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Transcripts: 563.6 & 563.7

Week: 563.6 Guest: Dr. Robert Haley, Epidemiologist, Univ. of Texas, Southwestern Med. Cntr. Topic: Gulf War Syndromes confirmed ( Part One of Two) Producer/Host: Steve Girard

NEMA: Over several years since the Persian Gulf War, veterans of the conflict have been afflicted by a strange, vague set of health problems. And their claims have been met with disbelief and dismissal. Now, there is hard information that what they're experiencing is real, and debilitating. Dr. Robert Haley, of the University of Texas Southwest Medical Center at Dallas, is the lead author of three papers on Gulf War Syndromes that appeared recently in the Journal of the American Medical Association. Doctor, what was the impetus for your facility to get into the study of Middle East War Veterans and their maladies?

HALEY: Well, in early 1994, we had no involvement in this issue at all...but Ross Perot came by our university after having talked to large numbers of veterans at various talks he gave over the country, and told us that he was very impressed that there might be something to this illness in Gulf War veterans that he'd been talking to. So he encouraged us to get a study going, and if so, he would help defray the costs of the study. And so we took him up on it and started such a study...ended up going about half and half in terms of paying for the study, and that's really how we got into it. Our first step in studying this was to attend a very important conference at the National Institutes of Health in Washington, which was stimulated by the Veterans Affairs office, the VA central office, to summarize all of the information that was known in early 1994 about this...and there was a considerable amount of research that had been done. And after attending that conference, in just a two day period, we went from knowing little about this to being almost completely up to speed. At that conference, it hit us...two things: one...that no case control study had been done, that is no one had yet compared sick veterans with well veterans. And that's usually the way that you discover the cause of a new disease, like this. And second...my colleague, Dr. Tom Kurt, being a toxicologist, noted that the most common risk factors that were mentioned in the previous research were what we call organophosphate toxins...or chemicals...and given the very confusing, ambiguous nature of the symptoms, it occurred to him that perhaps this disease was caused by a combination of these organophosphate chemicals, because they are known - like pesticides and similar chemicals - are known to cause brain and nerve damage that is long lasting. So, with those ideas in mind, we undertook the study in early 1994, and here we are.

NEMA: Can you give me a range of the types of problems these vets are experiencing...and how you found a kind of order to it all?

HALEY: Yes, in order to study this, we did something different. Instead of just studying the sick veterans, we went to a complete Naval mobile construction battalion...a group of Seabees, living in the Southeastern U.S., and studied 249 of them very thoroughly. In fact, we even applied a mathematical computer technique to try to see if there were some symptoms that grouped together, that is...is there a group of veterans that all have the same group of symptoms, and perhaps a second group of veterans that has another constellation of symptoms. Because see, by definition, those would be syndromes. And in fact, out of our mathematical analysis, we came up with three primary syndromes. The first one is, we call it "impaired cognition", because it has to do with difficulty in thinking and remembering, and just abnormalities of brain function, including depression and insomnia. And fatigue...meaning sleepiness all day. The second syndrome was the most severe one. This one we call the "confusion ataxia" syndrome, and it was characterized by veterans who felt confused a lot of the time...that is, they would go driving out around town and would not be able to remember where they were going, or where they were. They had balance problems, difficulty controlling their balance and feeling like the room was spinning, and so forth. And the third syndrome we called the "arthromyoneuropathy" syndrome, and it was characterized by pains in the joints, pains and weakness in the muscle, and fatigue...meaning feeling weak all over. And nerve problems in the form of tingling and numbness in the hands and feet.

NEMA: One of the cries we heard when these veterans' problems first surfaced was, "it's not a real disease, it's all in their heads from stress"... sounds like a tough thing to handle...how was your group able to determine that?

