GULF WAR and HEALTH

Treatment for
Chronic Multisymptom Illness

Committee on Gulf War and Health:
Treatment for Chronic Multisymptom Illness

Board on the Health of Select Populations

INSTITUTE OF MEDICINE

OF THE NATIONAL ACADEMIES

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 VA241-P-2024 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 authors and do not necessarily reflect the views of the organizations or agencies that provided support for the project.

International Standard Book Number-13: 978-0-309-27802-7

International Standard Book Number-10: 0-309-27802-3

“Knowing is not enough; we must apply.
Willing is not enough; we must do.”

—Goethe

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

Advising the Nation. Improving Health.

THE NATIONAL ACADEMIES

Advisers to the Nation on Science, Engineering, and Medicine

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. Charles M. Vest 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. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.

COMMITTEE ON GULF WAR AND HEALTH:
TREATMENT FOR CHRONIC MULTISYMPTOM ILLNESS

BERNARD M. ROSOF (Chair), Chairman, Board of Directors, Huntington Hospital, Huntington, NY

DIANA D. CARDENAS, Professor and Chair, Department of Rehabilitation Medicine, University of Miami Leonard M. Miller School of Medicine, Miami, FL

FRANK V. deGRUY, Woodward-Chrisholm Professor and Chair, Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO

DOUGLAS A. DROSSMAN, Adjunct Professor of Medicine and Psychiatry, Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina School of Medicine, and Drossman Center for the Education and Practice of Biopsychosocial Care, Chapel Hill, NC

FRANCESCA C. DWAMENA, Professor and Acting Chair, Department of Medicine, Michigan State University, East Lansing, MI

JAVIER I. ESCOBAR, Associate Dean for Global Health, University of Medicine & Dentistry of New Jersey, New Brunswick, NJ

WAYNE A. GORDON, Jack Nash Professor and Vice Chair, Department of Rehabilitation Medicine, Mount Sinai School of Medicine, New York, NY

ISABEL V. HOVERMAN, Physician, Austin Internal Medicine Associates, LLP, Austin, TX

WAYNE JONAS, President and CEO, Samueli Institute, Alexandria, VA

JOANNA G. KATZMAN, Associate Professor, Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, NM

ELAINE L. LARSON, Associate Dean for Research, Columbia University School of Nursing, New York, NY

STEPHEN RAY MITCHELL, Dean of Medical Education, Georgetown University School of Medicine, Washington, DC

KAREN A. ROBINSON, Assistant Professor, Departments of Medicine, Epidemiology, and Health Policy and Management, Johns Hopkins University, Baltimore, MD

KASISOMAYAJULA VISWANATH, Associate Professor, Department of Society, Human Development, and Health, Harvard School of Public Health, Boston, MA

LORI ZOELLNER, Associate Professor, Department of Psychology, University of Washington, Seattle, WA

Staff

ABIGAIL MITCHELL, Study Director

CARY HAVER, Associate Program Officer

JONATHAN SCHMELZER, Senior Program Assistant

NORMAN GROSSBLATT, Senior Editor

GARY WALKER, Financial Officer

JIM BANIHASHEMI, Financial Officer

FREDERICK ERDTMANN, Director, Board on the Health of Select Populations

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 of 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 thank the following for their review of the report:

Niloofar Afari, University of California, San Diego

Melvin S. Blanchard, Washington University School of Medicine

Paul W. Brandt-Rauf, University of Illinois at Chicago School of Public Health

Sandro Galea, Columbia University Mailman School of Public Health

Naomi L. Gerber, George Mason University

Thomas V. Holohan, Clinical Evaluation, LLC; formerly Veterans Health Administration

David R. Nerenz, Henry Ford Health System

Eliseo J. Perez-Stable, University of California, San Francisco

Karen S. Quigley, Northeastern University and Edith Nourse Rogers Memorial VA Medical Center

Sandra J. W. Smeeding, Veterans Affairs Salt Lake City Health Care System

Nancy Fugate Woods, University of Washington School of Nursing

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 the report was overseen by Lynn R. Goldman, Dean, the George Washington University School of Public Health and Health Services, and Enriqueta C. Bond, President Emeritus, Burroughs Wellcome Fund. Appointed by the National Research Council and the Institute of Medicine, respectively, they were responsible for making certain that an independent examination of the report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of the report rests entirely with the authoring committee and the institution.

Preface

To focus our efforts, we defined CMI as the presence of a spectrum of chronic symptoms experienced for 6 months or longer in at least two of six categories—fatigue, mood and cognition, musculoskeletal, gastrointestinal, respiratory, and neurologic—that may overlap with but are not fully captured by known syndromes (such as irritable bowel syndrome, chronic fatigue syndrome, and fibromyalgia) or other diagnoses.

Our review of the literature revealed that specific etiologic agents or histopathologic findings often are not associated with such symptoms, and the causes of many of the symptoms ascribed to CMI remain unknown. However, the lack of diagnostic and etiologic clarity does not undermine the legitimacy of the reports of the symptoms. The multiple manifestations of the symptoms make directed treatment more challenging, and clinicians are often frustrated by the difficulties in managing care for people who have CMI. However, for veterans whose function and life satisfaction are limited by their symptoms, it remains no less important.

Caroline Blaum, University of Michigan Health System; Daniel Clauw, University of Michigan Health System; Jeffery Dusek, Abbott Northwestern Hospital; Charles Engel, Deployment Health Clinical Center; Beatrice Golomb, University of California, San Diego, School of Medicine and San Diego VA Medical Center; Stephen Hunt, VA Puget Sound Health Care System; Kenneth Kendler, Virginia Commonwealth University; Kurt Kroenke, Regenstrief Institute; Ronald Poropatich, US Army Medical Research and Materiel Command; and Matt Reinhard, War-Related Illness and Injury Study Center, Washington, DC.

The committee thanks Patrick Furey of Consumersphere, a consultant who provided an analysis of the social media discussion surrounding CMI in veterans of the Gulf War. We also thank Michael Peterson and Terry Walters, of the VA Office of Public Health, for providing helpful background information.

I would like to thank the committee members for their time commitment to this important project, their diligence in reviewing every detail of complex issues, and their sensitivity to the concerns of our veterans. Finally, I thank the IOM staff for their thoroughness, knowledge, research expertise, and guidance throughout this journey to try to make a contribution to the understanding of a complex subject.

Bernard M. Rosof, Chair

Committee on Gulf War and Health:

Treatment for Chronic Multisymptom Illness

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Contents

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Boxes, Figures, and Tables

BOXES

FIGURES

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