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Captain Kenneth C. Hyams
An infectious disease specialist and Desert Storm vet,  Hyams wondered whether anything like Gulf War Syndrome had happened before. So he examined decades of military and medical records and looked at  symptoms that appeared in previous wars. Interview conducted September 1997.

Q: How did this decision come about to look back at the aftermath of previous wars?

A: When questions about Gulf War-related health problems were first raised, the question was asked repeatedly: Have we seen similar problems in the past? And I was working on the Persian Gulf Veterans Coordinating Board at the time, and I was pretty much the one designated to look at these prior war syndromes. I have a undergraduate degree in history, and so it naturally fell to me to evaluate these past war syndromes.

Q: So what did you do? You went back through all the records?


A: Yes. I started pretty much with the Civil War, because that's when we really come into our own with modern scientific medicine, where data is reported that could be compared with modern clinical and epidemiologic data. So I looked at, oh, articles going back all the way to the Civil War on war-related health problems. And it took over a year, actually, to find all the articles. This is an area that there's been a lot published on, but the previous publications aren't included in the computerized databases because the articles are so old.

Q: And these are written by military physicians in the past?

A: Most of the articles that I reviewed, that I concentrated on, were articles written by the physicians at the time or shortly after the war. I wanted sources who had actually observed the illnesses and examined the patients. I didn't want to rely just on secondary sources and authorities who hadn't been in the wars.

Q: Talk a bit about some of the things you found. Start with the Civil War.

A: Starting with the Civil War, we had a war-related health problem that was known as "irritable heart" or DaCosta syndrome. And it presented somewhat similar--similarity to the illnesses that we're seeing now amongst Gulf War veterans. The veterans complained of fatigue and shortness of breath and headache and problems with sleeping and problems concentrating and memory--the same sort of symptoms that we're seeing now amongst Gulf War veterans. In fact, after all the major wars, the veterans have had the sort of physical complaints that we're seeing amongst Gulf War veterans.

Q: Now, it's interesting, different names have been given. "Irritable heart." What was the rationale, for this name?

A: They thought it was due to a heart condition, initially. And that's why it was called "irritable heart". Later on it was called DaCosta syndrome, because it was pretty much shown that heart disease was not the problem.

Q: Talk about the First World War. What kinds of things showed up there?

A: At the beginning of the First World War, there was a major problem when the British had to evacuate soldiers from the front in France, because of condition known as "effort syndrome" or neurocirculatory asthenia. And again, like in the Civil War, this condition presented with fatigue and headache, shortness of breath, and problems remembering and concentrating. And it was a major problem for the British. They had to evacuate a lot of soldiers from the front. When the Americans entered the war, it was a problem again for us.

Q: What was it called again? Effort syndrome?

A: It's called "effort syndrome" in the United Kingdom; or it was also called DaCosta syndrome. It had a number of other names. United States, we gave it a different name. We called it neurocirculatory asthenia.

Q: But the idea, the notion of "effort syndrome" was, it took an effort to breathe?

A: The idea behind calling it "effort syndrome" was, it seemed like at the beginning that symptoms were worse with effort. But later on, that was pretty much shown not to be the case. But nevertheless the name stuck.

Q: Move on to Second World War.

A: "Effort syndrome" was again a major consideration at the beginning of the Second World War, when the British entered the war. There was a major question at the end of World War I whether effort syndrome was a psychological condition or a unidentified organic disease. And that question still persisted at the beginning of World War II. Some very well known studies were conducted by a famous doctor at the time, a renowned doctor, Dr. Paul Wood. And he determined that effort syndrome was a psychoneurosis and was not a heart condition or some other kind of medical condition. So after the first few years of the war, we did not hear much more about effort syndrome.

Q: So that's really the turning point. I mean, prior to this, these kinds of syndromes were thought by most physicians as being physical. But you're saying, around the Second World War it--

A: Oh, not most physicians. There was major controversy as to whether or not these symptoms were due to an organic physical disease, or whether they were due to a psychological condition. It was a major debate at the time, getting all the way back to the Civil War and going through the First World War and World War II. It's very similar to the debate we're having now as to whether Gulf War veterans' symptoms are mainly an occult, an unidentified physical disease, or whether or not they have a psychological basis.

Q: But you're saying, around the time after the Wood study, that it seemed to resolve it?

A: At that time, the idea that effort syndrome was caused by a physical condition lost favor, because of his studies. The questions still were never totally resolved at that time. But for most individuals, most physicians and professionals, the effort syndrome was attributed to psychological factors after that. These were very well done studies at the time.

