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Gulf War Exposure Linked to Symptoms in Veterans

Neuropsychological morbidity from toxic environmental and chemical hazards of war

by Bianca Garilli, ND

Exposures to environmental and chemical hazards while serving in the Gulf War (GW) is well documented and may have contributed to potential health risks in these active duty military personnel. Some of these toxic exposures include:1-2

  • Vaccinations (including anthrax and botulinum toxoid)
  • Pyridostigmine bromide, used as a pre-treatment drug to protect against nerve agent soman
  • Mefloquine, taken to prevent and treat malaria
  • Oil well fires
  • Burn pits
  • Pesticides used to repel or kill pests such as lice and to protect personnel from insect-borne illnesses
  • Infectious diseases
  • Chemical and biological warfare agents
  • Various other exposures

The Veterans Administration defines GW Veterans as those military personnel “who served on active duty in the Southwest Asia theater of military operations any time during the Gulf War starting August 2, 1990 through the Iraq War and subsequent reduced operations in Iraq. Military operations include Desert Shield, Desert Storm, Iraqi Freedom, and New Dawn.”3

Although some of these exposures such as skin rash, eye irritation, and respiratory problems, were short lived and had a relatively quick resolution of symptoms, other exposures may have resulted in longer lasting and often unexplained problems, including symptoms such as headaches, fatigue, muscle and joint pain, memory problems, confusion, attention deficits and mood issues including depression and anger.1-2,4

Over time, it was recognized that many veterans were suffering from these chronic, unexplained, and debilitating symptoms which, when taken as a whole, became known as Gulf War Illness or Gulf War Syndrome. More recently, the medical community started referring to this cluster as: chronic multi-symptom illness (CMI). CMI is defined as one or more chronic unexplained symptoms (present for ≥6 months) in at least two of the following categories:5

  • Fatigue
  • Mood and cognition (symptoms of feeling depressed, difficulty remembering or concentrating, feeling moody, feeling anxious, trouble finding words, or difficulty sleeping)
  • Musculoskeletal (symptoms of joint pain, joint stiffness, or muscle pain)

In 1998, Congress passed 2 laws: PL 105-277, the Persian Gulf War Veterans Act, and PL 105-368, the Veterans Programs Enhancement Act, in response to the high number of GW veterans presenting with CMI.6 These laws directed the secretary of the VA to contract with the National Academy of Sciences (NAS) to review and evaluate the literature and determine the nature of the relationship between CMI and toxic and hazardous material exposure during the GW.6 Follow-up studies were then assigned to the Institute of Medicine (IOM), now known as the National Academy of Medicine (NAM).6

Over the years, many follow up reports and studies have been produced and published both by the organizations tasked by these Acts as well as many other agencies and groups. One such report was the Environmental Exposure Report (EER) on pesticides initially published in 2001 and final version published in 2003.7 This report contained information on military personnel’s pesticide exposures during 1990-1991 while deployed to the Gulf region.7 A major recommendation from this report was the need for a future epidemiological study utilizing individuals from the same 41,000 GW veteran cohort used in the EER, which would more deeply address individual cognitive and health assessments to further understand the potential causes of the symptoms experienced by these Gulf War troops.7

In answer to the EER’s recommendations, Sullivan et al. undertook such a study and published their findings in the Neurotoxicology and Teratology journal.4 They explored cognitive and mood functioning in military personnel (termed Pest Control Interviewees or PCIs) with pesticide or pyridostigmine bromide (PB) exposures during the GW.4 The study collected self-reported measures of pesticide and PB exposures in a group of 159 GW-deployed personnel and rated them from low to high.4 It also further characterized the exposures based on whether they were individual material exposures (i.e., just pesticides or PB) or a combination (i.e., pesticides and PB).4 Participants were subsequently administered a battery of neuropsychological tests and their performance was assessed.4

Exposure routes for PCI veterans were through their specific military job roles, which spanned a variety of Military Occupational Specialties (MOS) including: physicians, entomologists, environmental science officers, preventive medicine specialists, field sanitation team members, military police, and other pest controllers.4 The individuals in this study represented every branch of service, both active duty and reservists, and included males and females.4

Potential exposures included fly baits, pest strips, sprayed liquids, sprayed powders, pesticide fogs, prisoner delousing materials and could be classified as either organophosphate pesticides or carbamate pesticides such as the PB pills.4 PB pills were often administered as a prophylactic against possible nerve agent attack and has been associated with cognitive decline in executive system functioning such as memory, attention span, reasoning, problem solving, etc.4

The results of this study confirmed previous findings of associations between more poor neuropsychological function and exposures to organophosphate pesticides (OP) and carbamate pesticides in the GW veteran population.4 It further strengthens previous conclusions by the Department of Defense (DOD) and RAND reports suggesting a possible connection between these exposures and undiagnosed illnesses seen in many GW veterans.4 This study also noted an increased rate of CMI in the population with higher pesticide exposure rates, with particular emphasis on worsening cognitive performances in attention, motor, memory, and mood domains.4

Another interesting note from this study was the authors’ consideration that other biological markers of chronic OP exposure, such as oxidative stress and inflammatory markers, may prove useful tools in determining exposure levels and individual effects of exposures.4 The authors went on to offer recommendations for innovative treatment approaches to these complex cases including antioxidants, anti-inflammatories, glial modulators, microtubule stabilizers, and other therapeutic considerations.4

In summary, many GW veterans have unexplained symptoms that often meet criteria for CMI. GW veterans may have been exposed to frequent, high levels of various pesticides and hazardous materials while serving in the GW and should be screened for exposures when presenting for unexplained symptoms or illness. GW exposures have been linked to poor neuropsychological performance, and hazardous material exposures may increase oxidative stress and inflammation. Therefore, clinicians should consider addressing these issues when treating CMI in GW veterans.


  1. US Department of Veterans Affairs. Public health., Accessed October 17, 2018.
  2. US Department of Veterans Affairs. Iraq war exposures. Accessed October 17, 2018.
  3. US Department of Veterans Affairs. Office of Academic Affiliations. Accessed October 17, 2018.
  4. Sullivan K et al. Neuropsychological functioning in military pesticide applicators from the Gulf War: Effects on information processing speed, attention and visual memory. Neurotoxicol Teratol. 2018;65:1-13.
  5. Committee on Gulf War and Health. Gulf War and health: treatment for chronic multisymptom illness. Washington (DC): National Academies Press (US); 2013. Accessed October 17, 2018.
  6. Institute of Medicine (US) Committee on Gulf War and Health. Update of health effects of serving in the Gulf War. . Washington (DC): National Academies Press (US); 2010. Accessed October 17, 2018.
  7. Winkenwerder W. Environmental exposure report. Accessed October 17, 2018.

Bianca Garilli, ND, USMC Veteran

Dr. Garilli is a former US Marine turned Naturopathic Doctor (ND). She works in private practice in Northern California as well as running a consulting company working with leaders in the natural and functional medicine world such as the Institute for Functional Medicine and Metagenics. She is passionate about optimizing health and wellness in individuals, families, companies and communities- one lifestyle change at a time. Dr. Garilli has been on staff at the University of California Irvine, Susan Samueli Center for Integrative Medicine and is faculty at Hawthorn University. She is the creator of the Veterans for Health Initiative and is the current President of the Children’s Heart Foundation, CA Chapter.


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