The Gulf War

The Debate

At the root of the controversy over Gulf War Syndrome are a few scientific, medical and factual questions.
FRONTLINE sponsored a debate between two leading experts with different perspectives on the issues: Jim Tuite III, former lead investigator of a U.S. Senate committee's inquiry into Gulf War Syndrome, who points to Iraqi nerve agents as the explanation for many veterans' sickness; and Jim Ware, environmental statistician at the Harvard University School of Public Health, who tilts toward battlefield stress as a more likely cause.
An edited transcript of their in-depth discussion on Dec. 18, 1996, is printed below, covering five principal areas.
Also available are excerpts of Real-Audio exchanges from the debate between Ware and Tuite.

Chemical weapons: a leading suspect?

Do you doubt the Pentagon and CIA when they say the Iraqis did not use chemical or biological weapons during the Gulf War?

Ware: I did not see, and I believe our panel did not see, evidence that the Iraqis used chemical weapons. That's really all we can say. We have not seen any credible evidence if the use of chemical weapons.

"We have not seen any credible evidence
of the use of chemical weapons." ... Ware

Tuite I, to a large degree, would tend to agree that we haven't seen evidence that would indicate the classic use of chemical or toxin weapons in the Gulf. But there are a number of events that do merit further investigation, like those at the Port of Jubayl and after some SCUD missile attacks, where chemical agents were detected using highly credible and reliable means - means that meet the Department of Defense standard for confirmation. Given that there were no immediate, severe casualties associated with use in those areas, I would have a hard time saying that there is direct credible evidence. On the other hand, given the inadequacy of our doctrine in the area of low-level exposure and given that Iraqi doctrine does acknowledge that low-level exposure can be a problem, that vulnerability could have been exploited. It's with that in mind that I do think that we need to keep an open mind that further investigation on a number of events needs to occur.

How much weight do you give General
Norman Schwarzkopf's assessment that, despite many preliminary
alarms, the US forces were unable to confirm any chemical weapons

Tuite Very little. We had all sorts of detectors deployed out there. Those detectors used at least six different scientific methods: ionization, ion mobility spectrometry, chemical reaction, biochemical enzyme reactivity, flame photometry and wet chemistry. When I have two or three or four of those scientific methods as idiot proof, if you will, as they may have been designed, saying the same thing at the same time and with that phenomenon only starting after the air war began, I have a very, very difficult time ascribing any credibility to the statement that there were no credible detections. Now, there is a second statement that's always made: that is, "in such a way as to cause physical harm to our soldiers." Now again you have to understand that our doctrine suggests that the effects of chemical agents are acute, immediate, and severely debilitating. So did the generals believe during the war that the exposures that the soldiers were receiving were irrelevant? And I would say probably yes. But now in retrospect they are saying things which, based on the facts as they existed during the war, could not be true. The headquarters logs are full of information indicating things that they would have had to have been informed about.

Ware: It is also my impression from talking to people that served in the Gulf that there were incidents of alarms going off. There wasn't any accompanying, supporting evidence from the American monitoring systems, either through assessment of missiles that landed or through attempts to measure chemicals. There was never any measurement or detection of chemical. There are a variety of explanations for the alarms. It could be that they were very transient trace levels of chemicals that did that. That's conceivable, but it seems unlikely in the absence of any evidence from ordnance or from the setting of the combat that, in fact, chemical weapons were in use.

Tuite I think the question was: do you believe that there were credible and reliable detections of chemical warfare agents?

Ware: Well, the alarms went off, and this was reported to me. It was reported to me that alarms went off, but that there were not measurements of ambient chemical warfare agents.

TuiteThere were nine or ten - and I believe the number is ten - Czech detections that occurred during the first week of the air war, which air monitors initially picked up biochemical enzyme reactivity using butyl cholinesterase. And they were taken back to a mobile laboratory where wet chemistry analysis was done on the air samples. And in each case chemical warfare agents were detected - sarin, tabun and mustard - the exact same agents that were in the facilities being targeted upwind. In the month of February, seven Fox (chemical detection) vehicles, (and this information is only two weeks old so I apologize, but these were mailed anonymously from the Aberdeen Proving Ground to the Persian Gulf investigative team), detected the presence of chemical warfare agents as well in the air.

Ware: You wouldn't see military delivery as the more likely route of exposure but rather demolition of dump sites and factories and so on.

