HL Deb 02 March 1998 vol 586 cc138-42WA

"Introduction: The Gulf War Medical Assessment Programme has been the main focus of the Ministry of Defence's investigations into the alleged Gulf War syndrome and any UK Gulf veterans, whether or not presently serving, who are concerned about their health have been invited to receive a full medical evaluation by military medical specialists. The Royal College of Physicians was asked to carry out an independent clinical audit of the assessment programme (Ministry of Defence News release 8/2/95).

This report summarises our findings and makes recommendations for future developments.

Background: About 51,000 UK service personnel served in the Gulf War conflict in 1990–91. Although not all of them saw active service, they were nonetheless involved through, for instance, vaccination programmes or taking medication for the prevention of damage from nerve gas (NAPS).

In the last two or three years attention has been increasingly focused on a wide variety of illnesses reported by veterans of the Gulf War. These reports led to the suggestion that a specific Gulf War Syndrome existed, which was attributable to some aspect of serving in this conflict. Factors that have been suggested as agents in the causation of theses illnesses include exposure to chemical or biological weapons, the vaccination programmes used and medication taken for the prevention of damage caused by nerve gas (NAPS). In addition to these agents are the stress and possible psychological trauma associated with involvement in all conflicts. Reports of illness by Gulf War veterans have appeared chiefly in the USA and UK, but also in Canada and Norway.

In response to these reports in the autumn of 1993 the Defence Medical Services started referring veterans to the hospital at RAF Wroughton, where a special clinic was established. We are informed that the aims of this programme were to ensure full clinical examination of veterans coming forward to facilitate any necessary treatment and to give an early indication whether the Gulf operations of 1990–91 have led to (a) the emergence of a new syndrome, or (b) a higher than expected incidence of known diseases. Assessment protocols were established in the first half of 1994. Veterans have not been contacted individually with offers of this service but it is well-known to veteran associations and to the Gulf War Solicitors' Action Group. Its existence has also been reported in the press. Veterans who have left the armed services who enquire about this service are asked to seek referral from their General Practitioner. To date some 260 individuals have come forward and over 200 of these have already been assessed. At first the waiting time for assessment was up to 12 weeks. Wing Commander Coker, who had been assigned to this work, was then seconded to it full-time and, for a while, had the assistance of another physician, Col. J. Johnson. Clinics are now held on five mornings each week and the waiting time has been reduced to a few weeks. There is some evidence that up to 500 UK veterans have expressed concern about their health, approximately 1 per cent. of those who served. The true size of this problem remains uncertain.

Assessment: The assessment commences with a medical interview and physical examination lasting about one hour. Routine investigations are then performed and include blood and urine analysis. Other specialist investigations performed where indicated are shown in Appendix 1. At first all veterans were also assessed by a psychologist-administered questionnaire and approximately two-thirds were then interviewed by a consultant psychiatrist with special experience of people who have endured very stressful experiences. This psychological and psychiatric assessment is now available only for personnel who are still serving. Any relevant medical records are requested from the individual's own doctor. For personnel who are no longer serving, recommendations for any further specialist investigations are made to the general practitioner involved.

Findings to date: The results obtained by assessment of the first 200 veterans are at present being entered by Wing Commander Coker into a computerised database. Preliminary analysis suggests that major organic illness, e.g. tumours or heart disease, was present in about 14 per cent. Forty per cent. suffered from a wide variety of less serious illnesses, e.g. skin disorders. Psychiatric disorders were present in some 36 per cent., especially the post-traumatic stress disorder. A diagnosis of Chronic Fatigue Syndrome, using the CDC Atlanta diagnostic criteria, was made in 8 per cent. Complex and multiple epidemiological studies would be required to establish whether any single disease encountered in this group occurred with greater frequency than would be expected randomly. Nevertheless the incidence of psychiatric disease, at least, is noteworthy and requires further attention. Provided consent is obtained from the patient, the results of the assessment can be made available at the War Pensions Agency in support of a disability claim.

RCP Audit:

(a) We had an in-depth briefing with Wing Commander Coker, the consultant at RAF Wroughton who runs the veterans' assessment programme.

(b) We have reviewed background literature supplied by the Surgeon-General, including extensive documentation about the work that has been performed in the USA.

(c) We have visited RAF Wroughton, where we attended a morning assessment clinic, interviewed personnel involved in the assessment and reviewed the diagnostic facilities available.

(d) We had a detailed presentation by Wing Commander Read and Squadron Leader Neal, consultant psychiatrists, of the protocol used in psychological screening, together with the results obtained to date.

