Gulf War Syndrome - Case Notes

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Author - John Shepherd (Fall 1997)

Teaching Notes I used this as an extended over 5 class days. I thought there was a payoff in doing the case slowly since it forced us to consider issues in detail that we would have passed over in a quick treatment. The case could be done more quickly as I suggest below.

A shorter version of this case could also be done. In a couple of class period, the students could read the articles marked by an asterisk in the reading list. They would not see any of the primary literature, but they would read summaries of it in the editorials.

DAY 1 ASSIGNED READING was posted to our web page as follows:

On Tuesday, November 18, we will start a study of the Gulf War Syndrome. To do that, read the following two articles:

• First, read these Selected Testimonies, which are excerpts from congressional hearings in which Gulf War veterans told of their experiences.
• Second, read this lecture by Joyce Riley, a nurse who interprets the situation for a general audience.

Based on the information in these two readings, decide for yourself:

1. What should be done, if anything, for these military personnel?
2. Why are some people resistant to helping these veterans?
3. What role can science play on this issue?

DAY 1 CLASS DISCUSSION At the start of class, the class discussed their general responses to the issue raised and a few gave accounts of friends or relatives who had been to Desert Storm. Then I asked them to identify each of the participants in the issue and to consider how they were related: US government, Allied governments, veterans, military establishment, media, medical establishment, general public, etc. We talked about the different motivations of some of these groups. Then I asked them to talk about where science could play a role in these interactions. We stumbled for a while (I had to remind them to expect ‘science’ in "Political Science."

DAY 2 ASSIGNED READING was posted to the web page as follows:

On Thursday November 20, we will continue our discussion of the Gulf War Syndrome. First we will look at two articles that examine the political process that has surrounded the treatment of this issue in the media and in our government. As you read each of the articles examine the 'facts' and the 'conclusion' drawn from the facts. Are the facts supported by data (evidence)? Is the evidence reliable (consensible and consensual)? Do the conclusions follow inevitably from the facts (observations)? Are we required to make assumptions in reaching the conclusions? If so, what are the assumptions and are they reasonable?

• Lindsey Arison. The Cover-Up of Gulf War Syndrome: A Question of National Integrity. argues that the evidence for GWS is compelling and examines the motives of the government in covering up this problem. In this article, you need to read sections 1 -4 (Facts, Conclusions, Reasons, and Bottom Line). The later section repeats a reading you have already done.
• James Tuite was a congressional researcher for Don Riegle, the congressman who reported Gulf War chemical and biological exposures in the House of Representatives. His article "When Science and Politics Collide" suggests that good scientific analysis is being subverted by politics.

DAY 2 CLASS DISCUSSION

Review: observations, conclusions, assumptions, facts, assertions, and deduction

• OBS: carbon dioxide concentration in the atmosphere is increasing
• OBS: carbon dioxide tends to trap heat in the atmosphere
• DEDUCTION: earth temperatures will become warmer
• ASSUMPTION: trends? Counterbalancing factors?

In Chapter 6.4 ("How much can be believed?") Ziman talks about the necessity of relying on authorities. In 5.6 ("Objectivity and Doubt") Ziman discusses the sceptical attitude of the sciences. We compared this to cynicism to skepticism

• Review: skepticism, cynicism I gullibility
• Skeptical perspective: "Show me the logic/evidence, then I’ll believe it."
• Cynical perspective: "You can believe anything they say."
• Gullible perspective: "It sounds reasonable to me."

Differences in Riley article with these two: these are clearer and less ambiguous, less bombast (more consensible Y more believable)

Focus on the Arison article in groups. Analyze his argument: What happened? What are the "facts"? Is his conclusion justified? How do his "Reasons for the Cover-Up" support/affect the believability of his conclusion?

DAY 3 ASSIGNED READING was posted to the web page as follows:

On Tuesday, November 25, we will talk about the following articles:

• Edward Campion. 1996. Disease and Suspicion after the Persian Gulf War. New England Journal of Medicine. 335(20): 1525-1527. This editorial discusses the results of the next two papers, which are from the same issue. I suggest that you read this one first. When you read the next articles, read the abstract first, then look through the results section and read the discussion. Look for the presentation of the information leading to the summary statements in this editorial by Campion.
• Han Kang & Tim Bullman. 1996. Mortality among US Veterans of the Persian Gulf War. New England Journal of Medicine. 335(20): 1498-1504.
• Gregory Gary et al. 1996. The Postwar Hospitalization Experience of U.S. Veterans of the Persian Gulf War. New England Journal of Medicine. 335(20): 1504-1513.
• Michael Fumento. 1996. How media and lawyers stir up false illness.

