Memorandum submitted by the Ministry of
Defence
1. The House of Commons Defence Committee
has asked the Ministry of Defence to comment on the document "Memorandum
Concerning Gulf Veterans' Illnesses" given in evidence to
the Committee by the Gulf Veterans' Association Scientific Adviser
Prof Malcolm Hooper PhD, B.Pharm, CChem, MRIC, Emeritus Professor
of Medicinal Chemistry, on 15 December 1999.
2. In order to assist the Committee, the
Ministry of Defence has prepared this outline response. In the
time which the Committee has allowed us it has not been possible
to address all the issues raised in Professor Hooper's long memorandum,
nor to refer to all of his sources. Failure to address particular
points of Professor Hooper's memorandum does not imply that the
Ministry of Defence agrees with or accepts them. We observe that
Professor Hooper's memorandum is often dismissive of, or hostile
to the Ministry of Defence and its positions on Gulf Veterans'
Illnesses. We therefore strongly recommend that the Committee
also seek independent scientific and medical opinions from reputable
authorities on the robustness of Professor Hooper's arguments
and analysis.
OVERVIEW
3. Overall, the Ministry of Defence does
not feel that Professor Hooper's memorandum gives a comprehensive
or balanced view of the outcome of medical and scientific and
historical research on, or related to, Gulf Veterans' Illnesses.
We have noted his reliance on references which include not only
peer reviewed scientific papers, but also unreviewed information
posted on the internet, media and other secondary sources, and
unsupported individual opinion or purely anecdotal evidence. The
Ministry of Defence believes it can be very misleading to cite
such reports or opinions as facts. There are many examples in
the memorandum of the use of inappropriate and journalistic language,
which would not be acceptable in a scientific paper.
4. The evidence for or against the likelihood
of any given exposure having occurred is not reviewed, and some
claims are not referenced at all, for example detection of lewisite.
Professor Hooper makes no attempt to distinguish between the relative
importance of the potential exposures. The memorandum persistently
confuses and compounds the alleged exposures of British and United
States veterans, which produces an exaggerated and misleading
picture of the distinctive exposures each may have had. Looking
at research, Professor Hooper deals in only the most cursory terms
with the contribution of epidemiological studies, yet both the
US and UK approach to Gulf Veterans' Illnesses research has placed
epidemiology at the core of the research effort. This approach
was recommended by eminent independent bodies, in the case of
the UK the Royal College of Physicians and the Medical Research
Council, in the case of the US by the National Academy of Sciences
Institute of Medicine. It was also endorsed by the previous Select
Committee(Eleventh Report, 1994-95).
THE NERVOUS
SYSTEM AND
PYRIDOSTIGMINE BROMIDE
(PB)
5. Professor Hooper's outline of the mechanism
of the blood-brain barrier and the interaction between the nervous,
immune and endocrine systems is dealt with in a very simplistic
manner, and not well referenced. Scientists are only just beginning
to gather information which hints at the interaction between nervous,
endocrine and immune systems, and evidence for a direct action
of acetylcholine on the immune system which results in well-defined
clinical abnormalities does not yet exist. There is also considerable
debate about what constitutes the blood-brain barrier. Professor
Hooper gives the impression that this is purely an anatomical
barrier, but this is an oversimplification. He continues by stating
that veterans show damage in their nervous, endocrine and immune
systems, and links this to chemical and biological insults. This
is misleading. Firstly, not all veterans report the same symptoms.
The variety of symptoms and the fact that few are common to all
veterans is a striking feature of Gulf Veterans' Illnesses. Secondly
the number of ill UK veterans seen at the Ministry of Defence's
Medical Assessment Programme who report symptoms indicative of
possible dysfunction in all three of the nervous, endocrine and
immune systems is extremely small.
6. Professor Hooper criticises with emphasis
the strategy of using PB in the Gulf in the following terms: "This
was completely new territory. No experimental data from human
studies were available. The strategy was unproven. The use of
PB would be experimental. The troops would be used as guinea pigs."
