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United States General Accounting Office: 
GAO: 

Testimony: 

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 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.[Footnote 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 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). 
 
Differences in Threat Assessment:  

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. 

Table 1: Differences in Threat Assessment by Country: 

Country: France; 
Biological warfare: No; 
Chemical warfare: Yes; 
Nuclear/radiation: No. 

Country: United Kingdom; 
Biological warfare: Yes; 
Chemical warfare: Yes; 
Nuclear/radiation: No. 

Country: United States; 
Biological warfare: Yes; 
Chemical warfare: Yes; 
Nuclear/radiation: Limited. 

[End of table] 

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.[Footnote 2] In November 1990, the U.K. specifically concluded 
that the Iraqis had dust impregnated with sulfur mustard, commonly 
known as "dusty mustard."[Footnote 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. 

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

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: 

Country: France; 
Anthrax: No; 
Botulinum toxin: No; 
Plague: No. 

Country: United Kingdom; 
Anthrax: Yes; 
Botulinum toxin: No; 
Plague: Yes. 

Country: United States; 
Anthrax: Yes; 
Botulinum toxin: Yes; 
Plague: No. 

[End of table] 

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 achieve adequate immunity by the 
projected onset of the war.[Footnote 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.[Footnote 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 stress and psychological stress. These 
symptoms were consistent with a working case definition of Gulf War 
illness developed by the Centers for Disease Control.[Footnote 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.[Footnote 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.[Footnote 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.[Footnote 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 discussed in articles and broadcasts in mainstream 
French media.[Footnote 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.[Footnote 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.[Footnote 
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, 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.[Footnote 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. 

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

Contacts and Acknowledgments: 

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. Other contributors to this testimony include Betty 
Ward-Zukerman, Ph.D. 

[End of section] 

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. 

[End of section] 

Appendix II: Organizations Contacted in France and the United Kingdom: 

France: 

Bureau Recherche, Sous-Direction Action Scientifique et Technique,
Direction Centrale, Service de Sante des Armees (Office of Research,
Scientific and Technical Division, Headquarters, Army Health Service), 

Business Development Directorate, GIAT Industries. 

Centre d'Etudes du Bouchet, Ministere de la Defense, Direction 
Generale des Armees. 

Conseiller Pour la Sante et les Actions Humanitaires, Cabinet du 
Ministre, Ministere de la Defense (Counselor for Health and 
Humanitarian Missions, Office of the Minister of Defense). 

Direction centrale, Service de Sante des Armees (Headquarters, Army
Health Service). 

Division Maitrise des Armements, Etat-Major des Armees (Arms Control
Division, Dept. of the Army). 

Federation Mondiale des Anciens Combattants (World Veterans
Federation). 

Groupement Defense Nucleaire Biologique et Chimique, Facteurs Humains--
Ergonomie, Section Technique de L'Armee de Terre (Human Factors,
NBC Defense Group, Army Technical Section). 

Hopital Henri Mondor de Creteil. 

Hopital Val de Grace (Military Hospital). 

La Commission de la Defense Nationale et des Forces Armees, Assemblee
Nationale (National Assembly Committee on National Defense and Armed
Forces). 

La Federation des Anciens des Missions Exterieures (Federation of
Veterans of Foreign Wars). 

l'Union Francaise des Associations de Combattants et de Victimes de
Guerre (Coalition of French Associations of Soldiers, Veterans, and
Victims of War). 

University Bordeaux, Institut de Sante Publique d'Epidemiologie et de
Developpement. 

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 section] 

Footnotes: 

[1] Coalition Warfare: Gulf War Allies Differed in Chemical and 
Biological Threats Identified and in Use of Defensive Measures 
[hyperlink, http://www.gao.gov/products/GAO-01-13], April 24, 2001. 

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

[3] In 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. 

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

[5] See 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. 

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

[7] Han 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. 

[8] 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. 

[9] See "Syndrome de la guerre du Golfe: vers une etude 
epiderniologique [Gulf War Syndrome: Towards an Epidemiological 
Study]," Le Monde, Sep. 1, 2000, p. 26.  

[10] See, for example, Nathalie Mattheiem, "Dix mille soldats 
americans de la "Tempete du desert" atteints Enquetes en chain 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 iraltien" [Radioactive 
arms against the "Iraqi Enemy"] Le Monde Diplomatique (April 1995), p. 
2. 

[11] See B. Cazeneuve, M. Rivasi, and C. Lanfranca, Guerre du Golfe: 
Write sur un conflit, vols. 1 (report) and 2 (hearing transcripts), 
Paris: Assemblee Nationale, 2001 (number 3055). 

[12] "La polemique sur le 'syndrome du Golfe' atteint Farm& frangaise: 
Aucun cas, selon les autorites 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. 

[13] See 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. 

[End of section]