The first 3 articles are available in the Mercer School of Medicine. As you enter the School of Medicine from the College Street side, the library is on the left side of the lobby. When you enter the library, the journals are arranged alphabetically in the stacks to your left. NEJM is close to the back of that row of stacks. There is a bound issue that contains these articles, and one unbound copy. You may sit and read the articles in the library or you may make a copy of the article with your Bear Card. If you can't find the issue you need in the stacks, look on the re-shelving cart next to the copy machines. Please be a good citizen as you represent CLA in the Medical School.

DAY 3 CLASS DISCUSSION

This was the last class before Thanksgiving and there was minimal enthusiasm for a discussion. We talk some about the structure of the studies that were to have read. Asking them to go read at the Med School library, cut the number of people who came prepared by about 50%. We talked as a whole class about the Fumento article and this could be usefully expanded in several ways.

DAY 4 ASSIGNED READING was posted to the web page as follows:

On Tuesday, December 2, we will talk about another set of studies from medical science that try to document details of Gulf War Illness. I have made short excerpts of these articles available here and an editorial that summarizes them is on reserve.. An article from the Washington Post, and a set of letters from JAMA, are variously critical and supportive of the results of these studies. After these readings, you willhave a substantial set of partially conflicting information about the nature of Gulf War Illness. Now what do we do? How can we reconcile the differences in the results of these studies? As you look through these materials, try to identify the key arguments each one is making and try to assess the validity of the argument. In class we will try sort the different points of view and set the stage for our final class meeting (Thursday) on GWS.

• Landrigan, Philip. 1997. Illness in Gulf War Veterans: causes and consequences. JAMA 277(3):259-261. This editorial summarizes the results of the four research articles and tries to put them in a general context. This is the best place to start. This is on reserve in the Main Library.
• Excerpts from Gulf War studies published in January 1997. I have put copies of the abstracts of four research articles here for you to look at.
• $3 Million Study of Gulf War Illnesses Criticized
• Letter to the editor of JAMA in August 1997. {These are on reserve in the main library.}

DAY 4 CLASS WORK

Students were assigned to one of 5 groups as described in the following post to the class web page. They were then given the class period to examine materials they had and find new ones on the web from links provided below.

On Thursday, December 4, we will hold congressional hearings on what to do about the Gulf War veterans and the Gulf war syndrome. Your assignment is to represent the position assigned to you, regardless of your personal opinions on the matter. You may choose to assign different individual roles to the people in your group. Come to class prepared to argue persuasively from that perspective. Bring a typed, half-page summary of your position to class; this will help you prepare and I will collect these. We will hear testimony from the following groups:

• Congressional Politicians (Shannon, Maggie, Charles, Leigh Ann) are divided between liberal and conservative perspectives. They must decide what congress should do, if anything. First consider the differences you might expect between liberal and conservative perspectives, then find out how these differences are played out in the political arena. You might start by look at the US Senate Committee on Veterans' Affairs testimony on this issue and the Gulf War Veterans Hall of Shame.
• Department of Defense (Laura, Jennifer, Ryan, Arshron) feels it acted responsibly in Desert Storm. Patriotism and service should be honored, but hysteria should not be rewarded, especially if it requires that the DoD accept responsibility for things that didn’t happen. Find out what specifically DoD has done "to get to the bottom of this issue." Be prepared to defend DoD against the criticisms that you have sold out vets and that you have deloberately covered up the dangers that faced troops in Desert Storm. Norman Schwartzkopf and officials from the CIA and Department of Defense testified before the US Senate Committee on Veterans' Affairs.
• Gulf War Veterans (Dione, Ana I., Anita, Jada) feel they served, they are sick, therefore they should be honored and taken care of. You might look at the Gulf War Veterans Resource page and the American Gulf War Veterans Association page.
• NIH Science Advisory Panel (Carrie, Nikia, Sheree, Brandon, Rachel) must interpret the results of studies in medical science to the other groups. You feel that science can decide what illness is Gulf-War-related (and compensible), and what is not. Examine in detail the editorials, letters, and studies from NJEM and JAMA as your resources.
• Citizens for Responsible Government (Romedro, Alexia, Patrick, Anna H) is a new non-profit group that thinks government should resist pressure from vets for a payoff out of public funds. You might look at the Gulf War Skeptic’s page and consider the arguments likely to be presented by the veterans themselves.

DAY 5 CLASS DISCUSSION

Students sat together in the 5 groups described above. I started by asking the veterans and DoD to make introductory comments and then drew in the other groups. The class period went very quickly once they people started to chime in. At the end of the class period, I tried to draw things to a close by talking about places "science" had been used, and places science had been more or less ignored. The students did very well in defending their assigned roles and we did discuss most of the important issues.