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Debating the Evidence on Gulf War Illnesses
By SCOTT SHANE
Published: November 16, 2004
http://www.nytimes.com/2004/11/16/health/policy/16gulf.html?oref=login&ex=1258347600&
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When a Department of Veterans Affairs panel produced a provocative
report last week on the illnesses of veterans of the 1991 Persian Gulf
war, it stepped into a treacherous territory where patients' suffering
meets scientists' skepticism.
By dismissing combat stress or other psychological causes and finding a
"probable link" between the veterans' health problems and exposures to
pesticides, sarin or other chemicals, the Research Advisory Committee on
Gulf War Veterans' Illnesses suggested that it was correcting the record
based on the latest scientific evidence.
But some outside scientists, including several whose earlier gulf war
studies found scant support for the chemical theory, wondered whether
the committee was instead stretching thin data to tell veterans what
they wanted to hear.
"What is their motive in drawing strong conclusions from weak evidence?"
asked Dr. Harold C. Sox, editor of The Annals of Internal Medicine, who
led an earlier gulf war study for the Institute of Medicine. "I think
the process the V.A. used was flawed. They asked experts to testify who
had at least the appearance of a conflict of interest. And they didn't
have a methodology for assessing the strength of the evidence."
Whatever the eventual consensus, the disagreement makes clear that gulf
war illnesses have joined a constellation of contentious health issues
that pit the frustration of ailing patients against scientists' demands
for meticulous data.
Like patients who believe their ills can be traced to silicone breast
implants or Agent Orange, the ailing veterans complain of a daunting
variety of symptoms: headaches, joint pain, fatigue, diarrhea, skin
rashes, dizziness and even hair loss.
Gulf war illnesses - like multiple chemical sensitivity, chronic fatigue
syndrome and fibromyalgia - have been attributed to numerous possible
causes. Some veterans have blamed the anthrax vaccine, smoke from oil
fires and exposure to depleted uranium for their ailments.
"You're dealing with a will-o'-the-wisp," said Dr. Marcia Angell, former
editor of The New England Journal of Medicine and the author of a 1996
book on the breast implant controversy.
"If someone says rhubarb causes colon cancer, the presumption is that it
doesn't until there's objective scientific data," Dr. Angell said.
Patients with multisymptom syndromes often suffer from depression, too,
leading some researchers to believe that some of the ailments are
psychosomatic.
But when patients are told their illness has a psychological origin, it
can add to feelings of isolation and frustration.
"I think in general the less competent doctors tell their patients,
'It's all psychological,' '' said Dr. Paul Greengard, a Nobel
Prize-winning neuroscientist at Rockefeller University, who says he
believes that a neurotoxin role in gulf war illness is plausible.
"That's the last escape for doctors who can't find an answer."
Financial issues can complicate the picture. With breast implants,
lawyers for women who said they had been harmed sought damages from
manufacturers. With gulf war illnesses, as with Agent Orange, a finding
that a sickness is "service-connected" can open the door to benefit
payments.
Faced with such thorny medical controversies, the government's response
is often to appoint a committee. But the committee's makeup may
influence its conclusions.
For example, the V.A. committee that produced the new report included
four gulf war veterans and six medical scientists, four of whom had
published previous studies of gulf war health problems.
The committee noted that Desert Storm was a brief war in which few
soldiers saw close-quarters combat that could cause lasting
psychological harm.
Dr. Lea Steele, a Kansas State University epidemiologist and the panel's
scientific director, said the committee found evidence that troops might
have suffered neurological damage from exposure to pesticides or to
sarin, a nerve gas possibly released when American forces destroyed
Iraqi weapons depots.
In contrast, the Institute of Medicine, composing a different committee
to study the effects of sarin on gulf war veterans, deliberately chose
no veterans and selected six scientists who had never studied gulf war
illnesses.
In August, that group found "insufficient evidence" that low-level
exposure to sarin from the destruction of Iraqi arms could cause
long-terms neurological effects.
"Our committee understood that the issues were highly politically
charged," said Dr. Jack M. Colwill, chairman of the Institute of
Medicine committee. "But we sat down and focused on the scientific
evidence."
James Binns, a former Defense Department official who headed the new V.A.
committee, said he believed his group reached a different conclusion
because it considered animal studies of sarin that the Institute of
Medicine panel ignored. He acknowledged, however, that panel members'
backgrounds played a role.
Mr. Binns said that when Anthony J. Principi, the secretary of veterans
affairs, selected the panel, he "looked for people who were open to
reaching new conclusions."
Another member of the V.A. panel, Dr. Beatrice Golomb of the University
of California at San Diego, said that if stress had been wrongly blamed
for gulf war illnesses, there was a precedent. For decades, doctors told
their patients that gastric ulcers were caused by stress.
Then a group of maverick researchers proved that most cases were caused
by a bacterium, Helicobacter pylori. Today, stress is believed to play a
minor role or none at all. "The medical community was very resistant to
accepting a new idea," Dr. Golomb said, adding that, with gulf war
illnesses, too, "it's challenging, because there have been very strongly
staked out positions."
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