However, Professor Hooper himself refers to the long experience
with PB as a treatment for myasthenia gravis. In its paper "Background
to the use of medical countermeasures to protect British forces
during the Gulf War (Operation Granby)" published in October
1997 MOD detailed (paragraphs 135-140) the human studies on PB
as a nerve agent pre-treatment undertaken at Porton Down from
1972. The October 1997 paper also gives the history of licensing
PB. This process began in 1980, but was delayed. Although NAPS
was unlicensed at the time of the Gulf, it cannot be described
as "experimental". NAPS received its licence from the
Medicines Control Agency in August 1993 on the basis of the same
data that existed at the time of the Gulf conflict. This data
included the unpublished results of the human studies at Porton
Down.
7. Professor Hooper asserts that the underlying
strategy for PB was fatally flawed, in that if PB cannot cross
the blood-brain barrier troops will die from the effects of nerve
agent poisoning on the central nervous system. The Ministry of
Defence disagrees. The UK's medical countermeasures comprise both
pre-treatment (PB) and immediate treatment in case of attack consisting
of atropine sulphate, pralidoxime mesylate (P2S) and avizafone.
In animal based studies designed to optimise extrapolation to
man the effectiveness of this combination has been clearly demonstrated.
It preserves life following poisoning by a range of nerve agents.
Its acceptability and practicability have been demonstrated in
human volunteer studies and bothpre- and immediate treatments
are fully licensed.
8. Neither PB nor P2S cross into the central
nervous system in significant amounts, but their actions on the
peripheral nervous system are vital in maintaining both life and
function. PB protects sufficient acetylcholinesterase to ensure
adequate electrical transmission between the peripheral nerves,
muscles and other organs. In particular it helps maintain adequate
function in muscles concerned with breathing. P2S is important
in the peripheral nervous system by reactivating acetylcholinesterase
inhibited by some nerve agents. Atropine and avizafone (metabolised
into diazepam) both readily cross the blood-brain barrier. Atropine
helps counteract the central effects of the excessive amounts
of acetylcholine that result from inhibiting central acetylcholinesterase.
Diazepam helps control the convulsions induced by nerve agents.
Overall protection thus depends on a combination of drugs, some
acting peripherally, and some centrally. The Ministry of Defence
acknowledges that there is scope for improving on the existing
protection, and research is continuing at CBD Porton Down to identify
improved pre-treatments which can further protect the central
nervous system.
9. Professor Hooper states, without evidence,
that the enzymes required to convert avizafone into diazepam in
the blood "would almost certainly be inhibited by nerve agents.
This casts serious doubt about the protective properties of this
drug under battlefield conditions." In fact the enzyme responsible
for the conversion of avizafone to active diazepam in the plasma
is an aminopeptidase of the C-esterase type. The pharmacokinetics
of this enzyme have been fully elucidated in a number of mammalian
species, and the effect of a number of possible inhibitors of
the enzyme investigated. The enzyme is not inhibited by cholinesterase
inhibitors such a nerve agents—see M P Maidment and D G
Upshall, Journal of Biopharmaceutical Sciences 1(1); 19-32,
1990, and D G Upshall et al Journal of Biopharmaceutical Sciences
1(2); 111-126, 1990.
10. Professor Hooper quotes selectively
from the RAND report on PB which considers seven hypotheses of
how PB might be the cause of illness in Gulf veterans. However,
he fails to mention that although only one of the hypotheses is
ruled out, the author quite clearly states at the beginning of
the report that "If sufficient evidence cannot be marshalled
to rule out a hypothesis, this does not imply that it is necessarily
a casual factor, only that the possibility cannot be dismissed."
The underlying message of this RAND report is not that PB is proved
to be a cause of ill health, but that further research is required.
