THE Critical Steps That Are NOW IN LIMBO For Gulf War Veterans
Next Steps
The symptoms of veterans suffering from Gulf War illnesses are subjective, and the causes, diagnoses, and treatments are elusive. Therefore, a guiding principle for this research program has always been that objective studies—verified by researchers at different institutions and replicated in representative and increasingly-large samples of veterans—are required to arrive at conclusions on which action can be based.
With this rigorous approach, the findings to date make us optimistic that this multi-perspective testing protocol might lead to objective diagnosis. If it continues to progress along these lines, the testing approach should prove useful for future clinical and research work in the following ways:
a.Developing an objective diagnostic testing protocol for clinical work and service connection.
b.Providing pathogenetically homogeneous groups for clinical trials so that promising treatments can be tested with far fewer participants, and thus with less time and cost.
In the next phase of the Neuroimaging and Biomarker Study beginning shortly, we are preparing to process through the successful brain imaging protocol at least 80 Gulf War veterans selected randomly from the National Survey of Gulf War-Era Veterans representing the three syndrome variants and well control veterans. The findings in this sample will examine the previously raised hypotheses about the nature of Gulf War illness in the larger population of Gulf War veterans—a vital step that is required before any of the prior findings can be considered strongly supported.
As far determining which neural mechanisms are in play, we have not analyzed the data sufficiently yet to favor one mechanism over others. We can state the following general working hypotheses about mechanisms:
a.Although we find evidence of abnormalities in both deep gray matter and white matter, primacy of the deep gray matter involvement seems likely (e.g., pain is not a symptom of primary diseases of white matter).
b.Deep gray matter abnormalities identified appear bilaterally asymmetrical.
c.White matter abnormality appears to involve myelin, rather than axonal, degeneration. If correct, this is optimistic for treatment; myelin may be more amenable than axonal damage.
Besides explaining the specific deficits, the mosaic of evidence points to certain general findings:
a.Structures activating during a task in well veterans often do not activate in sick veterans, but other structures do. This abnormal activation probably indicates the brain’s attempts to compensate for, or work around, damaged areas.
b.The brain in sick veterans appears to be hyper-aroused and hyper-responsive to stimuli.
1.The brain appears to be working overtime to overcome the many deficits.
2. Chronic fatigue may be due to the brain’s exhaustion from this overwork.
3.The emotional lability and hyper-reactivity may also be due to this overwork.
Next Steps
The symptoms of veterans suffering from Gulf War illnesses are subjective, and the causes, diagnoses, and treatments are elusive. Therefore, a guiding principle for this research program has always been that objective studies—verified by researchers at different institutions and replicated in representative and increasingly-large samples of veterans—are required to arrive at conclusions on which action can be based.
With this rigorous approach, the findings to date make us optimistic that this multi-perspective testing protocol might lead to objective diagnosis. If it continues to progress along these lines, the testing approach should prove useful for future clinical and research work in the following ways:
a.Developing an objective diagnostic testing protocol for clinical work and service connection.
b.Providing pathogenetically homogeneous groups for clinical trials so that promising treatments can be tested with far fewer participants, and thus with less time and cost.
In the next phase of the Neuroimaging and Biomarker Study beginning shortly, we are preparing to process through the successful brain imaging protocol at least 80 Gulf War veterans selected randomly from the National Survey of Gulf War-Era Veterans representing the three syndrome variants and well control veterans. The findings in this sample will examine the previously raised hypotheses about the nature of Gulf War illness in the larger population of Gulf War veterans—a vital step that is required before any of the prior findings can be considered strongly supported.
Division of Epidemiology and Preventive Medicine
The mission of the Epidemiology Division is primarily to perform research into the distribution, risk factors and pathophysiologic mechanisms of human diseases and to apply epidemiologic knowledge in preventing them.
Under the leadership of Dr. Robert Haley since its founding in 1983, the Division has focused on three disease categories: diseases of the nervous system (neuroepidemiology), infectious diseases, and cardiovascular diseases.
Research into the nervous system problems underlying illness in veterans of the 1991 Gulf War has led into extensive activities in brain scanning and laboratory investigations of neural mechanisms and genetic correlates, requiring specialized core facilities supporting these activities.