HALEY: Well, once we enumerated these three syndrome groups, we asked, "could those just be statistical or mathematical artifacts...or are those really three separate diseases"? So what we did was we brought representatives from each of those three groups, 23 in all, to Dallas along with 20 groups of the battalion who were not ill - the controls - and with the doctors and lab technicians here not knowing who was in which group...so it would be a fair test...we performed a bunch of very sophisticated neurological and neurophysiological tests. Tests of how fast nerves conduct impulses and so forth, that are beyond the control of the veterans, and we found in these tests that the ones with our three syndromes actually had neurological abnormalities...that is, evidence of nerve, spinal cord and brain damage. So that indicates these appear to be three real syndromes that involve nerve and brain damage. Now, that raises the question, "if these are three separate diseases, what are they due to"? So, in addition, in the initial survey, we asked the veterans a large number of standardized questions about very exposures they might have had during the war. For example, different chemicals they were exposed to...different places they went during the war, and what dates they went to each place. Questions about chemical weapons exposures, and the chemical alarms going off, and so forth...a broad range of questions. And then we studied each of those possible exposures to see which ones of those would be common among the sick veterans but not common among the well veterans. And see, that kind of analysis will give you a clue of what's the cause. And what we found is, each of the three syndromes was strongly associated with a different combination of chemicals, but they were not associated with the other risk factors we asked about. For example, Syndrome 1 was associated with almost totally in those troops who wore flea collars to ward off insects. Now flea collars contain a pesticide called dursban, or chlorpirophoss, as well as some other brands as well. But...and that chemical's been shown to cause brain and nerve damage. Our Syndrome 2, the more severe one, was related to those veterans who felt, believed they had been involved in a chemical weapon exposure, where the chemical weapon alarm went off and they felt side effects for 24 hours afterwards. And, as well as those veterans who had severe side effects from the pyridostigmine, or PB, anti-nerve gas tablets they were taking. And Syndrome 3 was found mostly in those veterans who used a large amount of highly concentrated insect repellent. Insect repellent that contained 75% DEET in alcohol...which would have penetrated right through the skin, and perhaps acting in concert with the PB anti-nerve gas tablets they were taking, may have produced nerve and muscle damage. So, those are the three syndromes, and each of the three syndromes was strongly associated with a different combination of the chemicals.

NEMA: Seems a couple of the contributing causes were from things it seems we should know better about... the flea collars? ....the DEET pesticide in high concentrations?

HALEY: I think the flea collars, in retrospect, was a mistake...but it was interestingly not the mistake of the Defense Department. Wearing flea collars in the war was not sanctioned by the military command, in fact, they were warning the troops not to do it, but many of them brought them from home and were wearing them anyway. Whereas the other agents...the PB anti-nerve gas tablets, and the pesticide use...there was actually a very strong reason to be doing that. During World War 2 we had troops in this same area that were very severely affected by insect borne diseases...particularly sand-fly fever... incapacitated large numbers of our troops, and so the military very wisely was trying to protect our troops from these very severe insect problems. And, at that time, nothing was known in the scientific world, about combinations of these chemicals. They were felt to be safe, and they used them, I think, in what was considered at that time a safe manner. It's just with such a high concentration of troops, and such intense use of these agents, I think some unfortunate exposures occurred and we've now learned about that. But that was not known at the time. So I don't think there's really anybody at fault over what's happened.

NEMA: Dr. Robert Haley, of the University of Texas Southwest Medical Center at Dallas. What is the prognosis and possible treatment for these veterans? Was there immune system damage? What does the research tell us about future conflicts. We'll talk with Dr. Haley in our next segment about these and other questions on Gulf War Syndromes. Access the Journal of the American Medical Association's web page at world wide web.ama-assn.org. to find the Syndrome papers in the January 15th edition of The Journal.

SPOT: 15 years in the prevention of heart disease, stroke and trauma - The National Emergency Medicine Association. This show is just part of what NEMA does. We send out millions of pieces of prevention information to people around the country, give grants to organizations in research, public information and emergency services, and have been instrumental in the creation and expansion of the Chest Pain Emergency Room movement. To play a role, call 800-332-6362.

NEMA: For more information or transcripts of our programs, check into our home page:

www.NEMAhealth.org (that's n-e-m-a)

...or use your search engine to find The National Emergency Medicine Assn. I'm Steve Girard at The Heart of the Matter.