VACCINATIONS
11. The eleven vaccines listed in the second
paragraph of the section on vaccinations in Professor Hooper's
memorandum is the correct list for immunisations given to UK troops
at the time of the Gulf conflict. He has contradicted his Preface
where he states "UK troops were exposed to the following
hazards . . . Mass Vaccinations . . . vaccines designed to counter
anthrax plague and botulism" (our emphasis). UK troops
were not vaccinated against botulism, nor was the botulinum anti-toxoid
that was available in the Gulf as apost-attack treatment ever
given, because there was no biological warfare attack.
12. Professor Hooper has substantially exaggerated
the probable number of immunisations for most UK troops by saying
"it is generally admitted by MOD that each soldier received
up to 10 different vaccines." The Ministry of Defence's paper
on "Implementation of the Immunisation Programme against
Biological Warfare Agents for UK Forces during the Gulf Conflict
1990-91", published on 20 January 2000, confirms (paragraphs
179-182) that most regular teeth-arm troops would probably have
had around four vaccines. Only troops all of whose routine public
health immunisations had fallen out of date, and who were working
in specialist medical or food handling jobs could have had as
many as 10 or 11 vaccines. The Ministry of Defence paper also
states that the highest number of immunisations in one day discovered
in the records reviewed was seven. The extant Department of Health
guidelines on the simultaneous administration of vaccines, and
of live vaccines, were followed.
13. The effects of possible interactions
between this combination of vaccines, together with PB, is being
investigated in the programme of research at CBD Sector Porton
Down which is overseen by the Independent Panel, on which Professor
Hooper sits as the representative of Gulf veterans. (A list of
panel members is attached at Annex A[11]).
This work will include re-visiting the experiment in mice at the
National Institute for Biological Standards and Control which
was the cause of the Department of Health's fax to the Ministry
of Defence on 21 December 1991. The background to the decision
to use pertussis as an adjuvant to anthrax vaccine, and the discussions
between the Ministry of Defence and the Department of Health are
detailed in paragraphs 50 to 73 of the paper "Background
to the use of Medical Countermeasures to Protect British Forces
during the Gulf War (Operation Granby)", which was published
in October 1997.
14. The present evidence for health effects
arising in Gulf veterans as a result vaccinations is scant. Professor
Hooper is correct to say that Unwin et al, Lancet, January 1999
found an association between incidence of self-reported symptoms
and antibiological warfare vaccines, as well as multiple vaccinations.
However, he fails to point out that they also found associations,
in most cases still stronger, with a variety of other exposures.
The Ministry of Defence looks forward to further work on the association
between ill health and vaccines which is expected to emerge from
King's College shortly.
15. Professor Hooper claims that many Gulf
veterans show a pattern of illness featuring active Epstein-Barr
virus infection, and autoimmune diseases, as a consequence of
compressed multi-vaccine administration. For UK Gulf veterans
this claim cannot be substantiated, since only some 6 per cent
of all Gulf veterans have been to the Medical Assessment Programme,
and there are no other comprehensive or centralised clinical data
available on the incidence of such conditions in British veterans,
nor any published research. As far as the now substantial cohort
of 2,900 who have been assessed at the MAP is concerned, all undergo
extensive tests of the immune system including immunoglobulins,
serum protein electrophoresis and full white cell count. There
is no evidence whatever of immune disorders of the types listed
by Professor Hooper occurring in these Gulf veterans at rates
higher than those routinely encountered in the general population.
UNDISCLOSED ADDITIONAL
VACCINES
16. Professor Hooper's belief in the existence
of additional undisclosed vaccines is well known to the Ministry
of Defence. When he raised this at a meeting of the Independent
Panel in March 1999, the true position was explained to him and
he was invited by the Ministry of Defence, a total of four times
in writing, to provide the evidence which he claimed to have for
additional vaccines. No such evidence was forthcoming. In the
light of this the Ministry of Defence finds it extraordinary that
he re-iterates these suggestions on the basis of such specious
argumentation in evidence to the Committee. If there is real documentary
evidence to back any of these claims then the Ministry of Defence
would be very keen to evaluate it. The work of the team examining
implementation of the anti-biological warfare programme gave a
further opportunity for the Ministry of Defence to evaluate all
the available evidence. The findings are at paragraphs 204 to
208 of the paper published on 20 January 2000. We found no evidence
of the issue of smallpox, tulareamia or any other vaccine not
already declared by the MOD. Once again for the record, the
Ministry of Defence states that the 1990-91 anti-biological warfare
immunisation programme for Operation Granby consisted of anthrax,
plague, and pertussis as an adjuvant, and nothing else.
