom and in unpublished data collected by the U.S. Department of Veterans
Affairs. In one U.K. study, three exposures-the number of inoculations, the
number of days handling pesticides, and the number of days exposed to smoke
from oil well fires- were consistently and independently related to the
severity of reported symptoms. The number of days handling pesticides was
specifically related to neurological complaints and the number of
inoculations was related to skin and musculoskeletal complaints. A second
U.K. study also noted a relationship between health complaints and receiving
multiple vaccines or inoculations against biological warfare agents.

13See L. Steele, "Prevalence and Patterns of Gulf War Illness in Kansas
Veterans: Association of Symptoms with Characteristics of Person, Place, and
Time of Military Service," American Journal of Epidemiology, 152 (10),
992-1002, Dec. 2000; C. Unwin et al., "Health of U.K. Servicemen Who Served
in the Persian Gulf War," The Lancet, 353 (9148), Jan. 16, 1999; N. Cherry
et al., "Health and Exposures of United Kingdom Gulf War Veterans. Part II:
The Relation of Health to Exposure," Occupational and Environmental
Medicine, 58: 299-306, 2001.

Mr. Chairman,  this ends my prepared  statement. I would be  happy to answer
any questions you have at this time.

Contacts and For further information about this testimony, please call Nancy
Kingsbury, Ph.D., (202) 512-2700, or Sushil K. Sharma, Ph.D., DrPH, at (202)
512-3460. Acknowledgments Other contributors to this testimony include Betty
Ward-Zukerman, Ph.D.

                      Appendix I: Scope and Methodology

We conducted structured interviews with officials of the French, U.K., and
U.S. governments and with members of their military and veterans'
organizations to (1) compare threat assessments and the extent to which they
were shared by the three countries and (2) assess use of various
countermeasures across the three forces. A list of the organizations
contacted in France and the U.K. is provided in appendix II. These
interviews addressed both the threats assessed before or during the war and
the medical countermeasures adopted in response. We supplemented these
interviews with reviews of published information, including U.S. and North
Atlantic Treaty Organization (NATO) nuclear, biological, and chemical
doctrines, as well as reviews of the Gulf War campaign produced by the
Department of Defense (DOD), the U.K. Ministry of Defence, and campaign
participants.

To supplement this work and to assess the extent of illnesses reported by
the three groups of veterans, we reviewed the following: official documents,
scientific literature, and reports of various veterans' organizations,
publications of the Office of the Special Assistant for Gulf War Illnesses,
the Gulf War Veteran's Illnesses Unit of the U.K. Ministry of Defence,
reports of the U.K. Defence Committee, the French National Assembly, DOD,
RAND Corporation, the Institute of Medicine, and various U.S. congressional
and executive advisory committees. We also reviewed key findings with the
U.K. Gulf War Liaison officer and with staff of the French Embassy. Finally,
we collected and reviewed media and legislative reports on (1) the extent
and nature of illness reported in the three countries and (2) the progress
of official investigations into these complaints.

Our work was limited primarily to describing the assessment and sharing of
information on chemical, biological, and nuclear/radiological threats and
the use of medical countermeasures against them. Thus, we did not
systematically examine the extent of exposure to many of the other potential
challenges that could have been encountered by the three groups of veterans,
such as oil fire smoke, depleted uranium, or any hazards that may have
emerged from air strikes on military targets. In addition, many of the
broad-based surveys of illness across coalition countries rely on health
information reported by veterans. While such self-reporting can be biased by
media influence, a large national survey of Gulf War-era veterans found that
their reports of doctor and hospital visits agreed with medical records.

We conducted initial data collection and site visits between August 1997 and
January 1998. At your request, we suspended this work to carry out a

higher priority engagement for you. In April 1999, we resumed our work and
conducted additional data collection and updated our findings. We completed
our work in January 2001 and issued a report to you. Subsequent to its
issuance, again at your request, we have continued to monitor developments
in the three countries and have updated our findings as appropriate.

Appendix II: Organizations Contacted in France and the United Kingdom

France 
Bureau Recherche, Sous-Direction Action Scientifique et Technique, Direction
Centrale, Service de Santï¿½ des Armï¿½es (Office of Research, Scientific and
Technical Division, Headquarters, Army Health Service)

Business Development Directorate, GIAT Industries

Centre d'ï¿½tudes du Bouchet, Ministï¿½re de la Dï¿½fense, Direction Gï¿½nï¿½rale des
Armï¿½es

Conseiller Pour la Santï¿½ et les Actions Humanitaires, Cabinet du Ministre,
Ministï¿½re de la Dï¿½fense (Counselor for Health and Humanitarian Missions,
Office of the Minister of Defense)

Direction centrale, Service de Santï¿½ des Armï¿½es (Headquarters, Army Health
Service)

Division Maï¿½trise des Armements, ï¿½tat-Major des Armï¿½es (Arms Control
Division, Dept. of the Army)

Fï¿½dï¿½ration Mondiale des Anciens Combattants (World Veterans Federation)

Groupement Dï¿½fense Nuclï¿½aire Biologique et Chimique, Facteurs Humains

- Ergonomie, Section Technique de L'Armï¿½e de Terre (Human Factors, NBC
Defense Group, Army Technical Section)

Hï¿½pital Henri Mondor de Cretï¿½il

Hï¿½pital Val de Grace (Military Hospital)

La Commission de la Dï¿½fense Nationale et des Forces Armï¿½es, Assemblï¿½e
Nationale (National Assembly Committee on National Defense and Armed Forces)

La Fï¿½dï¿½ration des Anciens des Missions Extï¿½rieures (Federation of Veterans
of Foreign Wars)

l'Union Franï¿½aise des Associations de Combattants et de Victimes de Guerre
(Coalition of French Associations of Soldiers, Veterans, and Victims of War)

Universit ï¿½ Bordeaux,  Institut de  Santï¿½  Publique d 'Epid ï¿½miologie et  de
Dï¿½veloppement

United Kingdom 
British Medical Association

Defence Committee, House of Commons

Gulf Veterans Association

Gulf Veterans' Illnesses Unit, Ministry of Defence

Institute of Neurological Sciences, Southern General Hospital

Institute of Occupational Medicine

London School of Hygiene and Tropical Medicine

National Gulf Veterans and Families Association

Royal British Legion

Royal Society of Medicine

University of Manchester, School of Epidemiology and Health Sciences
*** End of document. ***