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Inj Prev. Mar 2001; 7(1): 4–9.
PMCID: PMC2254187
NIHMSID: NIHMS28366

Proposed explanations for excess injury among veterans of the Persian Gulf War and a call for greater attention from policymakers and researchers

Abstract

Introduction—Death rates among US veterans of the Persian Gulf War were lower than rates among non-deployed veterans and the US population at large, with the exception of injury deaths; returning veterans were at significantly greater risk of injury mortality. Similar patterns of excess injury mortality were documented among US and Australian veterans returning from Vietnam. In spite of these consistent findings little has been done to explain these associations and in particular to determine whether or not, and how, war related exposures influence injury risk among veterans returning home after deployments.

Hypothesized pathways—Several potential pathways are proposed through which injury might be related to deployment. First, increases in injury mortality may be a consequence of depression, post-traumatic stress disorder, and symptoms of other psychiatric conditions developed after the war. Second, physical and psychological traumas experienced during the war may result in the postwar adoption of "coping" behaviors that also increase injury risk (for example, heavy drinking). Third, greater injury risk may be the indirect consequence of increased experiences of ill defined diseases and symptoms reported by many returning veterans. Fourth, veterans may experience poorer survivability for a given injury event resulting in greater mortality but not morbidity. Finally, the process that selects certain individuals for deployment may lead to a spurious association between deployment status and injury mortality by preferentially selecting individuals who are risk takers and/or exposed to greater hazards.

Conclusions—More research and attention from policymakers is needed to clarify the link between deployment and postwar increased risk of injury.

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Selected References

These references are in PubMed. This may not be the complete list of references from this article.
  • Fukuda K, Nisenbaum R, Stewart G, Thompson WW, Robin L, Washko RM, Noah DL, Barrett DH, Randall B, Herwaldt BL, et al. Chronic multisymptom illness affecting Air Force veterans of the Gulf War. JAMA. 1998 Sep 16;280(11):981–988. [PubMed]
  • Roy MJ, Koslowe PA, Kroenke K, Magruder C. Signs, symptoms, and ill-defined conditions in Persian Gulf War veterans: findings from the Comprehensive Clinical Evaluation Program. Psychosom Med. 1998 Nov-Dec;60(6):663–668. [PubMed]
  • Haley RW, Kurt TL, Hom J. Is there a Gulf War Syndrome? Searching for syndromes by factor analysis of symptoms. JAMA. 1997 Jan 15;277(3):215–222. [PubMed]
  • Ismail K, Everitt B, Blatchley N, Hull L, Unwin C, David A, Wessely S. Is there a Gulf War syndrome? Lancet. 1999 Jan 16;353(9148):179–182. [PubMed]
  • Ishøy T, Guldager B, Appleyard M, Suadicani P, Hein HO, Gyntelberg F. Helbredsstatus efter udstationering i Golfkrigsområdet. The Danish Gulf War Study. Ugeskr Laeger. 1999 Sep 27;161(39):5423–5428. [PubMed]