Q: Now, going back to the Second World War-- was this issue of a stigma being attached to a psychological condition something that was present? Was this a problem even then?

A: Yes. That goes back for a very long period of time. And it was-- It was found back in the First World War and particularly in the Second World War that if individuals were diagnosed as having a psychological condition, they were much less likely to be rehabilitated and return to the front. When it was recognized that symptoms and illnesses were caused by extreme stress from life-threatening experiences and wars, and this was recognized and not labeled as an illness, uh, the troops who were affected by these psychological conditions were much more likely to be rehabilitated and have a better long-term outcome.

Q: We were talking yesterday with Dr. Hamburg, and he was talking about General Patton and--- Was there, up until the forties and fifties certainly, a certain lack of sympathy towards the idea of a psychological disease?

A: Certainly that's very true in the past, and it persists today. There's something of a lack of sympathy for psychological conditions, because people feel that you have some control over them.

Amongst medical professionals, though, we recognize that psychological conditions cause just as much pain and suffering as any medical or surgical condition, and we treat them very much the same.

Q: Similar kinds of things sort of emerged in the Korean War and in the Vietnam War. Could you talk about any differences?

A: Not so much in the Korean War, but in the Vietnam War the Vietnam veterans had these same sort of symptoms that were seen amongst Gulf War veterans and we saw in World War I, World War II veterans, and Civil War veterans. They report these symptoms at higher rates than the veterans of the same era that did not go to Vietnam.

Q: And would you say, after Vietnam there's something of a breakthrough in terms of getting these established as legitimate medical entities--with post traumatic stress disorder, for instance?

A: Well, the psychological conditions associated with the war received much more legitimacy after the Vietnam War, because they were recognized as a unique condition. But if you read the medical literature going back with all major wars, the troops suffered from psychological problems after the wars. Anyone who's been traumatized or life has been threatened, is going to have some problems afterwards.

Q: One of the things I think the public perception of the Gulf War is the actual combat period is very, very short; it's over quickly; there's very few casualties on our side, and so forth. Therefore people tend to perceive it as a low-stress war.

A: Well, having served in Desert Storm, I can certainly directly speak to that issue. It was not a low-stress war. There was less direct combat for a shorter period of time than in previous wars. But there was a long build-up period over 5 months. And we're looking at this retrospect. Now, we know we won a quick and decisive victory. But no one knew that at the time. And for all of those troops who were deployed before the war, there was a lot of anticipation, a lot of anxiety and worry about the outcome of the war and about the use of chemical weapons or--or other types of weapons of mass destruction. So there was a lot of stress on all the troops, who were yanked out of their normal lives and sent to the Persian Gulf. And again, you can't just look at this now, after we know that it was a quick and decisive victory. No one knew that before the war ended.

Q: So it was the anticipation that caused the stress?

A: That, and the unexpected nature of the war: people being ripped out of their normal lives and sent over to the Persian Gulf, and not knowing what was going to happen in this wartime deployment. It was a stressful period for everyone. And certainly for all troops, even if they weren't involved in direct combat, there was the possibility of the Scud missile launches causing death and debility amongst all the troops. So all the troops were correctly threatened, even if they didn't see combat personally.

Q: But when the war was over, did you expect that we'd see a phenomenon like this? There was relatively little post traumatic stress disorder, in terms of the acute stress of individual [men]. That hadn't happened, had it?

A: No, I have to say, at least personally, no. We had very low rates of-- much fewer deaths than we initially feared in this war, and the disease non-battle injury rate, the amount of non-death medical problems we saw during this war, was lower than in any of our previous major military deployments. And so as far as the health of the troops during the deployment, during this wartime deployment, they were very healthy, compared to previous wars. And so based on that, we didn't anticipate as many problems after this war.

Q: Before we leave the actual battlefield, talk about the environment itself. One of the things in the debates afterwards has been, people have spoken about experiences they had there, like for instance seeing dead animals with dead insects and so forth on them. Is this kind of an unusual environment? And are the kinds of weapons spoken about, unusual? People don't have experience of them. Is it less constrained as regards their imaginations [than previously]?

A: This environment was unique, as everyone knows. In some ways it had a lot of health threats; in other ways it was a more healthy environment than, say, a jungle sort of environment, where our Vietnam troops fought.