Tuite I can't rule out military delivery at low level, and I cannot rule out the possible use of aflatoxins. But I can say that I do believe that the predominant mode of exposure was a result of the destruction of the Iraqis' chemical warfare infrastructure.

Did friendly fire - that is,
US aerial bombings in the first days of the war - subject
US. troops to  fallout from Iraqi chemical weapons?

Ware: Our general stance to this question was to try to see whether there was evidence in support of any of these hypotheses. Again, I think the evidence for that scenario is fragmentary. There are these incidents like the Czech detections that can't be totally dismissed, but they don't make a very strong story that there was any appreciable level of chemical exposure through any route.

Tuite I think that part of the controversy is, what constitutes an appreciable level of chemical agent exposure. The Defense Department has consistently taken the stand that, when these detections occurred, the wind was blowing the wrong way, and therefore, the Czech detections could not possibly be the result of fall-out. Now, the Czechs said that the detections occurred as a result of fall-out. The Czechs, by the way, have a much higher rate of illness among their soldiers than we do right now. And the French have said that it was a result of fall-out. I

"...the winds would have been going from
the areas where the facilities were
bombed down to the area where the
chemical agents were detected." ... Tuite

did some analysis, and I will provide this, but it shows that the national weather service maps indicate that the weather or the winds would have been going from the areas where the facilities were bombed down to the area where the chemical agents were detected. The satellite photographs, the infrared satellite images, show thermal plumes originating in one case right over Muthanna, the largest Iraqi chemical research production and storage facility, going down to the area where the chemical agents were detected. So, to answer the question, what I think we should be talking about is at what levels they were exposed.

Ware: I believe that that there were a few instances in which Czech instruments, Czech scientists, Czech chemists, field chemists believed that they detected really a trace of concentrations of the chemicals you named. That's my understanding.

Tuite Quite frankly, the logs indicate that after seven days of the Czechs continually detecting chemical agents, CENTCOM (Central Command) made a policy decision to disregard reports coming from the Czechs. It's in the log. Second, there is no pattern of exposure in terms of these flu-like symptoms. REAL AUDIO Well, in fact, you can talk to virtually any Gulf War veteran and ask him if he knows what the Saudi flu or the Saudi crud is and when did he first start to experience it. If they are going to be discounted out of hand before an epidemiology is done to determine whether or not they had these flu-like symptoms in the Gulf, symptoms that were dismissed as nuisance illnesses, then we'll never know the answer. That's unscientific. If the veterans are reporting flu-like symptoms and rashes, and those symptoms are consistent with organophosphate intoxication, which they are; and we ignore those reports, then we are not very good scientists. The next issue is dead animals. We don't know why the animals died. The Pentagon says that they die all the time, but this was a phenomenon that startled not only the soldiers but veterinarians who were there, some of whom were assigned to count these animals. They talked about birds dropping out of the sky during the air war. They talked about all sorts of phenomena occurring that they had never seen nor had they heard of. A connection between the acute symptoms and chronic effects. We don't know what causes these phenomena, but we know they occur.

Ware: You put forward the explanation that there were significant numbers of soldiers exposed to chemical warfare agents or chemicals at levels sufficient to cause in some cases transient symptoms, like rash and flu-like symptoms, and at levels sufficient to then persist in a complex of signs and symptoms that would be consistent with what people report when they have the Gulf War Syndrome.

Tuite Yes, given what we saw after World War One. And, by the way, there were not just exposures to nerve agents but also to airborne blister agents. But going back to what was reported after World War One, where we know chemical agents were used, and we know these soldiers were on the battlefields, and they didn't develop these serious and acute injuries, is that they are describing the exact same phenomena. There is an initial acute phase. Then the illness goes away. Then they start to develop this chronic illness.

Ware: But let me push you a little harder on this. In the first place, I say again that I think that there is not good evidence. There is not evidence, period, that troops were exposed to chemical warfare agents. There are some hints that sensitive instruments set off alarms. There is no description of a pattern of an exposure or, to me, evidence. I want to phrase