Week: 563.7 Guest: Dr. Robert Haley, Epidemiologist, Univ. of Texas, Southwestern Med. Cntr. Topic: Prognosis for Gulf War Syndrome(Part Two of Two) Producer/Host: Steve Girard

NEMA: We've talked with Dr. Robert Haley of the University of Texas Southwest Medical Center at Dallas, the lead author of a trio of papers in a recent edition of the Journal of the American Medical Association on Gulf War Syndromes. Dr. Haley and his team found that the somewhat scattered and vague symptoms some soldiers brought home from the war was due to their exposure to several chemicals during the crisis...and include three separate syndromes, or groups of effects. They have difficulty thinking and remembering, depression, insomnia, confusion, balance problems, joint pain, weakness and fatigue. Doctor Haley, what do we know about the prognosis for these syndrome affected veterans....will their symptoms get worse, better... become stable?

HALEY: Well, that's a difficult question to answer, because we're still trying to discover all the ins and outs of what parts of the body are injured, and how the symptoms are being caused. If it's true that they're caused by nerve and brain damage, and spinal cord damage, it's unlikely that they're going to be...that we're going to be able to cure them. Because as you know, you're born with all the nerves and brain tissue that you're going to have, and if it gets injured, there's no way to repair it at the the present time. However, that doesn't mean that it's not something we can treat with medications and rehabilitation strategies...and really make the veterans a lot more comfortable and more productive in their every day lives. For example, we don't cure diabetes, we don't cure coronary heart disease... what we do is we provide different strategies that allow patients with these illnesses to live with them and live productive lives with much less inconvenience and suffering. And that's what I think our objective would be...develop strategies that would minimize the inconvenience from these symptoms.

NEMA: Does the veterans exposure to the chemicals that have caused their symptoms make them more sensitive to future contact with everyday chemicals...?

HALEY: At the present time, we have no evidence that what happened in the Gulf made people more sensitive or more vulnerable to further damage by other agents, chemicals and other exposures they might have in civilian life back home. However, some veterans report that they seem to be getting worse over time, and some did not have the onset of their symptoms until maybe even a couple of years after the war. It may be that those are unrelated to the war, although it does suggest that there may be a sensitizing or increased vulnerability, but at the present time, we really have no evidence that would confirm that.

NEMA: Would these syndromes make the normal toll of aging more difficult?

HALEY: As we pointed out in our scientific papers we recently published, there is a phenomenon we call brain reserve capacity...that is, how much extra brain cells you have in your brain...because as we age, we lose some neurons - in fact, we lose some every day. And by the time you become very old, you notice that - because you have a loss of brain function and you develop certain problems of old age that are related to diminishing brain capacity. Veterans who have...if they have lost a substantial amount of brain and nerve capacity, then one might expect them to become more symptomatic at a younger age...as they age. But again, we don't have any direct evidence that that's true at this point.

NEMA: Suspicions that there might be an immunological problem associated with a Gulf War Syndrome haven't been borne out, have they?

HALEY: Many people have suggested that immunologic problems, problems with the body's immune system, may have resulted from the war. We studied that very thoroughly in one component of our study....where we had the cases and controls in to Dallas at U.T. Southwestern Medical Center...we were unable to find any evidence that the immune system was damaged. Now, that doesn't entirely rule out that possibility, but it rules out the most common types of immunologic damage that I think people were considering. So I...at this point, we don't have any evidence...and we have some considerable evidence that the immune system is not affected.

NEMA: Now that you and your associates have done the most complete study on the problems affecting Gulf War vets....is it your ball to carry, to find out more about some of the questions to which we don't yet have answers...?

HALEY: Well, our research team here at the University of Texas Southwestern Medical Center is now aggressively continuing this research. We plan to build on what we've found so far by continuing the Seabees unit that we studied initially, as well as to enlarge our studies to other populations of veterans, including veterans at our local Dallas Veterans Affairs Medical Center...and VA hospitals in other cities, where we hope to assist them in screening veterans with the survey techniques that we developed, and some of the neurophysiological testing, to see if we can duplicate our findings in other places. In addition, we're doing some basic science studies, trying to really pin down what parts of the brain and nervous system and other parts of the body are actually damaged, and how they're malfunctioning to help us develop really good medications or rehabilitation strategies to treat these symptoms. So we hope within the next year or so, to actually be leading to treatments for the veterans, to make them live better with this damage that they've received.

