Original Research

Improving Health Care for Veterans With Gulf War Illness

Fed Pract. 2019 May;36(5):212-219

References

1. US Department of Veterans Affairs. Research Advisory Committee on Gulf War Veterans’ Illnesses. Gulf War Illness and the Health of Gulf War Veterans: Scientific Findings and Recommendations. https://www.va.gov/RAC-GWVI/docs/Committee_Documents/GWIandHealthofGWVeterans_RAC-GWVIReport_2008.pdf. Published November 2008. Accessed April 16, 2019.

2. Institute of Medicine. Gulf War and Health. Update of Health Effects of Serving in the Gulf War. Vol 8. Washington, DC: National Academies Press; 2009.

3. Fukuda K, Nisenbaum R, Stewart G, et al. Chronic multisymptom illness affecting Air Force veterans of the Gulf War. JAMA. 1998;280(11):981-988.

4. Steele L. Prevalence and patterns of Gulf War illness in Kansas veterans: association of symptoms with characteristics of person, place, and time of military service. Am J Epidemiol. 2000;152(10):992-1002.

5. Kang HK, Mahan CM, Lee KY, Magee CA, Murphy FM. Illnesses among United States veterans of the Gulf War: a population-based survey of 30,000 veterans. J Occup Environ Med. 2000;42(5):491-501.

6. Kang HK, Li B, Mahan CM, Eisen SA, Engel CC. Health of US veterans of 1991 Gulf War: a follow-up survey in 10 years. J Occup Environ Med. 2009;51(4):401-410.

7. Dursa EK, Barth SK, Schneiderman AI, Bossarte RM. Physical and mental health status of Gulf War and Gulf era veterans: results from a large population-based epidemiological study. J Occup Environ Med. 2016;58(1):41-46.

8. Institute of Medicine. Gulf War and Health: Treatment for Chronic Multisymptom Illness. Washington, DC: National Academies Press; 2013.

9. Institute of Medicine. Chronic Multisymptom Illness in Gulf War Veterans: Case Definitions Reexamined. Washington, DC: National Academies Press; 2014.

10. United States Government Accountability Office. Gulf War illness: improvements needed for VA to better understand, process, and communicate decisions on claims. https://www.gao.gov/assets/690/685562.pdf. Published June 2017. Accessed April 16, 2019.

11. Johnson GJ, Slater BC, Leis LA, Rector TS, Bach RR. Blood biomarkers of chronic inflammation in Gulf War illness. PLoS One. 2016;11(6):e0157855.

12. Reno J. Gulf War veterans still fighting serious health problems. https://www.healthline.com/health-news/gulf-war-veterans-still-fighting-serious-health-problems#1. Published June 17, 2016. Accessed April 16, 2019.

13. McAndrew LM, Helmer DA, Phillips LA, Chandler HK, Ray K, Quigley KS. Iraq and Afghanistan veterans report symptoms consistent with chronic multisymptom illness one year after deployment. J Rehabil Res Dev. 2016;53(1):59-70.

14. Steele L, Sastre A, Gerkovich MM, Cook MR. Complex factors in the etiology of Gulf War illness: wartime exposures and risk factors in veteran subgroups. Environ Health Perspect. 2012;120(1):112-118.

15. US Department of Veterans Affairs. VA/DoD Clinical Practice Guideline for the Management of Chronic Multisymptom Illness. Version 2.0. https://www.healthquality.va.gov/guidelines/MR/cmi/VADoDCMICPG2014.pdf. Published October 2014. Accessed April 22, 2019.

16. Koslik HJ, Hamilton G, Golomb BA. Mitochondrial dysfunction in Gulf War illness revealed by 31phosphorus magnetic resonance spectroscopy: a case-control study. PLoS One. 2014;9(3):e92887.

17. Brewer KL, Mainhart A, Meggs WJ. Double-blinded placebo-controlled cross-over pilot trial of naltrexone to treat Gulf War illness. Fatigue: Biomed Health Behav. 2018;6(3):132-140.

18. Golomb BA, Allison M, Koperski S, Koslik HJ, Devaraj S, Ritchie JB. Coenzyme Q10 benefits symptoms in Gulf War veterans: results of a randomized double-blind study. Neural Comput. 2014;26(11):2594-2651.