"I want to emphasize that there is
no story about a substantial
number of soldiers being
exposed to chemical agents." ... Ware

this carefully. I want to emphasize that there is no story about a substantial number of soldiers being exposed to chemical agents. I am not implying that some soldiers might have been exposed or they might have been exposed at low levels. I am saying - at the time I reviewed the evidence, coming up to this summer - I didn't find evidence that persuaded me that exposure to chemical warfare agents was an important issue for the Gulf War troops. Now, secondly, you mentioned that there was this pattern of symptoms, flu-like symptoms and rashes. There has never been any organized epidemiologic description of that. There may have been some soldiers. Some individuals may have reported to the Banking Committee that they experienced that. But there is not any systematic information. In general, with no disrespect intended to the individuals, scientists don't tend to give a lot of weight in terms of ... It can provide an important lead to hear the stories of individuals. But in terms of putting together a story about a phenomenon in a population, the stories of a few individuals may be clues, but they are not proof. Now that's the second piece. The third piece is that the weight of scientific opinion, as I understand it, is that, if exposures did occur at levels insufficient to cause acute symptoms in individuals, it is not believed that those exposures, even if they occurred at extremely low levels, could be associated with persistent chronic effects, because of the biology of retention and release of the agents. Finally, there is no coherent connection of the exposure to the acute symptoms to the chronic symptoms. I mean, what a scientist would want to see is at least associations along the way and a trail and a pattern of evidence. I'm not saying this is not worth pursuing. I'm saying that the evidence isn't there right now to support that explanation of what happened to the Gulf War cohort.

Tuite Boy, am I glad I get the last word on this one. First of all, this is not a set of dumb instruments that have detected these chemicals. The Czechs had a laboratory present. This laboratory had chemists in it. Chemists ran laboratory analysis on the air samples. They detected sarin, tabun, and mustard in the air. That is a fact; that is not speculation. Many of these specialists went to universities where they studied chemical defense. They had degrees in chemical defense. That was their specialty. Much more highly trained than US. soldiers, and they detected the chemicals. I've got original footage from the war in which they are briefing the Saudis on the fact that they detected these chemical agents.

Ware: I believe it's true. I mean, I believe that that's correct, that there were a few instances in which Czech instruments, Czech scientists, Czech field chemists believed that they detected, really, trace concentrations of the chemicals you named. That's my understanding.

Tuite And I have a concern with the fact that a scientist on site doing empirical research is criticized as believing that he detected something when, in fact, he is a highly trained scientist in that particular field. This is a simple scientific experiment for him, and he is an expert in that area. Neither you nor I are experts in that area.

Is Kamisiyah, the Iraqi storage facility
in southern Iraq where the Pentagon says US. troops destroyed
sarin and mustard gas in March of 1991, a key to understanding
Gulf War sickness?

Tuite Yes, in that I guess we have learned, as a result of examining the (US troop) roster of Kamisiyah and examining the Comprehensive Clinical Evaluation Program registry and the Department of Veterans Affairs registry, that there is a 20 percent match between the people who were in that vicinity and who are sick. No, because we also know that during the air war they were also in the same areas as chemical agents were repeatedly detected by the Czech and US forces. So it makes it very difficult to isolate it to Kamisiyah. What we can say about Kamisiyah is that, while we've confirmed the presence of agents in the bunker, we don't know of any detections of the high degree of reliability that we have, for example, in the areas around King Khalid military city and Hafir Al Batin during the air war, where in fact we have highly reliable qualitative tests indicating the presence of agent in the air.

Ware: It's an interesting development because it raises a lot of issues. I think it's unlikely to be the explanation for the Gulf War Syndrome phenomenon. In order for it to be the explanation, we would have to discover that the entire problem of the Gulf War Syndrome was localized in the soldiers (at Kamisiyah) - whatever that group ultimately proves to be - some 20,000, it's now said. Then you'd have the smoking gun. I don't think it's going to be the smoking gun. I doubt that anyone is seriously putting that idea forward. Whether it is a contributor, whether those 20,000 soldiers who were in the vicinity of that dump when it was destroyed have an increased frequency of the kinds of problems we're talking about, is a very interesting question. And one that deserves investigation.

The Institute of Medicine committee's
study of Gulf War illness concludes that chemical and biological
weapons were not a factor.  Why?

Ware: Of course, one thing is that we really didn't have an opportunity to seriously consider this most recent evidence because our report had already gone to press when that information was first made public. So my comments about the dump site have to be taken as an addendum to our report. We concluded, and I think I've made this point before, that we, looking at the body of evidence, were not persuaded. This panel was not persuaded that there was evidence presently available to support a conclusion that exposure to chemicals was an explanation for increased illness among the Gulf War troops.

Tuite The one issue that I would argue with is, in part, the conclusions that were drawn by the Institute of Medicine had to be based on incomplete information from the Department of Defense. There was a reluctance or failure to go outside the Department of Defense for evidence of exposures, particularly in interviewing people who were involved in the congressional investigation that interviewed literally thousands of soldiers and many of the chemical specialists who detected these agents.