CURRENT VACCINES
AND VACCINE
RESEARCH
17. Professor Hooper makes a categoric statement
that "It is clear from research in the United States that
the present anthrax vaccine is unproven as an effective treatment
for soldiers exposed to aerosolised spores that would be inhaled."
The research quoted refers to work on the US, not the UK, anthrax
vaccine, in guinea pigs. It takes no account of a range of work
in non-human primates that shows greater levels of protection
and is likely to bear a closer relation to human immune response.
It is clearly impossible to test the efficacy of anthrax vaccine
in humans by exposing them to the live organism. However, we and
our expert independent advisers believe that the vaccine is an
effective form of protection and greatly increases the chance
of surviving exposure to anthrax.
18. Professor Hooper further states: "Both
anthrax and pertussis are known to induce autoimmune diseases,
Nass 1999, 1998." In fact the documents cited by Professor
Hooper in support of this statement do not say that anthrax and
petussis vaccines are know to induce autoimmune diseases, and
nor are we aware of any other evidence which would support this
assertion. The anthrax vaccine used during the Gulf conflict,
and between March and November 1998 was fully licensed by the
Medicines Control Agency (MCA), and has been repeatedly tested
for potency and toxicity. We made clear to personnel offered the
vaccine in 1998 that it was originally produced in 1991 with an
initial licensed shelf life of two years, but that it had been
fully safety tested in 1998 and re-licensed by the MCA until November
1998.
19. Professor Hooper goes on to discuss
the development of new plague vaccine. Development work at CBD
Porton Down did not start until after the Gulf war. It thus has
no bearing on Gulf veterans' illnesses or the work of the Independent
Panel (see paragraph 36 below). Various papers on its development
have been published over a number of years in the open scientific
literature. Professor Hooper is quite wrong to suggest that this
plague vaccine, or any other vaccine that we are developing, has
been given to UK armed forces on an experimental basis. We expect
to start clinical trials with the plague vaccine later this year.
These will be carried out according to the same stringent controls
that apply to all pharmaceutical products in development. We do
not "experiment" on troops with "untested"
vaccines.
PESTICIDES AND
DEET
20. Professor Hooper repeatedly uses the
word "excessive" to describe pesticide exposure, without
explaining what he means. He also draws on a series of individual
anecdotal sources to construct a lurid picture of a pesticide
swamped battlefield. The apparent confusion of American and British
experiences is particularly distorting in this respect. UK forces,
for example, did not use any organochlorine insecticides, eg Lindane.
The Organophosphate Pesticide Investigation Team (OPPIT) report,
published by the Ministry of Defence in December 1996, gave a
detailed account of UK pesticide policy and usage. The OPPIT report
details, so far as surviving records and memory permitted, the
types of pesticides used and the way in which they were applied.
The findings were that pesticides were applied by trained Environmental
Health personnel, generally in accordance with the proper procedures
(although there was evidence of a few personnel not wearing personal
protective equipment in all cases, and suggestions that it was
not always available), and in accordance with the directions for
use and safety data sheets. One unidentified pesticide, possibly
an organophosphate, may have been used for a very limited period
in small quantities. The OPPIT report does not include evidence
of excessive or inappropriate application of pesticides.