  • Ishøy T, Suadicani P, Guldager B, Appleyard M, Hein HO, Gyntelberg F. State of health after deployment in the Persian Gulf. The Danish Gulf War Study. Dan Med Bull. 1999 Nov;46(5):416–419. [PubMed]
  • Unwin C, Blatchley N, Coker W, Ferry S, Hotopf M, Hull L, Ismail K, Palmer I, David A, Wessely S. Health of UK servicemen who served in Persian Gulf War. Lancet. 1999 Jan 16;353(9148):169–178. [PubMed]
  • Kang HK, Bullman TA. Mortality among U.S. veterans of the Persian Gulf War. N Engl J Med. 1996 Nov 14;335(20):1498–1504. [PubMed]
  • Murphy F, Browne D, Mather S, Scheele H, Hyams KC. Women in the Persian Gulf War: health care implications for active duty troops and veterans. Mil Med. 1997 Oct;162(10):656–660. [PubMed]
  • Writer JV, DeFraites RF, Brundage JF. Comparative mortality among US military personnel in the Persian Gulf region and worldwide during Operations Desert Shield and Desert Storm. JAMA. 1996 Jan 10;275(2):118–121. [PubMed]
  • Writer JV, DeFraites RF, Keep LW. Non-battle injury casualties during the Persian Gulf War and other deployments. Am J Prev Med. 2000 Apr;18(3 Suppl):64–70. [PubMed]
  • Wasserman GM, Martin BL, Hyams KC, Merrill BR, Oaks HG, McAdoo HA. A survey of outpatient visits in a United States Army forward unit during Operation Desert Shield. Mil Med. 1997 Jun;162(6):374–379. [PubMed]
  • Gray GC, Coate BD, Anderson CM, Kang HK, Berg SW, Wignall FS, Knoke JD, Barrett-Connor E. The postwar hospitalization experience of U.S. veterans of the Persian Gulf War. N Engl J Med. 1996 Nov 14;335(20):1505–1513. [PubMed]
  • Gray GC, Smith TC, Kang HK, Knoke JD. Are Gulf War veterans suffering war-related illnesses? Federal and civilian hospitalizations examined, June 1991 to December 1994. Am J Epidemiol. 2000 Jan 1;151(1):63–71. [PubMed]
  • Hyams KC, Wignall FS, Roswell R. War syndromes and their evaluation: from the U.S. Civil War to the Persian Gulf War. Ann Intern Med. 1996 Sep 1;125(5):398–405. [PubMed]
  • Bullman TA, Kang HK, Watanabe KK. Proportionate mortality among US Army Vietnam veterans who served in military region I. Am J Epidemiol. 1990 Oct;132(4):670–674. [PubMed]
  • Breslin P, Kang HK, Lee Y, Burt V, Shepard BM. Proportionate mortality study of US Army and US Marine Corps veterans of the Vietnam War. J Occup Med. 1988 May;30(5):412–419. [PubMed]
  • Lawrence CE, Reilly AA, Quickenton P, Greenwald P, Page WF, Kuntz AJ. Mortality patterns of New York State Vietnam Veterans. Am J Public Health. 1985 Mar;75(3):277–279. [PMC free article] [PubMed]
  • Watanabe KK, Kang HK. Military service in Vietnam and the risk of death from trauma and selected cancers. Ann Epidemiol. 1995 Sep;5(5):407–412. [PubMed]
  • Watanabe KK, Kang HK, Thomas TL. Mortality among Vietnam veterans: with methodological considerations. J Occup Med. 1991 Jul;33(7):780–785. [PubMed]
  • Card JJ. Epidemiology of PTSD in a national cohort of Vietnam veterans. J Clin Psychol. 1987 Jan;43(1):6–17. [PubMed]
  • Bullman TA, Kang HK, Thomas TL. Posttraumatic stress disorder among Vietnam veterans on the Agent Orange Registry. A case-control analysis. Ann Epidemiol. 1991 Nov;1(6):505–512. [PubMed]
  • Bullman TA, Kang HK. The risk of suicide among wounded Vietnam veterans. Am J Public Health. 1996 May;86(5):662–667. [PMC free article] [PubMed]