19. Weiduschat N, Mao X, Vu D, et al. N-acetylcysteine alleviates cortical glutathione deficit and improves symptoms in CFS: an in vivo validation study using proton magnetic resonance spectroscopy. In: Proceedings from the IACFS/ME 12th Biennial Conference; October 27-30, 2016; Fort Lauderdale, FL. Abstract. http://iacfsme.org/ME-CFS-Primer-Education/News/IACFSME-2016-Program.aspx. Accessed April 22, 2019.

20. White RF, Steele L, O’Callaghan JP, et al. Recent research on Gulf War illness and other health problems in veterans of the 1991 Gulf War: effects of toxicant exposures during deployment. Cortex. 2016;74:449-475.

21. US Department of Veterans Affairs. Caring for Gulf War I Veterans. http://www.ngwrc.net/PDF%20Files/caring-for-gulf-war.pdf. Published July 2011. Accessed April 15, 2019.

22. National Academies of Sciences, Engineering, and Medicine. Gulf War and Health. Update of Serving in the Gulf War. Vol 10. Washington, DC: National Academies Press; 2016.

23. US Department of Veterans Affairs. War-Related Illness and Injury Study Center. Gulf War illness: a guide for veteran health care providers. https://www.warrelatedillness.va.gov/education/factsheets/gulf-war-illness-for-providers.pdf. Updated October 2018. Accessed April 16, 2019.

Discussion

The veterans participating in this QI survey had similar demographics, symptomology, and exposures as did those in other studies.^1-7 Therefore, improvements based on their responses are likely applicable to the health care of veterans experiencing GWI-associated symptoms at other VA health care systems as well.

Veterans with GWI can lose significant functional capacity and productivity due to their symptoms. The symptoms are chronic and have afflicted many Gulf War veterans for nearly 3 decades. Furthermore, the prevalence of GWI in Gulf War veterans continues to increase.^5-7 These facts testify to the enormous health-related quality-of-life impact of GWI.

Veterans who meet the Kansas case definition for GWI were not diagnosed or service connected in a uniform manner. Only 3 of the 30 veterans in this study were given a unifying diagnosis that connected their chronic illness to Gulf War deployment. Under current guidelines, Gulf War veterans are able to receive compensation for chronic symptoms in 3 ways: (1) compensation for chronic unexplained symptoms existing for ≥ 6 months that appeared during active duty in the Southwest Asia theater or by December 31, 2021, and are ≥ 10% disabling; (2) the 1995 Persian Gulf War Veterans’ Act recognizes 3 multisymptom illnesses for which veterans can be service connected: FM, CFS, and functional GI disorders, including IBS; and (3) expansion to include any CMI of unknown etiology is underway. A uniform diagnostic protocol based on biomarkers and updated understanding of disease pathology would be helpful.

Respondents shared experiences that demonstrated perceived gaps in HCP support or knowledge. Overall, more respondents found their HCPs supportive. Many of the reasons respondents found HCPs unsupportive related to acknowledgment of symptoms. Also, more respondents found that both VA and non-VA HCPs lacked knowledge about GWI symptoms. These findings further highlight the need for HCP education within the VA and in community-based care.

The treatments tried by respondents also highlight potential areas for improvement. Most of the treatments were for pain; therefore, more involvement with pain clinics and specialists could be helpful. Symptom-specific medications also are appropriate, although only one-third of patients reported use. While medications are not necessarily markers of quality care, the fact that many patients self-medicate or go without treatment suggests that access to care could be improved. In 2014, the VA and the US Department of Defense (DoD) released the “VA/DoD Clinical Practice Guideline for the Management of Chronic Multisymptom Illness,” which recommended treatments for the global disease and specific symptoms.¹⁵

Since then, GWI research points to inflammatory and metabolic disease mechanisms.^11-14,16 As the underlying pathophysiology is further elucidated, practice guidelines will need to be updated to include anti-inflammatory and antioxidant treatments used in practice for GWI and similar chronic systemic illnesses (eg, CFS, FM, and IBS).^17-19

Randomized control trials are needed to determine the efficacy of such medications for the treatment of GWI. As new results emerge, disseminating and updating evidence-based guidelines in a coordinated manner will be required for veterans to receive appropriate treatment. Veterans also seek alternative or nonpharmaceutical interventions, such as physical therapy and diet changes. Improving access to integrative medicine, physical therapy, nutritionists, and other practitioners also could optimize veterans’ health and function.