NEMA: On the occasion of one of my phone calls to you...you were on the phone with one of the veterans you're trying to find answers for. On the personal level...you can't help be affected by the experiences these people have had....

HALEY: Over this period of time...the last three years, I've talked to literally hundreds and hundreds of veterans who are ill...as well as those who are well, who remember what happened over in the gulf. And you know, the stories about what happened to these soldiers when they were over there are really remarkable. It's interesting, they didn't seem to have been very stressed by the combat threat, and the SCUD missiles and all that. Although it was worrisome to them, none of the ones I talked to describe combat stress like we saw in Vietnam or World War 2. In fact, I've heard some say, with such military superiority that we enjoyed over the Iraqis, they really weren't worried very much at all about their own personal safety, so there wasn't really that stress component that has been so much talked about. What they do talk about, though, is a sadness or frustration over coming back after the war, being clearly impaired...and in many cases, unable to do their job...and then have the authorities tell them there's nothing wrong with them. That's been very, I think that's one of the main things I ferreted out from talking to so many of these guys...most say they're not trying to get money, they're not trying to get benefits. What they're trying to do is get people to just agree that there is some problem here, and to see if they'll come up with a treatment. Make them better if it's possible. But if it's not, just the recognition that they were wounded in this war....would be enough to satisfy most of the people I talked to.

NEMA: It seems that we, and maybe most people in all countries, have a tendency...a desire, to forget about the situation and the pains of a war soon after it's done. And the bottom line is the very human side of it...the people like us who have gone through the experience...the fear and the unknown...and the resulting, real effects, like these health problems...I mean it happened in Vietnam with Agent Orange...but people forget...

HALEY: Yeah, I think you're exactly right...that these veterans put their lives on the line for their country, and I don't think that there's any American here who would deny them good medical care, complete understanding - including the physicians that are treating them. I think they feel the same way. Let me tell you about my observation on the reason for all of this concern about a cover-up and the military not taking care of them as they should. I don't think that's the case...I believe what the problem is, is when these fellas came back, they were complaining about a lot of very vague symptoms that are due to malfunctions of some of the deep parts of the nervous system. When these parts of the nervous system malfunction, it produces these vague symptoms that even the patients themselves can't articulate well. And then, when a doctor, very dutifully, does a thorough examination and laboratory work and so forth...all the tests are normal. And you see that's what led everybody, at first...for the first four or five years...to say there's really nothing to this. And to believe that is was just due to stress and psychological problems. Well now, with our study, we've shown that there really is a neurological basis...but it's deep seated, in deep seated parts of the nervous system, that are very difficult to measure with our usual medical tests. But now that that's understood, I think we will now get much more sophisticated with our testing and our diagnostic work....we'll understand this, and I think the veterans are going to feel a lot better about the treatment, and I think the country will be a lot prouder about how we're taking care of our veterans.

NEMA: And it may bode well for future soldiers going into similar situations...and returning from them...

HALEY: Another very important aspect of this is, if our studies are confirmed and borne out, we will have, I think, identified some risk factors for neurological injury in warfare that were not appreciated before. This will be very important in protecting our troops when they go to the next conflict. Particularly if there were chemical weapons involved, as there were here. I might add also that there's a chemical weapons ban treaty that is being held up in the Senate right now. My own feeling is that is something we ought to very seriously consider ratifying to prevent the spread of these chemical weapons, so they don't appear on the battlefield again against our troops.

NEMA: Our thanks to Dr. Robert Haley of the University of Texas Southwestern Medical Center at Dallas. The three papers from him and his team of researchers appears in the January 15th edition of the Journal of the American Medical Association.

SPOT: 15 years in the prevention of heart disease, stroke and trauma - The National Emergency Medicine Association. This show is just part of what NEMA does. We send out millions of pieces of prevention information to people around the country, give grants to organizations in research, public information and emergency services, and have been instrumental in the creation and expansion of the Chest Pain Emergency Room movement. To play a role, call 800-332-6362.

NEMA: For more information or transcripts of our programs, check into our home page:

www.NEMAhealth.org (that's n-e-m-a)

...or use your search engine to find The National Emergency Medicine Assn. I'm Steve Girard at The Heart of the Matter.


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