21. The health effects of organophosphate
pesticides have been extensively reviewed in recent work, most
notably by the Institute of Occupational Medicine (IOM) and the
Committee on Toxicity of Chemicals in Food, Consumer Products
and the Environment (COT). The IOM report on the relationship
between OP sheep dips and illness in exposed sheep farmers and
dippers found the critical exposure factor to be contact with
the concentrate dip. Much higher rates of symptoms, particularly
of a sensory nature, were reported among those who had been principal
concentrate handlers. There is very limited evidence that long-term
low level exposure leads to long-term neurotoxic effects. The
COT report concluded that long-term neuropsychological abnormalities
can occur as a long-term complication following acute and severe
organophosphate poisoning. Persistent peripheral neuropathy (disorders
of the peripheral nerves) may occur, but not generally at a level
which would give rise to symptoms. The body of evidence gives
little support to the hypothesis that low level exposure to organophosphates
can cause chronic disease of the nervous system. However, the
report notes that there remains a question over whether a small
proportion of subjects may be at increased risk of clinically
significant disease following low exposure, and recommends further
research in this area.
CHEMICAL WEAPONS
22. Professor Hooper has interpreted the
numerous alarms and activations of detection equipment as proof
that Chemical Weapons were present on the battlefield. False alarms
were, in fact, a very commom occurrence, because substances other
than chemical agents can set them off. These possibilities were
detailed in the Ministry of Defence paper "British Chemical
Warfare Defence During the Gulf Conflict", published on 7
December 1999. Professor Hooper has concluded that the paper "clearly
shows that there were no effective detection facilities available
to UK troops in the Gulf". The paper shows no such thing.
All UK detection systems would have been effective in the face
of real chemical attack. The Ministry of Defence assessment, shared
by the US DoD, remains that there is no evidence that Iraq used
chemical weapons against the coalition forces. Extensive investigation
of suggested incidents, and progressive publication of results,
continues on both sides of the Atlantic.
23. Professor Hooper draws particular attention
to the incident at the Kuwaiti Girls' School, Sabahiyah, in August
1991. He neglects to mention that the Ministry of Defence and
the US Department of Defense undertook an intensive investigation
of these events, and published a joint 86 page case narrative
inMarch 1998. The result of this in-depth survey was the assessment
that chemical warfare agent was definitely not present in the
storage tank at the Kuwaiti Girls' School, but that Inhibited
Red Fuming Nitric Acid, the fuel oxidiser for SILKWORM anti-ship
missiles definitely was present. It is not clear to the Ministry
of Defence how Professor Hooper reconciles the detailed explanation
of events which we have given with the alternative, journalistic
source he chooses to quote, to reach his assessment that our explanation
does not fit the basic facts of the case.
DEPLETED URANIUM
24. Professor Hooper uses figures from groups
with anti-nuclear agendas to state how much Depleted Uranium (DU)
was fired in the Gulf. He chooses to ignore the official US assessment
in the Environmental Exposure Report on Depleted Uranium in the
Gulf, published by DoD in July 1998, which, with detailed calculations,
estimates the usage of DU as around 320 US tons. Citing UK expenditure
of 59 tons, he claims to have photographic evidence disproving
the Ministry of Defence's assessment that UK tanks fired fewer
than 100 120mm DU rounds in combat, equating to less than one
metric tonne of DU. This photographic evidence has never been
shared with the Ministry of Defence. Whilst we are sceptical that
any photographic evidence could prove more extensive usage, unless
it showed every single firing of DU by UK forces, we would be
happy to evaluate it if it is provided to us.
25. In the section "Gulf exposures
to DU", Professor Hooper makes statements about the work
ofDr McDiarmid and the Baltimore group who are following some
US veterans exposed to DU. The statements made by Professor Hooper
are inaccurately referenced and the conclusions he draws have
not been drawn by the research group. The Ministry of Defence
has followed this work very closely, attended the major conferences
where it has been presented, and discussed the findings directly
with Dr McDiarmid.
