Middle East trip provides useful information exchange

WASHINGTON, January 27, 1988 (GulfLINK)- Dr. Bernard Rostker, the special assistant for Gulf War illnesses, recently completed a fact-finding trip to the Middle East. Accompanied by a physician-researcher from the Rand Corporation and two Senate Committee staff personnel, the Gulf War illnesses team visited Kuwait City, Kuwait; Riyadh and Dhahran, Saudi Arabia; Cairo, Egypt and Tel Aviv, Israel.

"We went to these countries to share our medical findings and to discuss how the results of the Khamisiyah plume analysis may have affected them," said Rostker. "We wanted to see if there were similar health issues experienced by the civilian or military population and noted by medical personnel."

In Kuwait City, the Gulf War illnesses team met with representatives of the Environmental Public Authority, the Kuwait Institute for Scientific Research, the Ministry of Health and the Kuwait Oil Company Hospital. During the visits, the head of each organization expressed sincere appreciation to all Americans who were involved in the liberation of their country.

A meeting with the director general of Kuwait's environment public authority provided the team with an opportunity to ask questions about the environmental damage Kuwait suffered from oil well fires during and after the war, and the effects on people. The agency was established in 1996 as a successor to the environmental division in the Ministry of Health.

"The team learned that the agency has collected raw, unanalyzed data since 1996 concerning the effect of oil well fires on humans and has data on air quality measurements from before the war," said Lt. Col. Dee Morris, deputy director, investigation and analysis directorate, office of the special assistant for Gulf War illnesses.

During discussions, the Kuwaitis offered to make the data available for analysis to the Gulf War illnesses team as well as the published proceedings of a 1994 Conference on Oil Well Fires, she said.

At the Ministry of Health, Rostker and staff discussed the medical evaluations of U.S. Gulf War veterans and the symptoms of those without a definitive diagnosis. The U.S. team asked the Kuwaitis if there were any noticeable changes in health or disease complexes observed in the Kuwaiti people or the expatriate inhabitants of the region since the war. Officials told the team they had not identified direct health problems associated with Gulf War illnesses in their medical reporting channels.

Regarding the expatriate population, Kuwaiti officials noted that of the 1.6 million people inhabiting Kuwait, 600,000 are Kuwaitis and the remainder are expatriates. However, the expatriate population is not comprised of the same nationalities as the pre-war population. Many Jordanians and Palestinians returned home after the war, and Pakistanis and Filipinos have arrived.

Officials further explained that the total destruction of the Kuwait infrastructure, loss of records and equipment and the change in the population, presented obstacles to conducting post-war epidemiological studies that would provide insights into long term health effects.

Nevertheless, the Kuwaitis reported no adverse health effects or apparent symptoms observed as a result of Gulf War risk factors such as oil-well fire smoke, oil spills or depleted uranium, said Morris.

In conversations with officials of the Kuwait Oil Company Hospital, senior advisors were told that the Kuwaitis saw many people with asthma having more frequent attacks during the oil fires.

"The Kuwaitis believe there are more problems with asthma now in the population than before the war, but there are no data for comparison," said U.S. Navy Captain Michael Kilpatrick, M.D., director, medical and health benefits collaboration, of the special assistant's office.

A Kuwait hospital physician commented that he observed more infectious disease problems in the expatriate population; however, he attributed this to infectious diseases arriving individuals brought with them rather than effects of the Gulf War. While he noticed a slightly higher incidence of cancer since the war in the expatriate community, he also thought the increase was related to country of origin of those with cancer and not connected with the Gulf War.

The physician further explained that due to the total destruction of Kuwaiti's infrastructure, health effects research was a recent endeavor and has been approached with no baseline data available. He told Rostker and senior delegation members that noticeable changes in birth defects have not been detected nor has a higher incidence of cancer been reported. The team also learned that Kuwaitis who remained in the country did not receive pyridostigmine bromide, the nerve agent pre-treatment drug used by many U.S. troops.

A visit to the 14-acre area known as the "boneyard" was also on the trip itinerary. This site contained the damaged Iraqi military vehicles struck by allied weapons enhanced with depleted uranium as well as buried penetrators which were collected by coalition partners after the war. The Kuwaitis indicated that there were no health symptoms reported as a result of depleted uranium exposure associated with this clean-up work.

"The visit reaffirmed the U.S. team's understanding of the military superiority depleted uranium provides in combat," said Kilpatrick.

In Saudi Arabia, Rostker met with the Minister of Health and presented briefings at the Ministry of Defense Hospital, the Saudi Arabia National Guard Hospital and the American Embassy in Riyadh. Briefings in Dharan were at the American Consulate and the Arabian-American Oil Company-Aramco-Hospital.

During meetings at the Saudi Arabia National Guard Hospital, Rostker found that the hospital possessed an excellent medical records system which predated the Gulf War. The hospital's officials suggested areas of collaborative research which the U.S. team will use for possible follow-on studies.

Vigorous question and answer sessions followed the symposia held in Dharan and Riyadh. In Riyadh, the briefing at the American Embassy was attended by physicians and nurses from King Faisal Hospital, by the Saudi Military physicians and medical personnel from several other organizations.