Research in infectious disease epidemiology originally focused on hospital-acquired (nosocomial) infections and has moved into developing responses to bioterrorist attacks and applying them at the local level through leadership in the Dallas County Medical Society.
Research in cardiovascular epidemiology has involved supporting the Cardiology Division in designing and implementing the Dallas Heart Study.
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Division of Epidemiology: Neuroepidemiology
Since 1994 the Division has been performing research on the nature, causes and pathophysiologic mechanisms of Gulf War syndrome, a neurologic condition that affects tens of thousands of veterans of the 1991 Gulf War.
This research has led to a quantitative description and definition of a new illness, epidemiologic links with low-level sarin nerve agent and other environmental exposures in the war, definition of a genetic predisposition from deficiency of paraoxonase and cholinesterase enzymes in the blood, and association with brain cell damage in deep brain structures underlying the symptoms.
In response to concerns of an excess incidence of ALS, or Lou Gehrig’s disease, by Gulf War veterans who developed the disease, the Division has performed an epidemiologic investigation to determine whether the number of ALS cases in young Gulf War veterans has exceeded the expected number.
To further research on brain involvement in Gulf War-related illnesses and related conditions, the Division has established a Neuroimaging Research Center and is conducting a nationwide survey of Gulf War-era veterans.
Dr. Haley serves on the VA Research Advisory Committee on Gulf War Veterans’ Illnesses which advises the Secretary of Veterans Affairs on directions for research on this problem.
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Division of Epidemiology: Infectious Disease Epidemiology
From its inception in 1983 the Division has performed extensive research on defining the problems and developing solutions to hospital-acquired (nosocomial) infections. This involved surveys in nationwide samples of U.S. hospitals studied in the Study on the Efficacy of Nosocomial Infection Control (SENIC Project). The results of this research has contributed to the scientific basis for using targeted surveillance techniques to reduce nosocomial infection risks in hospitals.
Starting in the early 1990s the Division has conducted a large study to define the modes of transmission of hepatitis C virus (HCV), which has become the largest chronic viral disease epidemic in U.S. history. The study has confirmed the causal role of injection drug use and defined the importance of HCV transmission in commercial tattoo parlors and to healthcare workers in hospitals.
Immediately after September 11, 2001, the Division focused research efforts on developing effective responses to bioterrorist attacks with microbiological agents such as anthrax, smallpox, plague and botulinum toxin. This is has led to coordinated planning for basic research in combating biowarfare pathogens, training physicians on recognition and treatment, and educating the public on responding effectively to bioterrorism attacks.
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Division of Epidemiology: Cardiovascular Epidemiology
The Division has assisted the Cardiology Division in designing and implementing the Dallas Heart Study, a population study of phenotypic and genotypic measurements to define the pathophysiology of heart diseases in a probability sample of the residents of Dallas County, Texas. A major emphasis of the study is to fill in gaps in understanding of why heart diseases are more frequent and cause greater mortality rates in black Americans.
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Division of Epidemiology: Gulf War Associated Illnesses
Dr. Robert Haley and colleagues at UT Southwestern have been conducting epidemiologic, clinical and laboratory research on the "Gulf War syndrome" and related neurologic illnesses in Gulf War veterans since March 1994. The work has been supported by a continuing grant from the Perot Foundation and by a cooperative agreement with the U.S. Department of Defense. The objectives of the research are to define new or unique clinical syndromes among Gulf War veterans, determine their causes, identify areas of damage or dysfunction in the brain and nervous system responsible for the symptoms, develop a cost-effective battery of clinical tests that can diagnose the illness, search for underlying genetic traits that might predispose to the illness, and perform clinical trials of promising treatments.
The initial studies identified three primary syndromes in a Naval reserve construction battalion (seabees) that appear to be unique, demonstrated that the syndromes are associated with subtle dysfunction of the brainstem and lower parts of the brain, and found epidemiologic associations between the syndromes and risk factors of exposure to combinations of chemicals in the Gulf War.