Preliminary Findings of RCP Audit:

1. Wing Commander Coker is well placed to conduct the assessments. He is a well trained consultant physician who has an honorary degree in chemistry and a toxicology background. He spent three years at Porton Down running clinical trials of nerve gas prophylaxis. He was also part of the United Nations Special Chemical Destruction Group that spent several months in Iraq in 1992.

2. Although there was initially a delay in seeing veterans, the assessment programme is now working well with acceptable waiting times.

3. The history, examination and baseline investigations are appropriate. However, limited use has to date been made of sophisticated tests of immunological function, but the precise place of such investigations is not yet established. Also, the psychological and psychiatric assessment that was instituted in spring 1994 was later limited to veterans still serving. This is unfortunate because of (a) the frequency of psychological abnormalities and (b) the great expertise available at RAF Wroughton for post-traumatic stress disorder.

4. The initial assessment is thorough but follow-up for personnel no longer serving is uncertain. Communication by Wing Commander Coker to the veteran's general practitioner is satisfactory, but there is no certainty that his request to be kept informed of subsequent developments will be met. Consideration should be given to the establishment of a mechanism for the collation of follow-up information.

5. Referral of veterans to RAF Wroughton at present depends on an unstructured "grapevine". This may well be efficient but it is not known at present how far news of this service has spread amongst the 51,000 Gulf War veterans.

Conclusions and Recommendations: The findings at present are hard to assess in the context of the possible existence of a specific "Gulf War Syndrome". This is partly due to the fact that the population studied is self-selected by coming forward for assessment. The plurality of diseases encountered in this group makes it difficult to conceive of a single aetiological agent. It is notworthy that, after extensive study, it has been stated to Congress by the US assistant secretary of defence for health affairs that no evidence has been found to implicate chemical or biological weapons as causes of illness in Gulf War veterans. Nevertheless doubts persist, for instance concerning the significance of high blood levels of lead found in a small number of deceased veterans.

We note particularly the high incidence of psychiatric illness revealed in veterans by the Wroughton programme. There is a need for further assessment, with subsequent treatment where needed, of veterans in this particular respect.

In addition we believe that greater expertise in tropical disease should be available to the assessment programme, especially given the concern expressed in the USA about the occurrence of visceral leishmaniasis in veterans.

The frequency amongst veterans of short-term malaise following vaccination against biological warfare agents is noteworthy but not surprising. We are not aware at present of reasons to believe long-term damage to the immune system following such vaccination but we advise the involvement of expert immunologists in assessment of this possibility. Study of the vaccination issue will not be facilitated by the poor vaccination records we encountered in the medical documents of veterans. We do not underestimate the difficulty of maintaining such records in wartime circumstances but the patchiness of such documentation remains regrettable.

Thorough epidemiological assessment of the findings to date would involve very large and expensive studies. Even with unlimited resources the difficulties to be overcome in this area are enormous. The US Institute of Medicine Committee asked by Congress to report on Defence Department studies made of illness in Gulf War veterans has advised large scale epidemiological studies with particular reference to toxicological aspects of the problem. US investment in this area is already large and continuing. With the limited resources available in the UK it would seem prudent to take full advantage of the US studies. We are therefore pleased to learn that a MoD team, including Wing Commander Coker, has recently visited the US Defence Department. The Surgeon-General had already visited the USA to discuss these issues.

We are not at present in a position to comment on a recent report from Glasgow of unexplained damage to the nervous system detected in some veterans. To the best of our knowledge the findings are not yet published and will require scrutiny and confirmation as with any research findings. We are also not able yet to comment on claims made by the group in Duke University, North Carolina, in support of the hypothesis that a combination of the anti-nerve gas agent with an insecticide used by the US forces in the Gulf War can cause damage to the nervous system.

Finally we have not investigated reports of pregnancy failures and birth defects occurring in the children of Gulf War veterans. This was outside both our remit and our competence.

Summary: The Gulf War assessment programme addresses appropriately the medical needs of those veterans reporting illness and attending the clinic at RAF Wroughton. It demonstrates commitment to them and provides advice to their general practitioners and service doctors. With the exception of the psychological assessment programme, the resources at present provided are adequate for these purposes. The clinical aim of this programme, namely to examine veterans and facilitate treatment, is being achieved (See page 1).

The complexities of the issues raised by illness occurring in veterans need further specialist advice, notably requiring immunological, toxicological and tropical disease expertise. The epidemiological issues raised are complex and require very large scale studies for their solutions. Further progress in these areas will require the deployment of far greater resources than have yet been made available.

We note the publication by the American Institute of Medicine entitled Health Consequences of Service during the Persian Gulf War. It is clearly desirable that the UK keeps abreast of the findings of the extensive research programme in this area that is continuing in the USA."

Appendix 1