Defence and armed forces – guidance

Gulf veterans' illnesses

Find out about Gulf War Syndrome, research programmes, medical countermeasures and reports.

Gulf veterans’ illnesses issues remain important for the government. Our intention is to ensure that Gulf veterans receive appropriate support and recognition via healthcare services through the NHS and the MOD’s Medical Assessment Programme (MAP). The MAP has been moved to Chilwell and merged into the Veterans and Reserves Mental Health Programme. Financial assistance is provided through MOD War Pensions and Armed Forces occupation pension schemes.

In addition to the stresses associated with preparation for, and participation in, armed conflict, UK Service personnel in the 1990/1991 Gulf Conflict may potentially have experienced a number of health challenges, including those from terrain; endemic infections; climate; and the threat of chemical and biological warfare agents. In addition, there was unprecedented media interest and speculation in relation to all aspects of the campaign, including health issues.

We have always accepted that some 1990/1991 Gulf veterans have become ill and that this ill health may be related to their Gulf experience. Epidemiological research has shown that Gulf veterans report more illness than those who were not deployed to the Gulf, but the patterns of symptoms are similar to those experienced by personnel who did not deploy, and overall severity of the symptoms is not high.

History of UK Gulf veterans’ illnesses

Reports of ill health in UK veterans started to emerge in 1993 and the MOD established the Gulf Veterans’ Medical Assessment Programme (GVMAP) to help UK veterans who were concerned about their health.

The ill health reported by veterans covered a wide range of ailments that is similar between the different coalition countries involved in the 1990/1991 Gulf Conflict. No one cause was identified but a range of different exposures to chemical, biological or radiological hazards and medical countermeasures used to protect Servicemen and women were alleged as possible causes.

On 7 November 1995, the House of Commons Defence Committee published it’s first report on what it refers to as Gulf War Syndrome. In May 1996, following discussions with the MOD, the Medical Research Council (MRC) called for research proposals into Gulf veterans’ ill health from independent researchers.

In December 1996, the MOD released details about the vaccines used to counter the threat of Iraqi biological warfare agents used during the 1990/1991 Conflict (anthrax and plague and pertussis). The release addressed a major complaint about the lack of information provided by MOD.

In February 1997, the MOD’s Gulf Veterans’ Illnesses Unit (now DCDS(PERS) Pensions, Compensation & Veterans) was specifically formed to deal with the health and related personnel issues raised by veterans of the 1990/1991 Gulf Conflict. In July 1997, MOD published the “Gulf Veterans’ Illnesses: A New Beginning” document that sets out government policy on the issue and listed 20 key points on which specific action is to take place.

In 1999 and 2000, MOD published various papers on possible exposures from the 1990/1991 Gulf Conflict. Mortality data was published by the Manchester University on Gulf veterans for the first time and showed that veterans do not suffer any excess in overall mortality. In early 2001, MOD offered depleted uranium tests to veterans of the 1990/1991 Gulf Conflict and Bosnia.

The MRC published the results of their independent review of UK research into Gulf veterans’ ill health in May 2003. The MRC report stated that no evidence of a unique syndrome had been found in this country or aboard following research of troops deployed to the Gulf.

In January 2005, MOD published a paper which evaluated work undertaken by the US Department of Defense modelling the distribution of nerve agents released by US demolitions of Iraqi chemical weapons at the end of the 1990/1991 Gulf Conflict. The paper explained that the level of nerve agent released would have been too low to have any biologically detectable effect on UK troops and would have a minimal impact on health. The closest UK Force was some 130km from Khamisiyah.

In October 2005, a Pensions Appeal Tribunal in the case of a Gulf veteran reached the clear conclusion that Gulf War Syndrome does not exist as a discrete pathological entity but decided that the term should be used as an umbrella term for those conditions which are accepted as due to service and connected with the 1990/1991 Gulf conflict. The MOD welcomed the decision by the tribunal and in a statement on 24 November 2005 stated that it hoped that this would provide an element of closure for those who sought some acknowledge that their ill-health is connected to their Gulf service.

In July and October 2006, the MOD announced that final scientific papers relating to its Vaccines Interactions Research Programme had been published. These looked at the possible adverse health effects of the combination of vaccines and tablets given to troops to protect them against the threat of biological and chemical warfare. The overwhelming evidence from the programme was that the combination of vaccines and tablets that were offered to UK forces at the time of the 1990/1991 Gulf Conflict would not have had adverse health effects.