Genetic studies have identified a genetic trait (PON1 enzymes) that may explain why some soldiers sustained brain damage from exposure to neurotoxic chemicals while others working alongside them remained well. Most recently, research using magnetic resonance spectroscopy has demonstrated a loss of functioning brain cells in deep brain structures of ill Gulf War veterans. Additional commentaries by Dr. Haley have challenged the government’s stress theory of Gulf War syndrome and findings of no difference in mortality, hospitalization and birth defects between Gulf War-deployed and nondeployed military populations. Additional research and publications are in process.
1. A list of the papers published in peer-reviewed scientific journals.
2. Findings showing that there is a Gulf War syndrome, it is due to organic neurologic dysfunction, and it is associated with exposure to combinations of chemicals in the Gulf War.
3. Dr. Haley’s refutation of the stress theory of Gulf War illness.
4. Dr. Haley’s refutation of government research showing no increase in mortality, hospitalization, or birth defects in Gulf War veterans compared with the nondeployed military population
5. Findings on the genetic predisposition to Gulf War Syndrome.
6. Findings linking dizziness in Gulf War Veterans to subtle brain injury.
7. Findings on brain cell loss by magnetic resonance spectroscopy.
8. Findings on abnormal brain dopamine levels.
9. Stress does not cause pyridostigmine to enter the brain.
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Division of Epidemiology: Neuroimaging Research Center
The Division has established the Neuroimaging Research Center to bring to bear the most advanced brain scanning technology to understand the nature and distribution of brain injuries that underlie the Gulf War syndrome and similar diseases in the civilian population.
Directed by Dr. Richard Briggs, the Center features a 3 Tesla full bore human imaging magnet, housed in the Meadows MRI Center on the UT Southwestern campus near the General Clinical Research Center. This facility will be used for functional magnetic resonance imaging (MRI), MR spectroscopy, and the diffusion tensor imaging.
The Center will also conduct studies using other brain imaging technologies, such as positron emission tomography (PET) and single photon emission computed tomography (SPECT), and will correlate these results with those obtained from MR studies.
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Name: Robert Ware Haley, M.D.
Endowed Title: U.S. Armed Forces Veterans Distinguished Chair for Medical Research, Honoring Robert Haley, M.D. and America’s Gulf War Veterans
Academic Title: Professor
Primary Appointment: Internal Medicine – Epidemiology
Secondary Appointment: Clinical Sciences
School: Southwestern Medical School
Degree Program: Master of Public Health
Clinical Science
Clinical Research Scholar
Department Website: Internal Medicine Department/Division of Epidemiology and Preventive Medicine
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EDUCATION
1967 Southern Methodist University
BA Philosophy and Social Sciences
1971 University of Texas Southwestern Medical School, Dallas
M.D.
RESIDENCIES
1971 – 1973 Parkland Memorial Hospital/UT Southwestern Medical Center
Internal Medicine
1974 – 1976 U.S. Centers for Disease Control and Prevention, Atlanta
Preventive Medicine
FELLOWSHIPS
1973 – 1975 U.S. Public Health Service, CDC, Atlanta
Epidemic Intelligence Service
1981 National Institute for Occupational Safety and Health, CDC
Occupational Medicine
1982 American Management Associations
The Management Course
HONORS AND AWARDS
1971 Alpha Omega Alpha
A national medical honor society
1976 Commissioned Officer Commendation Medal
U.S. PHS award for research accomplishments at CDC
1994 Listed in The Best Doctors in America
Recognition based on a national poll of physicians
2000 Distinguished Alumni Award
Southern Methodist University
2004 Association of American Physicians
A society for the advancement of scientific and practical medicine
BOARD CERTIFICATIONS
Public Health and General Preventive Medicine by the American Board of Preventive Medicine
PROFESSIONAL ASSOCIATIONS / AFFILIATIONS
Fellow, American College of Epidemiology; Fellow, American College of Physicians
Member of the House of Delegates, Texas Medical Association
Past President, Member of the Board of Health, Dallas County Medical Society
Past President, Texas Club of Internists
Society for Epidemiologic Research ; Society of Healthcare Epidemiology of America
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