It's a complex picture. As far as the oil well fire smoke and those sort of known threats, it was a harmful environment, because people were breathing in harmful substances. But as far as the desert environment goes, our troops were deployed into barren desert locations, away from major population areas, and away from the oases and other areas where a lot of diseases are transmitted. In some ways, they were isolated from some disease threats. We had much better control over the use of alcohol and other sort of problems we've seen in other deployments.

So in some ways the troops were separated from some of the health threats, and in other ways there were increased health threats, like from the oil well fire smoke. So it's a complex picture. In some ways, it was a healthier environment than Vietnam; in other ways, it was worse.

As far as the dead animals, that was one of the first questions raised. When I was deployed to Saudi Arabia in August, 1990, I was asked, because I'm an infectious disease specialist, about the dead animals in the desert. And I saw at least a half a dozen or more piles of these dead animals in the desert. And there's large herds in this region--the Bedouin maintain--of camels, sheep, and goats. And when animals die, they pile them up in specific locations and they get compensation from the government when their animals die. And so these dead animals, these piles of dead animals, were in the desert at least five months before the war began.

These piles of dead animals were not considered a direct threat to our troops, because most of them weren't camped directly on top of the animals. They'd locate their camps away from these dead animals. But they were considered potential breeding grounds for insect-transmitted diseases. And so we recommended that these piles of dead animals be thoroughly sprayed with insecticides. And this may explain some of the reports of dead insects on these piles of dead animals. I didn't spend much time, myself, looking closely at these dead animals, but I know that they were thoroughly sprayed with insecticides by our military personnel.

Q: Now let's leave the war and come afterwards. You've been quite a close observer of what's happened, both as a scientist but as a person in the military. Talk a bit about your observations, about when this surfaced and people first started using the word "Gulf War syndrome". What did you think at the time? What did you notice?

A: I didn't really know what to think. I mean, this is somewhat different than the sort of medical conditions that we usually deal with, because it's ill defined. And my first thought was that it might be due to, say, leishmaniasis infection, since that's my field, infectious diseases. And we were actively looking for cases of leishmaniasis, trying to determine whether or not this was causing problems amongst our veterans. So my first thought was: Are we dealing with something like that?

Q: But then you went on and you found that many of these symptoms were these ill defined symptoms. Could you describe them for us? What kinds of things?

A: Well, the most common symptoms reported by the veterans are fatigue, headache, joint pains, problems with sleeping, insomnia, nightmares, difficulty concentrating, difficulty remembering. These are the main sort of symptoms our veterans are complaining of. These are also the sort of non-specific somatic symptoms, physical symptoms that we've observed in veteran populations going all the way back to the Civil War. These are very common symptoms [in] veterans, and they're also very common symptoms in the general population.

Q: So when you did your research and you found that, what did you conclude from that? That there was a big psychogenic component for this? What was your conclusion?

A: It's very interesting to observe the historical record. What we found is, these symptoms that had been difficult to explain after every major war, some of-- And there's been a major debate as to the cause of these symptoms. Sometimes the symptoms are attributed to psychological factors, and in other patients these symptoms are attributed to a unknown organic disease. And we've seen this same pattern going all the way back to the Civil War--similar sort of symptoms in our veterans, and this question whether or not they're due to psychological conditions or whether or not they're some sort of unidentified disease.

Q: Now, several blue ribbon panels looked at this problem. They have concluded that the popular risk factors are not very probable, and that stress is a contributing factor. Why has stress been such a hard sell?

A: Well, somewhat inexplicable as a physician, because we know that stress causes a lot of suffering in population, and that the individual suffering from psychological illnesses or stress deserve our compassion and our help. And so it's difficult to explain why this has been stigmatized--the idea that there may be stress-related illnesses. I think that there's still a certain perception among some people that for some reasons, stress and psychological illnesses aren't real, which is certainly not the case.

There's going to be a certain level of disease in any adult population, particularly as that population gets older. And so in any war veteran population, you're going to see lots of psychological illnesses and lots of medical diseases over time. This is going to occur. This occurs in all populations. And the question always is: Are these illnesses related to the wartime experience? And it's difficult to determine that, because we see diseases and illnesses in all populations.whether it's lung disease or kidney disease or cancer or any other conditions.

The real question is: Are these veterans having these diseases, these illnesses at higher rates? Are they [at] more risk of developing these diseases than other groups of adults? That's the real question. Not that they're having these diseases.

Q: Now, some of these questions have been addressed, like mortality, acute morbidity, birth defects and so forth. Give us just a summary of what it looks like so far.