The independent Depleted Uranium Oversight Board published in March 2007 the results of a screening programme for veterans of the 1990/1991 Gulf Conflict and subsequent Balkans operations concerned about possible exposure to depleted uranium. A total of 496 applicants completed the test and no evidence of the excretion of depleted uranium was found in the urine of any of the test participants.

A Rehabilitation Research Study to support ill Gulf veterans began work in January 2009. The project’s objective was to develop a cost effective intervention taking account of physical, personal, psychological, social and occupational obstacles to recovery and better functioning in ill Gulf veterans. Phase 1 of the project involves working with international rehabilitation experts with military experience and Gulf veterans themselves to develop an intervention for exploratory trial (Phase 2).

UK position on Gulf War Syndrome

Whilst we acknowledge that the phrase “Gulf War Syndrome” has become quite widespread in popular usage, the overwhelming consensus of the scientific and medical community is that there are too many different symptoms reported for this ill health to be characterised as a syndrome in medical terms. The government was pleased to note that a Pensions Appeal Tribunal in 2005 supported our position on this issue.

The tribunal also stated that Gulf War Syndrome was a “useful umbrella term” to cover accepted conditions which are causally linked to the 1990/1991 Gulf Conflict. A Written Statement was published in the House of Commons on 24 November 2005 (Official Report, Column 128WS-129WS) welcoming this development. We hope that the use of the umbrella term will address the known concern of some Gulf veterans that we have not recognised a link between their ill-health and the 1990/1991 Gulf Conflict. We hope that this will help to provide an element of closure for those who have sought some acknowledgment that their ill-health is connected to their Gulf service.

The umbrella term is considered routinely when a claim for Gulf War Syndrome, Gulf War illness or a similar claimed condition is received. Any resultant decision to apply, or not apply, the term to any accepted disablement carries a right of appeal to the First-tier Tribunal, War Pensions and Armed Forces Compensation Chamber.

Medical countermeasures

Coalition nations involved in the 1990/1991 Gulf Conflict faced the possibility that Iraq might use weapons of mass destruction at its disposal against them. The attraction of such weapons for Iraq was their potential to inflict massive casualties upon any forces opposing its regional ambitions.

The UK embarked on a programme to provide the best available means of protection for British Service personnel deployed to the Gulf against the specific and highly lethal agents which Iraq was believed to possess. This included a programme of immunisation that was classified at the time. Details about the immunisation programme were released in December 1996.

The lack of information on the immunisation programme following the conflict and MOD’s acknowledgement that poor medical record-keeping during and after the Gulf Conflict meant that many veterans were unclear what anti-biological warfare agents immunisations they received in 1990/1991. To address the lack of information available to veterans the MOD undertook to provide as much factual information as possible.

On 28 October 1997, the MOD published a paper entitled: ‘Background to the use of Medical Countermeasures to protect British Forces during the Gulf War (Operation Granby)’. This paper discussed the background to the use of medical countermeasures not only in terms of the scientific issues involved, but also of procurement and other matters which were raised by Gulf veterans.

On 20 January 2000, the MOD published a report called: ‘Implementation of the Immunisation Programme against Biological Warfare Agents for UK Forces during the Gulf Conflict 1990/91’. The report confirms that no unusual or previously undisclosed immunisations were given during the Gulf conflict and also demystifies the codewords which were sometimes used for the vaccines.

British troops were given a pre-treatment regime of Nerve Agent Pre-treatment Set (NAPS) tablets during the conflict and both documents contain details about the precautions taken against nerve agent poisoning.

In July and October 2006, the MOD announced that final scientific papers relating to its Vaccines Interactions Research Programme had been published. These looked at the possible adverse health effects of the combination of vaccines and tablets given to troops to protect them against the threat of biological and chemical warfare. The overwhelming evidence from the programme is that the combination of vaccines and tablets that were offered to UK Forces at the time of the 1990/1991 would not have had adverse health effects.

Lessons identified from the 1990/1991 Gulf Conflict

As part of our commitment to investigate 1990/1991 Gulf veterans’ illnesses issues openly and honestly and to learn the lessons of the past, the MOD published the paper ‘The 1990/1991 Gulf Conflict Health and Personnel Related Lessons Identified’ in November 2004.