In Dharan, the briefing held at the American Consulate was attended by staff representing six organizations including the ministry of Health, Aramco, the National Guard Hospital, as well as the Saudi military.

The Aramco hospital staff said they observed symptoms exhibited by U.S. Gulf War veterans in some expatriate patients; however, they saw no clear connection to Gulf War illnesses.

Pesticide use during the Gulf War was another issue discussed at the briefings. The risks of pesticides to Gulf War veterans has been a subject of investigation by the Office of the Special Assistant, explained Kilpatrick. One of the greatest potential health problems veterans faced during the war was the transmission of diseases due to flies. As part of the preventive medicine program to protect soldiers, DoD shipped pesticides approved by the Environmental Protection Agency or the Food and Drug Administration to the Gulf region. These were distributed or applied by trained military personnel. The Gulf War illnesses team has received reports from a number of veterans that pet flea collars were used by some troops and crystal or granular fly bait insecticides, available in the local markets in Saudi Arabia, were used in sleeping and eating areas during the war. This has raised questions regarding possible adverse health effects.

"Because of concerns expressed about organophosphate risk factors, the team acquired samples of one local product, SNIP, and organophosphate insecticide, for future analysis," Kilpatrick said.

The team also learned that some expatriates are concerned about pesticide use in the Dharan area. Specifically, their concerns revolve around the frequent use of fogging with pesticides.

"These pesticides used for fogging are bulk chemicals mixed by pesticide workers and the combinations are very plausibly dangerous," said Kilpatrick.

In Cairo, the entire team met with Ministry of Defense officials representing the Departments of Chemical Warfare, Medical Services and Scientific Research and briefed them on the Department of Defense findings. The Egyptian official indicated that their soldiers had not experienced symptoms known to be related to Gulf War service. They noted that all the Egyptian military conscripts who served in the Gulf War have left the military and their health status is unknown.

Rostker and his team also met with the staff of the United States Naval Medical Research unit, Number 3. This facility was established in 1946 to investigate regional endemic infectious disease threats in order to provide appropriate prevention, diagnosis and treatment to troops. Following discussions, unit staff offered to be a base of support for proposed medical research to be conducted in Saudi Arabia.

In Israel, Rostker and the team received a detailed briefing on the psychological reaction of the Israeli population to the threat of chemical warfare. The conclusions were gathered from numerous real time studies performed at the time of the war. Although the Israelis were the target of 39 Scud missile landings in Tel Aviv during Operation Desert Storm, the Israeli government made a political decision not to retaliate. The Israeli people-forced to adapt to emergency routines, evacuate neighborhoods, adjust to curfews and, at times, deal with the difficulties of wearing protective masks-were subject to feelings of anxiety and helplessness during the ordeal. Psychological surveys and interviews at the time captured citizen reaction to this environment. The studies concluded that people tended to exhibit adaptive behavior. As subjects became habituated to routine changes, their stress level went down. Further, they observed that those who were most severely affected by war time stressors were Holocaust survivors. Previous psychological trauma left people less able to adapt to current psychological stressors, they explained.

Israel has a significant research program in the area of cholinesterase inhibitors which include nerve gas, organophosphates and pyridostigmine bromide. Health officials shared with the Gulf War illness team the findings of various research studies they had performed. Of particular interest were extensive research studies conducted by the Israeli Defense force in 1989 and 1991 on the issue of pyridostigmine bromide. They routinely issued pyridostigmine bromide to their military recruits during the most stressful five days of their recruit training. They saw no negative outcome either acutely or for six months following. In laboratory studies using pyridostigmine bromide in mice, one study showed no adverse effects; a second study which subjected the laboratory animals receiving pyridostigmine bromide to stress, showed that pyridostigmine bromide crossed the blood-brain barrier. The blood brain barrier is a complex system of small blood vessels and specialized cells which, when working properly, allows necessary chemicals and nutrients to move between the circulating blood and the brain itself, but which prevents other substances from doing so.

When discussions turned toward the issue of pesticides, the Israelis said that SNIP, a particular brand, is commonly used by military and civilians with no negative consequences when used as directed. In the region, pesticides are predominately used in agricultural settings. Patients with acute, toxic reactions are routinely followed medically. Efforts to reduce the amount of pesticides applied has reduced the frequency of toxic reactions.

The U.S. Team also discussed with the director of the Israeli Scud Recovery Unit the Israeli experience with Iraqi Scud missiles during the war. The team was able to examine El-Hussein Scud missiles recovered by the unit. The meeting confirmed prior reports that in-air hits destroyed the Scuds' booster rocket, not the warhead. Recovered warheads had no chemical or biological components, the director said. When a Scud was shot down, a yellow cloud of mist was produced by the release of red fuming nitric acid, and oxidizer for the propellant used to power the Scud missiles. People exposed to the mist at the time of impact did experience burning sensations on their exposed skin. This important piece of information dispels some earlier assumptions that the orange cloud was nerve agent.

Throughout the visits, host countries were most receptive to the Gulf War Illnesses team.

"The information exchange was unrestricted and honest. Opportunities for additional research opportunities look very promising," said Dr. Rostker. "We hope the relationships we developed will help us gain further insights into the events we are investigating."