  • Fett MJ, Nairn JR, Cobbin DM, Adena MA. Mortality among Australian conscripts of the Vietnam conflict era. II. Causes of death. Am J Epidemiol. 1987 May;125(5):878–884. [PubMed]
  • Dalager NA, Kang HK. Mortality among Army Chemical Corps Vietnam veterans. Am J Ind Med. 1997 Jun;31(6):719–726. [PubMed]
  • McCarroll JE, Ursano RJ, Fullerton CS. Symptoms of PTSD following recovery of war dead: 13-15-month follow-up. Am J Psychiatry. 1995 Jun;152(6):939–941. [PubMed]
  • McCarroll JE, Ursano RJ, Fullerton CS. Symptoms of posttraumatic stress disorder following recovery of war dead. Am J Psychiatry. 1993 Dec;150(12):1875–1877. [PubMed]
  • Perconte ST, Wilson AT, Pontius EB, Dietrick AL, Spiro KJ. Psychological and war stress symptoms among deployed and non-deployed reservists following the Persian Gulf War. Mil Med. 1993 Aug;158(8):516–521. [PubMed]
  • Stretch RH, Bliese PD, Marlowe DH, Wright KM, Knudson KH, Hoover CH. Psychological health of Gulf War-era military personnel. Mil Med. 1996 May;161(5):257–261. [PubMed]
  • Southwick SM, Morgan A, Nagy LM, Bremner D, Nicolaou AL, Johnson DR, Rosenheck R, Charney DS. Trauma-related symptoms in veterans of Operation Desert Storm: a preliminary report. Am J Psychiatry. 1993 Oct;150(10):1524–1528. [PubMed]
  • Southwick SM, Morgan CA, 3rd, Darnell A, Bremner D, Nicolaou AL, Nagy LM, Charney DS. Trauma-related symptoms in veterans of Operation Desert Storm: a 2-year follow-up. Am J Psychiatry. 1995 Aug;152(8):1150–1155. [PubMed]
  • Engel CC, Jr, Ursano R, Magruder C, Tartaglione R, Jing Z, Labbate LA, Debakey S. Psychological conditions diagnosed among veterans seeking Department of Defense Care for Gulf War-related health concerns. J Occup Environ Med. 1999 May;41(5):384–392. [PubMed]
  • Sutker PB, Uddo M, Brailey K, Allain AN, Errera P. Psychological symptoms and psychiatric diagnoses in Operation Desert Storm troops serving Graves registration duty. J Trauma Stress. 1994 Apr;7(2):159–171. [PubMed]
  • Erzurum VZ, Varcellotti J. Self-inflicted burn injuries. J Burn Care Rehabil. 1999 Jan-Feb;20(1 Pt 1):22–24. [PubMed]
  • Ultmann MH, Geller TJ, Chilakamairi JK, Kaplan SL. Multidisciplinary rehabilitation management of depression in the carbon monoxide injured patient. Pediatr Rehabil. 1998 Apr-Jun;2(2):101–106. [PubMed]
  • Cameron DR, Pegg SP, Muller M. Self-inflicted burns. Burns. 1997 Sep;23(6):519–521. [PubMed]
  • Li G, Ling J, DiScala C, Nordenholz K, Sterling S, Baker SP. Characteristics and outcomes of self inflicted pediatric injuries: the role of method of suicide attempt. Inj Prev. 1997 Jun;3(2):115–119. [PMC free article] [PubMed]
  • Tuohig GM, Saffle JR, Sullivan JJ, Morris S, Lehto S. Self-inflicted patient burns: suicide versus mutilation. J Burn Care Rehabil. 1995 Jul-Aug;16(4):429–436. [PubMed]
  • Minnaar GK, Schlebusch L, Levin A. A current study of parasuicide in Durban. S Afr Med J. 1980 Feb 9;57(6):204–207. [PubMed]
  • Henriksson TG. Close range blasts toward the maxillofacial region in attempted suicide. Scand J Plast Reconstr Surg Hand Surg. 1990;24(1):81–86. [PubMed]
  • Frierson RL, Lippmann SB. Psychiatric consultation for patients with self-inflicted gunshot wounds. Psychosomatics. 1990 Winter;31(1):67–74. [PubMed]
  • Hadjiiski O, Todorov P. Suicide by self-inflicted burns. Burns. 1996 Aug;22(5):381–383. [PubMed]