26. The article in the November 1999 edition
of Health Physics quoted by Hooper actually compared urinary uranium
levels in those with confirmed DU shrapnel and other veterans
with no suspected shrapnel, self-reported shrapnel, or physician
reported shrapnel, but who had nevertheless had high risk of exposure
to DU. The clinical assessments on the DU shrapnel retaining group
of 15 subjects showed that many had persisting impairments relating
to their original injuries, but many were still working, and half
remained in the armed services. Laboratory tests were generally
normal and all tests of renal function were normal. Urinary uranium
levels in the DU shrapnel group in 1993 had a mean of 4.47 micrograms
per gram of creatinine, while in 1995 the mean was 6.4. For the
other groups the range of means was 0.03-0.06 in 1993 and 0.01
to 0.05 in 1995. In other words the groups without confirmed DU
shrapnel were excreting uranium at rates within the normal range.
27. The Baltimore researchers have separately
reported that neurocognitive performance using standard tests
indicated normal functioning. Using non-standard computerised
tests showed a weak association between high urinary uranium and
lowered neurocognitive performance. The results were within the
range of normal and had showed no deterioration over time. The
effect is subtle and of doubtful significance. Baltimore further
found high prolactin levels within those with high urinary uranium,
but these remained within the normal range, which is very wide.
The significance remains unclear. Five of the group have DU in
the semen. In the light of the lack of birth defects in 17 children
born to this small but highly exposed group the significance is
unclear. There is no evidence that DU is being concentrated in
semen, and it cannot be assumed that genetic damage will occur.
28. Table 3 which follows is unreferenced,
and of no scientific value. It does not reveal the type of uranium
used in the studies, how it was introduced to the subjects or
levels of exposure. It appears to have been drawn up without reference
to the RAND review of Scientific Literature as it pertains to
Gulf War Illness, Volume 7, Depleted Uranium, RAND 1999. This
concluded that there were no peer reviewed published reports of
detectable increases in cancer or other negative effects from
radiation exposure to inhaled or ingested uranium at levels far
exceeding those likely in the Gulf. Large variations in natural
uranium from the normal environment are also not associated with
negative health effects. RAND concluded that the kidneys were
most vulnerable to toxicological effects of uranium as a heavy
metal, but very high levels of exposure were required to cause
this. RAND found no evidence of increased illness or frequency
of end-stage renal disease in relatively large populations chronically
exposed to uranium at concentrations above normal ambient ones.
None of the conditions listed in the table is pathognomic of uranium
toxicity, nor is there any evidence of excess incidence of these
conditions in Gulf veterans.
29. Professor Hooper proceeds to link DU
to birth defects in veterans. The Ministry of Defence considers
that the use of a single anecdote in this way without any balancing
or scientific evidence is highly irresponsible. Professor Hooper
has made other unsubstantiated statements about birth defects
in the past (for example in the Gulf Veterans Association Information
Pack dated July 1999.) Veterans do become very worried about this.
The Ministry of Defence therefore wishes to make it clear that
there is no epidemiological evidence linking service in the Gulf,
let alone exposure to DU, with excess levels of birth defects.
American studies (Penman et al, Military Medicine, January 1996,
Cowan et al, New England Journal of Medicine June 1997), one on
a very large scale, found no evidence of an increase in birth
defects among the children of Gulf War Veterans. No comparable
data currently exists for UK Gulf veterans. The Ministry of Defence
is funding the Medical Research Council sponsored study by the
London School of Hygiene and Tropical Medicine which is examining
the reproductive health of UK Gulf veterans.
30. Professor Hooper states "A number
of UK veterans have been found to have DU in their urine almost
10 years after the Gulf conflict (Sharma, 1999; Horan, 1999)".
