THE IRRITABLE HEART

"..the unspeakable loneliness of individual suffering".(Wheelwright, p51)

Many will be astonished - and dismayed- to learn that George W Bush has been nominated for the Nobel Peace Prize. The Bush administration has budgeted for $460 billion on arms for the year ahead. While America prepares for a second Gulf War against Saddam Hussein (never mind what's happening now in Afghanistan) -as a central plank of President Bush's resolve to destroy the supposed 'axis of evil' in the aftermath of Sept 11 - the debate (and the individual suffering) drags on about the medical condition known as the Gulf War Syndrome (GWS). 'Desert storm' was an unconvincing victory because of this persisting GWS problem, and because Hussein remains at large and in control. What guarantee is there that a new Gulf War will not produce another crop of disabled veterans to add to the substantial group of vets left over from the 1990s conflict still awaiting effective treatment or even adequate and fair compensation? In 1991 some 700,000 US troops went to the Gulf and about 15% of the vets came back with the syndrome; that is 1 in 7, or 100,000 individuals. Allied troops (British, Danish, Canadian, Czechs and Slovaks) also began to report such casualties in the mid 1990s. Yale graduate Jeff Wheelwright, once the science editor of Life magazine, is an American investigative journalist who set himself the task of analysing the mysteries of GWS from two angles, from the individual perspectives of a handful of victims (a case study or anecdotal approach), and from what he sees as two polarised and opposing scientific/medical points of view of the cause of the syndrome (the statistical approach). The scientific viewpoints are divided into the psychological stress camp versus the toxic poison camp. It is true that a medical consensus is still not yet reached on the causes of GWS or on how to treat it. It is also the case that the debate has taken place in a context of suspected cover-ups by the American and British authorities. The author takes his title from the old 'irritable heart' hypothesis of the disabled soldier who is too unfit to continue fighting because of vague cardiac symptoms - of palpitation, shortness of breath, disturbed sleep and dizziness, chest pains and fatigue on exertion. Today clinical psychologists might look for 'hyperventilating syndrome' in such casualties; a breathing disorder brought on by anxiety. In the old days, - until psychologists came to his rescue - the shell-shocked soldier of the Great War in Europe was shot - executed - as a malign influence on other soldiers. Now he sees the psychiatrist. This malady is firmly in the stress camp. These days such individuals might be labelled as Type A personality over-achievers. In other words, it was their own fault if they got sick - although it is hard to imagine how combat personnel can over-achieve. If there is no obvious organic cause for the symptoms - at least within the compass of the existing diagnostic test batteries - why not label it 'psychiatric' and then no expert loses face while psychiatry, the cinderella medical specialty gains added territory? The author points to a rash of professional papers which appeared in the professional journals in the 1990s on GWS and 'post-traumatic stress disorder' (PTSD) - a fashionable catch-all term, in the 'blame the victim' category. A similar concept fashionable in the medical fraternity is 'functional somatic syndrome' which is another garbage can psychiatric diagnosis for conditions impossible to detect with present-day tests and diagnostic tools. Most worrying of all are the many recent professional papers cited by the author which propose an early history of childhood abuse leading to an inability to cope with stress in adult life, which is suggested by the author as the ultimate source of this illness. It does indeed appear likely that some soldiers, like policemen and firemen, will experience PTSD as a result of job trauma, but the story has another side. The US Dept of Commerce approved the sale and export of biological materials to Iraq in the late 1980s. The toxic hypothesis is the other side of the mind/body split. Multiple vaccines, oil well fires, insecticides, and pyridostigmine bromide pills used in the assumed protection from nerve gas like Saran thought to have been unleashed by Hussein during the conflict along with biological weapons such as mycoplasma, even depleted uranium from US shells - any or all of these may be the toxic culprits here. In trying to solve the GWS mystery and to resolve the mind-body dualism conundrum that it implies Wheelwright floats the new discipline of 'psychoneuroimmunology' as a possible road to enlightenment. The book's dust cover refers to ''physical symptoms greatly magnified by psychological distress". And that "(t)he only way to understand these elusive sicknesses is to consider the mind and body as one suffering system". The dust cover further claims that the author " takes the subject of chronic illness far beyond the medical aftermath of a desert war." But I doubt that. The mystery remains despite the welter of published papers that the author has listed, and the last 50 pages of 'Notes & Sources' which completes the book. Perhaps there is something about the vets that made them more vulnerable than average to chemicals. Perhaps they were more neurotic and more stressed and chronic emotional stress hormones led to the breaching of the blood-brain barrier 1 thus facilitating the transport of chemicals through