Is the Pentagon right that there were
no confirmed reports during the war of acute, immediate symptoms
caused by chemical weapons?

REAL AUDIO Tuite Given the Pentagon's doctrine at the time, yes. Given what we know about low-level exposures, no. Well, first of all, there actually were four, that I'm aware of, acute immediate injuries. One is Pfc. (David) Fisher, which occurred in a bunker up in the 3rd Armored Division area of operations, which the Pentagon has now admitted was a mustard injury. The second was the blistering of two Marine Corps enlisted men going through "Breach Lane Red One" during a period of time in which both chemical, mustard and blister agents were being detected by two separate Fox vehicles. The third was a British soldier who received an injury during a mop-up operation, if you will, in August of 1991, in a container that is believed to have contained, if you believe the people who were there, mustard and phosgene oxime; and if you believe the Pentagon, fuming nitric acid. So there were those injuries. But again - knowing what we know about organophosphate intoxication, and the acute symptoms associated with that, and the reports that we have received, and the fact that the Pentagon would have dismissed these or the medical practitioners who were looking at chemical injuries would have dismissed these as nuisance illnesses during the war - I think it's very difficult for them to say, definitively, that there were no confirmed acute exposure illnesses or injuries.

Ware: We didn't see any evidence of a pattern of acute illnesses. There may have been. I can't speak to these four instances of, really, occupational injury almost. That is, those are important, but those would not be an explanation for the Gulf War Syndrome, those four incidents that were mentioned. So as to an experience among the troops of acute symptoms, we have not seen any evidence of such a phenomenon.

Tuite Just one more thing in passing: the experience of the seabees (Navy engineers) at at the Port of Jubayl. Certainly, they did describe an acute set of symptoms as a result of their exposures. And we do know that blister agent was detected in five locations by three different kinds of instruments, including two M-256 kit tests, which is what the Pentagon considers a confirmed detection, on January 19th, after an otherwise unexplained explosion that was explained to the soldiers as a sonic boom. We are aware of that as well. That's one of the events that I was talking about that I believe needs further investigation.

Is The New England Journal of
Medicine right that there is no evidence that a brief,
unrecognized exposure to nerve gas can produce a chronic illness?

Ware: That editorial reflects the prevalent view - not consensus, maybe that's too strong - but the prevalent view among scientists. And I'm not expert in that area. So I rely on the judgment of those more expert than I. But that is my understanding of the evidence, of the current scientific thinking.

Tuite And, to respond to that, there are credible, mainstream scientists who do research, including doctors at your own institution, who do believe that these brief exposures could result in these kinds of effects. So it is not a resolved issue. It is a contentious issue, and I would agree that probably the majority of researchers agree with the position that Dr. Ware has taken. But it is by no means an area in which there is consensus or anything near consensus among the research community.

Ware: You know, the consensus has been wrong plenty of times. I felt all along that we have to be prepared to access new evidence as it comes forward. So I try to emphasize in my comments that, based upon what I know now, this is my opinion. I think as new information becomes available we have to try to interpolate that.

How do you come down on the issue:
Is chemical weapons exposure a likely cause of Gulf War illness
or not?

REAL AUDIO Ware: My stance is, I don't believe that there is evidence to support that explanation. There's not evidence of the scale and magnitude of exposure to chemical warfare agents at a level and to a number of troops that could explain the numbers of reported illnesses and affected individuals. There's not evidence of acute illnesses among individuals that potentially would have been exposed. And there's no chain of association or potential causality that would point to make a story like that come together. One can make that story, but there's no evidence to support it, essentially.

Tuite I would counter with: the sounding of the alarms throughout the theater, coinciding with the bombing of the Iraqi chemical weapons infrastructure; the confirmation of these detections using wet chemistry analysis and gas chromatograph mass spectrometry or scientific instruments that are used in laboratories, although not as precise as those same scientific instruments, confirming the presence of these agents in the air; the reports from the soldiers, again, of these rashes and flu-like symptoms consistent with organophosphate intoxication; and an illness which very closely follows the illness of organophosphate-induced delayed neuropathies, to me, would suggest that we have to assume that most or all of these soldiers may have been exposed. And, therefore, we have to start looking at this issue from the perspective that this could very well be a principal cause of Gulf War Syndrome.

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