The Sharma reference is "unpublished data" and Horan
is not even referenced at all. The fact remains that since these
claims were first made on behalf of UK veterans over one year
ago, no scientifically valid data has been provided to the Ministry
of Defence or published to substantiate it. It is in this context,
and to provide re-assurance to the veterans tested in Canada and
the United States, that the Ministry of Defence has offered tests
for DU at independent laboratories for them. A draft protocol,
for discussion with veterans was issued on 1 November 1999. To
date the Ministry of Defence has had no response from veterans
groups to this suggestion. The Ministry of Defence wishes to see,
and evaluate, the data from Sharma, Horan, and others on urine
testing for DU in British veterans. In the meantime the Ministry
of Defence believes it is premature, and highly irresponsible,
to speculate on figures for suggested increases in the future
incidence of cancer among Gulf veterans, as Professor Hooper's
paper and his sources do. The alarmist (and unreferenced) calculations
by Sharma and Bertell do not seem to follow internationally accepted
models published by the International Commission on Radiological
Protection. Furthermore, it is unclear why they choose around
3 micrograms of uranium in a 24 hour sample as a baseline, when
the published evidence from the Baltimore work would suggest that
highly exposed veterans were excreting between 0.04 and 0.15 micrograms
per litre (say 0.06 and 0.23 micrograms in 24 hours.)
BIOLOGICAL WEAPONS
31. There remains no reliable evidence that
Iraq used biological weapons. These issues and the Ministry of
Defence response to the threat were addressed by the previous
Defence Select Committee (Fifth Report, Session 1993-94.). Professor
Hooper is wrong to say that "there were no detection devices
available for the rapid detection of any biological weapons."
A detailed paper on the UK's biological warfare detection efforts
in the Gulf is in preparation, and should be published shortly.
The Ministry of Defence has already published, in April 1998,
a paper on "Dead Animals During the Gulf Conflict"
which examined claims that the presence of dead animals indicated
the presence of chemical or biological weapons.
SMOKE FROM
BURNING OIL
WELLS
32. Professor Hooper has ignored the RAND
report, Spektor D M, a Review of the Scientific Literature as
it pertains to Gulf Veterans Illnesses, Volume 6, Oil Well Fires,
RAND 1998. This reviewed the health effects and concluded that
the cumulative doses of relevant pollutants would fall below doses
known to cause adverse health effects. It also concluded that
there are no data to support the symptoms of Gulf veterans as
being associated with oil fire exposure.
33. In March 1991 the Ministry of Defence
considered the health risk from oil well fires. Shell UK advised
that Kuwaiti crude oil had a high (2\5 per cent) sulphur content.
Combustion products contained carbon dioxide, carbon monoxide,
nitrogen oxides, sulphur dioxide, and particulates which were
not carcinogens. The threat to health was compared with the respiratory
problems experienced in industrial areas prior to the Clean Air
Act. The population most at risk was the elderly or those with
existing respiratory disease. This advice was corroborated with
the US Environmental Protection Agency and experts employed in
the Kuwaiti oil industry. In addition to those listed above they
advised that combustion products could also include polyaromatic
hydrocarbons. Air monitoring showed that oxygen content was satisfactory;
carbon monoxide levels were well below those considered safe for
communities continually exposed; sulphur dioxide levels were within
acceptable margins; no hydrogen sulphide had been detected; the
smoke was made of carbon particles of varying sizes, some capable
of reaching the smaller air passages in the human lung, although
the majority would be trapped in the upper respiratory tract and
expectorated. The particles were inert. The polyaromatic hydrocarbons
were not expected to cause skin problems, provided exposure was
intermittent and short, and the risk of exposure in the lungs
was judged small in the long term, again provided exposure was
not heavy or prolonged.
34. Based on the advice received, the Ministry
of Defence purchased 10,000 commercially available filter masks
that would filter out the particulates in the smoke. These were
freely distributed to those working in areas affected by the smoke.
From June to October 1991 the health of personnel serving in 21
EOD Squadron Royal Engineers, who worked in these areas was monitored.
The results were published in the Royal Army Medical Corps Journal
in 1993, and concluded that exposure to oil fire smoke did not
appear to have any effect on respiratory function.
POST TRAUMATIC
STRESS DISORDER
35. Professor Hooper states that "there
are sound grounds for rejecting the diagnosis of PTSD in most
GWVs who suffered a massive assault on the cholinergic system."