  • Greene KA, Dickman CA, Smith KA, Kinder EJ, Zabramski JM. Self-inflicted orbital and intracranial injury with a retained foreign body, associated with psychotic depression: case report and review. Surg Neurol. 1993 Dec;40(6):499–503. [PubMed]
  • Lesage AD, Boyer R, Grunberg F, Vanier C, Morissette R, Ménard-Buteau C, Loyer M. Suicide and mental disorders: a case-control study of young men. Am J Psychiatry. 1994 Jul;151(7):1063–1068. [PubMed]
  • Reynolds P, Eaton P. Multiple attempters of suicide presenting at an emergency department. Can J Psychiatry. 1986 May;31(4):328–330. [PubMed]
  • Bozzacco V. Vulnerability and alcohol and substance abuse in spinal cord injury. Rehabil Nurs. 1990 Mar-Apr;15(2):70–72. [PubMed]
  • Davis RE. Trauma and addiction experiences of African American women. West J Nurs Res. 1997 Aug;19(4):442–465. [PubMed]
  • Friedman MJ, Schnurr PP, McDonagh-Coyle A. Post-traumatic stress disorder in the military veteran. Psychiatr Clin North Am. 1994 Jun;17(2):265–277. [PubMed]
  • Hierholzer R, Munson J, Peabody C, Rosenberg J. Clinical presentation of PTSD in World War II combat veterans. Hosp Community Psychiatry. 1992 Aug;43(8):816–820. [PubMed]
  • Sims A, Sims D. The phenomenology of post-traumatic stress disorder. A symptomatic study of 70 victims of psychological trauma. Psychopathology. 1998;31(2):96–112. [PubMed]
  • Greyson B. Varieties of near-death experience. Psychiatry. 1993 Nov;56(4):390–399. [PubMed]
  • Greyson B. The near-death experience as a focus of clinical attention. J Nerv Ment Dis. 1997 May;185(5):327–334. [PubMed]
  • Orne RM. The meaning of survival: the early aftermath of a near-death experience. Res Nurs Health. 1995 Jun;18(3):239–247. [PubMed]
  • Kroenke K, Koslowe P, Roy M. Symptoms in 18,495 Persian Gulf War veterans. Latency of onset and lack of association with self-reported exposures. J Occup Environ Med. 1998 Jun;40(6):520–528. [PubMed]
  • Joseph SC. A comprehensive clinical evaluation of 20,000 Persian Gulf War veterans. Comprehensive Clinical Evaluation Program Evaluation Team. Mil Med. 1997 Mar;162(3):149–155. [PubMed]
  • Spencer PS, McCauley LA, Joos SK, Lasarev MR, Schuell T, Bourdette D, Barkhuizen A, Johnston W, Storzbach D, Wynn M, et al. U.S. Gulf War Veterans: service periods in theater, differential exposures, and persistent unexplained illness. Portland Environmental Hazards Research Centre. Toxicol Lett. 1998 Dec 28;102-103:515–521. [PubMed]
  • Roland PS, Haley RW, Yellin W, Owens K, Shoup AG. Vestibular dysfunction in Gulf War syndrome. Otolaryngol Head Neck Surg. 2000 Mar;122(3):319–329. [PubMed]
  • Jones JK, Triplett RG. The relationship of cigarette smoking to impaired intraoral wound healing: a review of evidence and implications for patient care. J Oral Maxillofac Surg. 1992 Mar;50(3):237–240. [PubMed]
  • Bell NS, Amoroso PJ, Williams JO, Yore MM, Engel CC, Jr, Senier L, DeMattos AC, Wegman DH. Demographic, physical, and mental health factors associated with deployment of U.S. Army soldiers to the Persian Gulf. Mil Med. 2000 Oct;165(10):762–772. [PMC free article] [PubMed]
  • Bricknell MC, Amoroso PJ, Yore MM. What is the risk associated with being a qualified military parachutist? Occup Med (Lond) 1999 Apr;49(3):139–145. [PubMed]
