The last nine Institute of Medicine committees that prepared the Gulf War and Health series of reports have diligently assessed the evidence for possible health effects associated with exposures experienced by veterans during the Gulf War. All the prior committees, as well as the current committee, have sought to identify diseases and health conditions caused by Gulf War exposures to help the Department of Veterans Affairs (VA) care for those veterans who were harmed. Several volumes in this series have recommended carefully designed research endeavors in the hope of finally understanding the long-term health effects caused by the war.

Unfortunately, all of the Gulf War and Health committees have faced similar challenges in their attempts to identify the health effects that are clearly the result of deployment to the Gulf War. Foremost among these is the ever unknowable impact of the various chemical exposures that occurred during the 1990–1991 Gulf War, whether alone or in combination with other environmental, chemical, and/or genetic factors. Objective exposure data gathered during and after the war have been, and are expected to continue to be, unavailable.

Studies of Gulf War illness specifically, the most frequently reported health outcome in these veterans, have been hampered by the relatively amorphous nature of the disorder and its multiple definitions over the past two decades, including chronic multi-symptom illness, Gulf War syndrome, and multiple unexplained physical symptoms. Even though the evidence base for Gulf War illness has increased over the past few years, it has provided little new information that has increased our understanding of the disease or how to effectively treat or manage it.

The committee's discussions also included the potential significance of both time and aging, both of which can present substantial difficulties for research efforts. Specifically, the time that has elapsed since the war—25 years—brings with it the potential to impact veterans' recall of events, including the frequency, duration, and intensity of their exposures during their service. At the same time, advancing age can provoke new health concerns and the development of new diseases long after the war. In any population, it can be difficult to distinguish aging-related effects from those caused by a war many years ago. The committee emphasized that some health consequences with a long latency period, such as some cancers and neurodegenerative conditions, may not yet be fully described or be characterized by Gulf War illness. While the symptoms of Gulf War illness are expected to have developed soon after the deployment, similar symptoms, such as headache or cognitive problems, appearing 20 years after the war are unlikely to be related to Gulf War service but may be caused by other exposures or conditions that are entirely unrelated to the Gulf War. Thus, it is ever more important that any future research endeavors use well-designed protocols to minimize the effects of time and aging on the interpretation of Gulf War veterans' health.

The committee did take note of research focused on the determination of potential biomarkers for Gulf War illness; this focus highlights the importance of exploring all avenues of research that might prove fruitful in diagnosing and treating veterans with this debilitating illness. Critical to both the diagnosis and treatment of Gulf War illness, however, is acknowledging the brain–body continuum. This committee concurs with the findings of previous Gulf War and Health committees in that Gulf War illness is not a psychosomatic illness, and it is cognizant of the residual stigma associated with having a mental health disorder and veterans' frustration of being told that their persistent and disabling symptoms are “all in their heads.” Nevertheless, as the committee has tried to emphasize, there is a requisite interconnectedness of the physiological systems of the body and the brain, such that dysfunctions of either have consequences that can extend to both. In the same context, the committee has also tried to reiterate that although Gulf War illness should not be called a psychosomatic disorder, this does not mean that it or any chronic disease, including cancer, diabetes, and heart disease, does not have psychological components that might be amenable to mental health therapies as well as other treatments. For example, many investigations into biomarkers of Gulf War illness acknowledge this brain–body continuum by looking for explanations of the illness in brain functioning. The committee believes it would be a disservice to Gulf War veterans to ignore treatments that might address the mental health and neurocognitive components of Gulf War illness.

The committee would like to acknowledge and give sincere thanks to Dr. Ralph Loren Erickson and Dr. Robert Bossarte of VA; Dr. Beatrice Golomb and Dr. Roberta White from the VA Research Advisory Committee on Gulf War Veterans' Illnesses (RAC); Ronald Brown and James Bunker from the National Gulf War Resource Center, Mr. James Binns and Dr. Lea Steele, former RAC members; Anthony Hardie, David Hatfield, Remington Nevin, Denise Nichols, Daniel Sullivan, Peter Sullivan, and the other Gulf War veterans for their presentations to the committee which it found both illuminating and moving. The committee would also like to thank Dr. Carolyn Clancy, Under Secretary for Health of VA, for her informative remarks.

The committee gained valuable insight and context from the many veterans who attended the committee's first and second meetings or participated by phone. Their experiences and concerns echoed the seriousness of their health conditions even 25 years after the Gulf War. Their needs and concerns resonated with the committee as it endeavored to review the evidence objectively. The committee sincerely thanks the many individual veterans and veteran service organization representatives who took the time and made the effort to inform the committee's deliberations.

I would like to express my sincere gratitude to the expert committee members for their thoughtfulness, insights, and hard work. I know I speak for the entire committee in expressing many thanks to Roberta Wedge for efficiently guiding the report through its various stages and keeping the committee organized and moving forward; to Cary Haver and Anne Styka for their research efforts; to Nicole Freid for her administrative support, and to the National Academies Research Center's Daniel Bearss for creating and executing the literature search strategy and Ellen Kimmel for fact checking.

Deborah A. Cory-Slechta, Chair

Committee on Gulf War and Health, Volume 10: Update of Health Effects of Serving in the Gulf War