x PREFACE that more such studies be undertaken for the Gulf War veterans, but, there would be value in continuing to monitor the veterans for some health end points, specifically, cancer, especially brain and testicular cancers, neurologic diseases including Amyotrophic Lateral Sclerosis (ALS), and causes of death. Therefore, despite the serious limitations of the available studies as a group, they do point the way to actions that might benefit Gulf War and other combat veterans. I am deeply appreciative of the expert work of our committee members: Marcia Angell, W. Kent Anger, Michael Brauer, Dedra S. Buchwald, Francesca Dominici, Arthur L. Frank, Francine Laden, David Matchar, Samuel J. Potolicchio, Thomas G. Robins, George W. Rutherford, and Carol Tamminga. Although our committee developed conclusions independently of input from IOM and its staff, we deeply appreciate their hard work and attention to detail and the extensive research that they conducted to ensure that we had all the information that we needed from the outset. It has been a privilege and a pleasure to work with the IOM staff directed by Carolyn Fulco and with our consultant, Miriam Davis. Without them, this report would not have been possible. Most of all, our committee appreciates the veterans who served in the Gulf War and who have volunteered again and again to participate in the health studies that we reviewed. It is for them that we do this work. We hope this report will inform those who have given so much to our nation about what researchers have been able to learn about their health. LYNN R. GOLDMAN, MD, MPH PROFESSOR JOHNS HOPKINS UNIVERSITY Committee on Gulf War and Health: A Review of the Medical Literature Relative to the Gulf War Veterans’ Health Board on Population Health and Public Health Practice THE NATIONAL ACADEMIES PRESS • 500 Fifth Street, NW • Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract V101(93)P-2155 between the National Academy of Sciences and the Department of Veterans Affairs. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-10: 0-309-10176-X International Standard Book Number-13: 978-0-309-10176-9 Library of Congress Control Number: 2006934960 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu. Copyright 2006 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org . COMMITTEE ON GULF WAR AND HEALTH: A REVIEW OF THE MEDICAL LITERATURE RELATIVE TO GULF WAR VETERANS’ HEALTH LYNN R. GOLDMAN, MD, MPH, (chair) Professor, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD MARCIA ANGELL, MD, Senior Lecturer on Social Medicine, Department of Social Medicine, Harvard Medical School, Boston, MA W. KENT ANGER, PhD, Associate Director for Occupational Research, Center for Research on Occupational and Environmental Toxicology, Oregon Health and Science University, Portland, OR MICHAEL BRAUER, ScD, Professor, School of Occupational and Environmental Hygiene, University of British Columbia, Vancouver, British Columbia DEDRA S. BUCHWALD, MD, Director, Harborview Medical Center, University of Washington, Seattle, WA FRANCESCA DOMINICI, PhD, Associate Professor, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD ARTHUR L. FRANK, MD, PhD, Professor, Chair, Department of Environmental and Occupational Health, Drexel University School of Public Health, Philadelphia, PA FRANCINE LADEN, ScD, Assistant Professor of Medicine, Channing Laboratory, Harvard Medical School, Boston, MA DAVID MATCHAR, MD, Director, Center for Clinical Health Policy Research, Duke University Medical Center, Durham, NC SAMUEL J. POTOLICCHIO, MD, Professor, Department of Neurology, George Washington University Medical Center, Washington, DC THOMAS G. ROBINS, MD, MPH, Professor, Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, MI GEORGE W. RUTHERFORD, MD, Professor, Vice-Chair, Department of Epidemiology and Biostatistics, Division of Preventive Medicine and Public Health, School of Medicine, University of California, San Francisco, CA CAROL A. TAMMINGA, M.D., Professor, Department of Psychiatry, University of Texas, Southwestern Medical Center, Dallas, TX v STAFF CAROLYN FULCO, Senior Program Officer ABIGAIL MITCHELL, Senior Program Officer DEEPALI PATEL, Senior Program Associate MICHAEL SCHNEIDER, Senior Program Associate JUDITH URBANCZYK, Senior Program Associate HOPE HARE, Administrative Assistant PETER JAMES, Research Associate DAMIKA WEBB, Research Assistant RENEE WLODARCZYK, Intern NORMAN GROSSBLATT, Senior Editor ROSE MARIE MARTINEZ, Director, Board on Population Health and Public Health Practice CONSULTANTS MIRIAM DAVIS, Independent Medical Writer, Silver Spring, MD ANNE STANGL, Tulane School of Public Health and Tropical Medicine, New Orleans, LA vi REVIEWERS This report has been reviewed in draft form by persons chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following for their review of this report: ARTHUR K. ASBURY, MD, Department of Neurology, University of Pennsylvania, Philadelphia, PA SHARON COOPER, PhD, Professor and Chair, Department of Epidemiology and Biostatistics, Texas A & M University School of Rural Public Health, College Station, TX PETER J. DYCK, MD, Director, Peripheral Nerve Research Laboratory, Mayo Clinic College of Medicine, Rochester, MN DAVID GAYLOR, PhD, MS, President, Gaylor & Associates, LLC, Eureka Springs, AR JACK M. GORMAN, MD, President and Psychiatrist in Chief, McLean Hospital, Belmont, MA PHILIP GREENLAND, MD, Executive Associate Dean for Clinical and Translational Research, Northwestern University Feinberg School of Medicine, Chicago, IL HOWARD KIPEN, MD, MPH, Director, Clinical Research and Occupational Medicine Division, Environmental & Occupational Health Sciences Institute, UMDNJ-Robert Wood Johnson Medical School, Piscataway, NJ JOSEPH LADOU, MD, Editor, International Journal of Occupational and Environmental Health, Professor, Division of Occupational and Environmental Medicine, University of California, San Francisco, CA ELLEN REMENCHIK, MD, MPH, Assistant Professor, Occupational and Environmental Medicine, The University of Texas Health Center, Tyler, TX KATHERINE S. SQUIBB, PhD, Associate Professor & Head, Division of Environmental Epidemiology & Toxicology, University of Maryland School of Medicine, Baltimore, MD Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by David J. Tollerud, Professor and Chair, Department of Environmental and Occupational Health Sciences, University of Louisville and by Harold Sox, editor, Annals of Internal Medicine, American College of Physicians of Internal Medicine. Appointed by the National Research Council, Dr. Sox was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. vii