to the brain. But that may be too simple an explanation. On the other hand, an author's bias shows. Wheelwright's bias is on the stress-psychiatry side. His five case studies include John who has been diagnosed with 'dystonia' which is a 'somatoform' condition. We are given an unflattering picture of him. He is politically-aware and campaigns for the rights of the veterans, including his own. Carol is more benignly portrayed, perhaps because she is apolitical. She has occupational chemical sensitivities that preceded her Gulf War experience. She could be a case of MCS, (Multiple Chemical Sensitivity), CFS (Chronic Fatigue Syndrome or ME), or FM (Fibromylgia) which are the 'waste basket diagnoses' into which GWS is slipping. She is a typical CFS/MCS patient apparently, by virtue of her age and sex and because she has the two years minimum of college education. We are not told if she had suffered childhood abuse. All of Ron's symptoms, on the other hand started out there in the Gulf. He has 'irritable bowel syndrome', another supposed stress disease. But he also has colon cancer and one is left to wonder if that was stress-induced. As for Pete, has he become hypochondriac by now? He had become one of a subgroup of vets (20,000/100,000) who had received repeated and elaborate testing to no avail. Finally we are presented with Darren with a dominating partner who takes charge of dispensing his many daily pills. She, apparently, reinforces his 'illness-seeking behaviour'. The author shows no convincingly genuine sympathy for the plight of these people. "But I don't know how to balance 'caring' and 'objective'. So I am going to breach another possible label for Darren's health condition. The most bitter label of all: hypochondriasis". (Wheelwright, p287/8) He admits to an antipathy for a supposed American tendency to treasure the individual, presumably at the expense of the general good.(p179180) "It's the intellectual sloppiness of the process that irks me…people have learned a way to be sick - a rationale for their symptoms." And later, another supposed somatoform disease - repetitive strain injury - is denounced as " a good example of money's fertilizing influence on illness behaviour" (p228. ) As for GWS " What happened was that people got sick, and then some of them surrendered to the sick role…The frequent medical exams and forms to fill out, the claims and appeal process, the angry pride and silent self-doubts act like padding on the trap of illness behaviour."(p228) This is certainly journalism and not science. But is it responsible journalism? The author lets these individuals down. They trusted him and he adds to their burdens. It is (I think) possible that a breach of the elusive blood-brain barrier made this particular group - bombarded by combat stress hormones -especially vulnerable, but evidence for a strictly biological cause as the basis to the breach as opposed to psychological (or some interaction between the two), is not reviewed at all here…perhaps because the author is unaware that the picture for multifactorial disease is more sophisticated. Another journalist reviewing the syndrome came to a very different conclusion to that of Wheelwright (W Thomas -reviewed in this journal - Network 74, Dec 2000, 45-46). For Thomas GWS is quite categorically a neurophysical disability. A common symptom of GWS and the other waste basket syndromes is increased chemical sensitivity - a chemical neurotoxicity. We don't have to go the Gulf to get sick. There is a growing epidemic of chemically-induced illness at the level of ordinary everyday life. The EC recently announced a programme of testing chemicals for possible ill health effects when chemicals are working together in synergy. This is a rational move quite apart from any ethical considerations. 'Amplicons' is a biological marker found in GWS and CFS/ME which, it has been proposed, leads to chronic immune dysfunction and chronic degenerative disease.2 This aberrant or 'voyager' RNA is homologous to regions on chromosome 22, a 'hotspot' for genetic rearrangements sensitive to environmental genotoxins, causing the interaction among causative factors seen in multifactoral disease. Two amplicons are found to be unique to GWS. The implication is that there has been actual damage at the level of RNA/DNA. Such RNAs can persist in sera and be Rnase-resistant. This is deadly serious information. There may be a mutated genetic basis to this process with environmental toxin as the trigger, although persistent and chronic infection (such as a mycoplasma bacterium or a particular enterovirus) may be another source of the problem. GWS appears therefore to be an entirely different disease from those of the 'all the mind' variety. The above biological aberrations may be the cause of 'irritable hearts'. We just do not have the full picture. It doesn't make economic sense to carry on as we are with unlimited amounts of polluting chemicals filtering into the average home and workplace, regardless of the chemical and other perils to be found in the theatre of modern combat….but then there are the politics of it. Political conspiracies and cover-ups aside, however, scientific investigation into GWS (and similar diseases capable of causing great distress as well as lost productivity) has been dogged by a lack of systematic record-keeping on the types and duration of chemical and other noxious exposures. Let us hope the lesson has been learnt and that some of the American budget in the next war is at least spent in keeping better records.