  • Bleich A, Kron S, Margalit C, Inbar G, Kaplan Z, Cooper S, Solomon Z. Israeli psychological casualties of the Persian Gulf war: characteristics, therapy, and selected issues. Isr J Med Sci. 1991 Nov-Dec;27(11-12):673–676. [PubMed]
  • Achté K, Jarho L, Kyykkä T, Vesterinen E. Paranoid disorders following war brain damage. Preliminary report. Psychopathology. 1991;24(5):309–315. [PubMed]
  • Ahlberg A, Corea JR, Sadat-Ali M, al-Habdan I, Marwah S, Moussa M, al-Othman A, Basyuni A. The scud missile disaster in Al-Khobar, Saudi Arabia, 1991: the orthopaedic experience. Injury. 1994 Mar;25(2):97–98. [PubMed]
  • Bajec J, Gang RK, Lari AR. Post Gulf war explosive injuries in liberated Kuwait. Injury. 1993 Sep;24(8):517–520. [PubMed]
  • Bleich A, Dycian A, Koslowsky M, Solomon Z, Wiener M. Psychiatric implications of missile attacks on a civilian population. Israeli lessons from the Persian Gulf War. JAMA. 1992 Aug 5;268(5):613–615. [PubMed]
  • Bowyer GW, Stewart MP, Ryan JM. Gulf war wounds: application of the Red Cross wound classification. Injury. 1993 Oct;24(9):597–600. [PubMed]
  • Brandt GT, Norwood AE, Ursano RJ, Wain H, Jaccard JT, Fullerton CS, Wright K. Psychiatric morbidity in medical and surgical patients evacuated from the Persian Gulf War. Psychiatr Serv. 1997 Jan;48(1):102–104. [PubMed]
  • Dillingham TR, Spellman NT, Braverman SE, Zeigler DN, Belandres PV, Bryant PR, Salcedo VL, Schneider RL. Analysis of casualties referred to Army physical medicine services during the Persian Gulf conflict. Am J Phys Med Rehabil. 1993 Aug;72(4):214–218. [PubMed]
  • Dillingham TR, Braverman SE, Belandres PV. Persian Gulf War amputees: injuries and rehabilitative needs. Mil Med. 1994 Oct;159(10):635–639. [PubMed]
  • Reyna TM. Observations of a pediatric surgeon in the Persian Gulf War. J Pediatr Surg. 1993 Feb;28(2):209–213. [PubMed]
  • Williams CS. F-16 pilot experience with combat ejections during the Persian Gulf War. Aviat Space Environ Med. 1993 Sep;64(9 Pt 1):845–847. [PubMed]
  • Helmkamp JC. United States military casualty comparison during the Persian Gulf War. J Occup Med. 1994 Jun;36(6):609–615. [PubMed]
  • Burkle FM, Jr, Newland C, Orebaugh S, Blood CG. Emergency medicine in the Persian Gulf War--Part 2. Triage methodology and lessons learned. Ann Emerg Med. 1994 Apr;23(4):748–754. [PubMed]
  • Humphrey JC. Casualty management: scud missile attack, Dhahran, Saudi Arabia. Mil Med. 1999 May;164(5):322–326. [PubMed]
  • Riddle JR, Hyams KC, Murphy FM, Mazzuchi JF. In the borderland between health and disease following the Gulf War. Mayo Clin Proc. 2000 Aug;75(8):777–779. [PubMed]
  • Jones BH, Perrotta DM, Canham-Chervak ML, Nee MA, Brundage JF. Injuries in the military: a review and commentary focused on prevention. Am J Prev Med. 2000 Apr;18(3 Suppl):71–84. [PubMed]
  • Jones BH, Hansen BC. An armed forces epidemiological board evaluation of injuries in the military. Am J Prev Med. 2000 Apr;18(3 Suppl):14–25. [PubMed]
  • Amoroso PJ, Smith GS, Bell NS. Qualitative assessment of cause-of-injury coding in U.S. military hospitals: NATO standardization agreement (STANAG) 2050. Am J Prev Med. 2000 Apr;18(3 Suppl):174–187. [PubMed]

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