A: There's been a large number of studies conducted amongst this veteran population. And we know at the present time, based on the number of deaths in Gulf War veterans, and based on hospitalizations, and also based on over 100,000 medical examinations of Gulf War veterans, we know that this population tends to be more healthy than the general population of adults.

Q: So they're not dying, and they're not getting ill at a--

A: From the studies that have been conducted so far, their health seems to be better than the general population of adults. And we would expect that, because soldiers, military personnel are selected for good health. But at the present time, they seem to be healthier than general population. We have seen a slight increase in stress-related illnesses, which we expect after every war. Any time a population's life is threatened, any time an individual's life is threatened, they're going to have some psychological problems afterwards.

Q: So from your point of view, do you see a mystery disease?

A: Well certainly, we haven't seen in the overall veteran population evidence of greatly increased ill health. The symptoms that some veterans are complaining of, we haven't totally explained. And this has been true after previous wars. And so there is a mystery, if you will, as to what is--is causing these symptoms amongst some of our veterans.

Q: But is it unique to this war?

A: No, it's not. And it's not unique to any adult population. Any busy physician in a clinic will deal with these sort of symptoms on a daily basis: complaints of fatigue or joint pain or headache. These sort of symptoms are very common in all adult populations.

Q: Now, are there any lessons from this?

A: Well, if you look at the historical record and these questions that have been raised about these symptoms after previous wars, it's usually taken a couple of decades before there's been a consensus about the cause of these symptoms. After previous wars, there was the thought that these unexplained symptoms were due to some unidentified disease. When a disease was not identified over a 10-, 20-, 30-year period, most of the symptoms were attributed to psychological factors, or to the sort of normal complaints that every-- that every adult population experiences.

And so we may have a certain amount of closure over time. Most diseases will manifest themself after a while. And if there's a disease we currently can't detect, it'll probably show itself over time. And so there should be a certain amount of closure involved with this issue. It's still early days, to a certain extent. We've only followed these veterans for about six years.

Q: So you're saying, over a couple of decades, if it's there, it'll show itself. If it doesn't show itself, what?

A: Usually that's true. In the historical record, what it indicates is, --if a disease is not identified and confirmed over time, that generally these symptoms are attributed to psychological factors or to the normal complaints that any adult population experiences.

Q: And you're not worried about this argument that we started too late in the day to investigate this thing?

A: No. t would have been good if we had had more time-- a greater amount of wartime records of potential exposures, and if we had had more documentation of certain events. But the real question is here is whether there's a unique disease that our veterans are suffering from. And we don't have to wait to examine that issue. And we can examine veterans who have symptoms at any time. If there's a disease there, we can look for it right now. And the fact that we're six years away from the war doesn't make any difference on that account.

Q: Are there any lessons for handling future post war syndromes?

A: Difficult to explain symptoms are found in all adult populations. And unless we can totally explain these symptoms in all populations, we're going to see them after future wars. And we should be prepared for that. I do think we have a moral duty to take care of the health problems caused by this war. Also think at the same time, it's very important that we do not stigmatize all Gulf War veterans as being sick, or as having a health problem, a public health problem. These veterans who fought for their country shouldn't suffer by being unable to obtain jobs or insurance because of misconceptions about their health.

Q: I see. So even the ones who aren't presenting symptoms might be stigmatized?

A: I think that that's a possibility that we worry about, that there will be this perception that all Gulf War veterans are sick, or that they are causing some sort of public health problem. And I think that's wrong. Individuals who fought for their country should not suffer in obtaining insurance or obtaining a job, based on misconceptions about their health.

Q: Last thing. What do you think is the most important thing you want people to understand about this affair?

A: I think the most important thing to understand is, this is a very complex medical and scientific issue. And answers don't come easy in these complex issues. These sort of questions about these symptoms are raised in lots of other populations, not just amongst war veterans. We haven't solved all these questions in the past. And it's going to be very difficult to sort through all these questions and all these issues and provide answers that everyone will agree upon.

Q: Now, you say that they exist in all populations, whether they're military or not. Do you think that's something that's just not very well appreciated? Are you saying that in any group of citizens, we'll get these kinds of symptoms?

A: Well, all of us at time complain of fatigue or headache or joint pains, problems sleeping, problems remembering--particularly as we get older. So these symptoms are quite common. The real question is: Where do we divide these sort of normal complaints from illness?

That's a question that has been raised repeatedly over the question of chronic fatigue syndrome. When do the individuals have fatigue that is so great that they have a unique illness, chronic fatigue syndrome? And when are these symptoms the sort of symptoms that all of us experience?


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