To dismiss Post Traumatic Stress Disorder and other psychiatric
diagnoses in such sweeping terms is to ignore the clinical finding
of substantial numbers of consultant psychiatrists who have examined
Gulf veterans. PTSD is a well understood and well defined condition,
occurring also in veterans of other conflicts, and in civilians
with traumatic histories. It can be treated successfully. A significant
minority of UK Gulf veterans are diagnosed with PTSD or another
recognised psychiatric condition.
CONFERENCES
36. Professor Hooper suggests that international
conferences should be held, with the implication that they are
not. The Ministry of Defence and UK academics in fact attended
three significant open international conferences in the United
States during 1999, including the Research Planning Conference
convened by the Centre for Disease Control at Atlanta Georgia,
which had precisely the agenda which Professor Hooper sets out
for such a conference. Professor Hooper describes the only conference
of its type organised in the UK so far, that held by the Section
of Epidemiology and Public Health of the Royal Society of Medicine
in December 1998, as a sham. This meeting was open to anybody,
and the Royal Society of Medicine who organised it (not Colonel
Graham as alleged by Professor Hooper) cannot be held responsible
for the failure of individuals to attend or speak. In fact there
are regular open academic conferences which tackle the issue of
Gulf health in the round, or aspects relevant to it, which give
all scientists and researchers an opportunity to air their views
on these subjects.
THE INDEPENDENT
PANEL
37. Professor Hooper seems to have misunderstood
the basis on which the Independent Panel was established. Its
function is explicitly to provide independent oversight of the
programme of research which was commissioned from CBD Porton Down
to look at vaccine and PB interactions. This was in recognition
of the need for the Ministry of Defence to be seen to be impartial,
having decided to conduct this work within MOD instead of in an
academic institution. For overall guidance on the appropriate
direction of research into Gulf health the Ministry of Defence
is relying on the Medical Research Council, who evaluate proposals
on MOD's behalf and recommend which should be pursued. The emerging
work from the portfolio of MOD funded research agreed under MRC
auspices will guide future decisions on the way forward. The guinea
pig work at CBD has not been abandoned as Professor Hooper claims.
The results from the initial work showed no adverse effects from
the combination of vaccines and PB. The Independent Panel therefore
decided that it was not necessary to continue guinea pig work,
but instead move directly to work in marmosets.
MEDICAL ASSESSMENT
PROGRAMME
38. The paper on the first 1,000 patients
seen at MAP (Coker et al, BMJ January 1999) did not describe itself
as "deeply flawed" (Hooper's words). It set out the
limitations of the study as required in the Guidelines for Authors
published by the BMJ. It received peer review to be published,
and has not met with peer reviewed criticism. The Ministry of
Defence notes that Professor Hooper confines himself to an (inaccurate)
listing of the shortcomings in the paper, and fails to go on to
discuss its findings at all.
39. The Ministry of Defence cannot comment
on the accuracy of notes taken by Professor Hooper at the informal
and un-minuted presentation to the Independent Panel on 29 March
1999. As repeated in his memorandum, these take no account of
the context in which remarks may have been made, and substantially
misrepresent Professor Lee's views, and what he said. A detailed
rebuttal of the inaccuracies of Professor Hooper' recollections
was provided at a meeting with Gulf veterans' representatives
and the Countess of Mar on 31 March 1999.
40. The Medical Assessment Programme was
audited by the Royal College of Physicians in 1995, and by the
King's Health Quality Fund in 1998. The MOD response to the latter
audit was published on 20 January 2000. All the recommendations
are accepted. A clinical audit of tests at the MAP has also been
undertaken in conjunction with the Royal College of Pathologists,
and the outcome of this will be reported shortly. Although veterans'
groups have been critical of the Medical Assessment Programme,
many individual veterans continue to be referred and attend appointments.
The Ministry of Defence believes, on the basis of direct feedback,
that these veterans find the service offered by the Medical Assessment
Programme helpful and professional. All Gulf veterans with a concern
about their health are encouraged to attend the Programme.
9 February 2000
11 p 85. Back
|