The purpose of the paper is to focus on the health and personnel related issues resulting from the 1990/1991 Gulf Conflict, with the key aim of learning from the problems identified. In producing the paper, we attempted to be as open and forthright as possible in examining the health problems experienced by serving personnel, veterans and civilians since the conflict.

The paper identified what the MOD had already done to improve procedures and assesses how these have been applied to the Iraq deployment (Operation Telic). In making these assessments it has been acknowledged that during operations it is not always possible to achieve the ideal situation; inevitably, in the heat of battle there will always be some things that do not go as intended.

The aim of this paper was not to seek to attribute blame but to identify how the MOD can do better in future.

The Vaccines Interactions Research Programme

1990/1991 Gulf veterans’ illnesses

A central principle of the MOD’s approach to addressing the health concerns of veterans of the 1990/1991 Gulf Conflict has been that there should be appropriate research into veterans’ illnesses and factors that may have a bearing on these.

As a key part of that research, the MOD sponsored a Vaccines Interactions Research Programme into the possible adverse health effects of the combination of vaccines and tablets given to troops to protect them against the threat of biological and chemical warfare. The programme, which was overseen by an independent panel of experts and veterans representatives, consisted of 3 main studies. The first examined the interaction of certain vaccines in mice. The findings were reported in 2005 in the journal ‘Human Vaccines’.

The second, and main, study was undertaken at Dstl Porton Down and involved monitoring marmosets for up to 18 months following the administration of vaccines and/or pyridostigmine bromide (the active ingredient in Nerve Agent Pre-treatment tablets). Partial results from the study, covering cognition, muscle function, general health and sleep, were published in July 2006 in the journal Pharmacology, Biochemistry and Behaviour. Papers reporting the key final results on the immunological aspects of the study were published online in the journal International Immunopharmocology.

The papers report that the immune system had not been compromised by any of the treatments given and that there was no evidence of adverse health effects due to the administration of vaccines and/or pyridostigmine bromide. The study findings have been independently endorsed. Donald Davies, Emeritus Professor in Toxicology Imperial College London, who chaired the independent group which oversaw the study, said: “This study has addressed a valid question in experiments that were well designed and conducted. I have discussed the results with expert immunologists from the group and we support the conclusion that the animals suffered no adverse health effect, despite exposure to exaggerated doses of vaccines.”

The final study examined whether staff from Dstl Porton Down who received multiple vaccinations during their employment had higher levels of sick leave than their unvaccinated colleagues. The findings show that staff at Porton Down who had received multiple vaccinations suffered no excess sick absence.

The overwhelming evidence from the programme is that the combination of vaccines and tablets that were offered to UK Forces at the time of the 1990/1991 Gulf Conflict would not have had adverse health effects. This has been a key area of concern among Gulf veterans and the results of the research should be reassuring to those veterans who have been concerned about the safety of the medical countermeasures that they were given. We hope too that it will reinforce confidence in the countermeasures that are offered today and in the future.

Medical countermeasures

Coalition nations involved in the 1990/1991 Gulf Conflict faced the possibility that Iraq might use weapons of mass destruction at its disposal against them. The attraction of such weapons for Iraq was their potential to inflict massive casualties upon any forces opposing its regional ambitions.

The UK embarked on a programme to provide the best available means of protection for British Service personnel deployed to the Gulf against the specific and highly lethal agents which Iraq was believed to possess. This included a programme of immunisation that was classified at the time. Details about the immunisation programme were released in December 1996.

The lack of information on the immunisation programme following the conflict and MOD’s acknowledgement that poor medical record keeping during and after the Gulf Conflict meant that many veterans were unclear what anti-biological warfare agents immunisations they received in 1990/1991. To address the lack of information available to veterans the MOD undertook to provide as much factual information as possible.

On 28 October 1997, the MOD published a paper entitled: ‘Background to the use of Medical Countermeasures to protect British Forces during the Gulf War (Operation Granby)’. This paper discussed the background to the use of medical countermeasures not only in terms of the scientific issues involved, but also of procurement and other matters which were raised by Gulf veterans.

On 20 January 2000, the MOD published a report called: ‘Implementation of the Immunisation Programme against Biological Warfare Agents for UK Forces during the Gulf Conflict 1990/91’. The report confirms that no unusual or previously undisclosed immunisations were given during the Gulf conflict and also demystifies the codewords which were sometimes used for the vaccines.

British troops were given a pre-treatment regime of Nerve Agent Pre-treatment Set (NAPS) tablets during the conflict and both documents contain details about the precautions taken against nerve agent poisoning.

In July and October 2006, the MOD announced that final scientific papers relating to its Vaccines Interactions Research Programme had been published. These looked at the possible adverse health effects of the combination of vaccines and tablets given to troops to protect them against the threat of biological and chemical warfare. The overwhelming evidence from the programme is that the combination of vaccines and tablets that were offered to UK Forces at the time of the 1990/1991 would not have had adverse health effects.

United States Institute of Medicine report

The Institute of Medicine (IOM) published its report ‘Gulf War & Health Volume 8: Update of health effects of serving in the Gulf War’ in April 2010.

The MOD is aware that some UK Gulf veterans are interested in the IOM findings as the report comments on an earlier report published by the US Research Advisory Committee on Gulf Veterans’ Illnesses published in November 2008. A note was therefore prepared for the Central Advisory Committee on Pensions and Compensation, available below.

Gulf War & Health Volume 8 - Update of Health Effects of Serving in the Gulf War

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Sickness absence of multi-vaccinated employees at Porton Down

Details of a retrospective cohort study into the sickness absence of staff at Porton Down who were multi-vaccinated.

Objective

To establish whether multiple vaccinations in DSTL Porton Down staff were associated with an excess of sickness absence and possible adverse health effects.

Methods

A retrospective cohort study of employees at DSTL Porton Down (a U.K. Ministry of Defence research establishment), using records covering a 2-38 year period and held in the Occupational Health and Personnel Departments. The study involved 118 civilian staff at DSTL Porton Down who had been vaccinated against 4 or more diseases during their adult lives. The study included 89% of multi-vaccinated staff. Most individuals received 5 different vaccines, while 7 received 10 or more. Only very rarely was more than 1 vaccine given on the same day to any individual. A matched contemporary control group of 212 employees was used for comparison. All absence from work attributed to sickness during the period the subjects were employed at DSTL Porton Down was recorded.

Results

Mean annual sick leave was 3.4 days for the multi-vaccinated group and 4.3 days for the controls (medians 1.4 and 2.1 days respectively). This compares to a mean of 7 days for all DSTL employees during a single 12-month period (April 1998 to March 1999).

Conclusions

No excess sickness absence occurred amongst DSTL staff vaccinated against 4 or more diseases, compared to a matched control group. Sickness absence rates did not increase as a function of the number of diseases vaccinated against or the length of employment and thus the total number of vaccinations.

A study into the health and wellbeing of the UK Armed Forces

This study was conducted by Professors Simon Wessely and Christopher Dandeker of the King’s Centre for Military Health Research (KCMHR).

Phase 1 (2003-2006)

In 2003 the Ministry of Defence commissioned the KCMHR to conduct a study on the health and wellbeing of UK Armed Forces personnel. The study included personnel from all 3 Services, regulars and reservists, deployed and non-deployed personnel, and those who have left Service since the study began. Phase 1 of the study aimed to (1) monitor the physical and psychological health of those who served in Iraq (Operation Telic), and (2) more generally look at experiences of personnel as they progressed through their military careers and afterwards when they had returned to civilian life.

Phase 1 found no evidence of ill-health in regular personnel as a result of serving in Iraq, although it did report some evidence for a health effect in reservists. As a result a number of initiatives were put in place aimed at improving the mental health of regulars and reserves both during and post deployment.

Phase 2 (2007-2010)

In 2006 the MOD commissioned a 3-year extension to the study so that any emerging trends could be detected. The scope of the research was also broadened to include the health of personnel who serve on Op Herrick, the current UK military operation in Afghanistan. By the end of Phase 2 the study included over 20,000 service and ex-service personnel.

The phase 2 study findings showed that overall the physical and mental health of the UK Armed Forces remains stable. It also confirmed the continuing low incidence rates of probable PTSD (4%) for the UK Armed Forces which are similar to rates in the UK general population (3-7%).

Phase 3 (2010-2013)

A further 3-year extension to this study has been put in place to enable continued reporting on the health and wellbeing of the study group.

The study is funded by the Ministry of Defence as part of its duty of care to serving personnel and in response to lessons learned from the 1990/91 Gulf conflict. The MOD fully supports the research. However, KCMHR is an independent academic research team based at King’s College London. The information provided by participants remains completely confidential.