The study sample selected consisted of a convenience sample of men who were Soldiers, or civilians, between the ages of 18–45 years and resided in the Iraq provinces of Basrah or Messanat the time of the 1991 Gulf War. They had to live within 300 km of the Kuwait border to be eligible for the study. Participants were enrolled during 2002. Three surgical residents from Basrah University were trained by one of the coauthors to administer a questionnaire to participants and their acquaintances (Soldiers and civilians) found in waiting rooms at 3 local medical clinics and government outpatient clinics. Individuals who accompanied patients attending the 3 outpatient clinics in the Basrah and Messan Provinces in Iraq were eligible to participate in the study. Thus, in order to minimize selection bias, we only interviewed persons accompanying patients to the health clinics. The 3 clinics were run by the Iraq Ministry of Health and were available to all Iraqis, further limiting the possibility to differential recruitment biases. Potential participants were approached by the medical residents and asked about their interest in participating in a study evaluating long-term health effects from the Gulf War. Participation was voluntary and respondents were able to withdraw from the study at any time. Once verbal consent was obtained, the medical residents proceeded to ask each question and read their respective response choices in Arabic and recorded the participants’ responses.
A structured interviewer-administered questionnaire was based on the survey developed and used in several studies of large numbers of US Gulf War Veterans.36,37
This questionnaire was initially designed and validated at the University of Iowa, the Iowa Department of Health, and the Centers for Disease Control and Prevention, and was used with permission. The original questionnaire was translated into Arabic and back-translated into English to ensure the validity of the phrasing of the questions. In this study, we excluded a total of 24 questions from the original English version since 12 questions were not applicable, and an additional 12 questions were deemed culturally too sensitive.
Briefly, the questionnaire contained questions concerning socioeconomics, smoking history, age, height, and weight. Body mass index (kg/m2) was calculated arid participants were classified into 3 categories: underweight, <18.5; normal weight, ≥18.5 to <25; overweight to obese, ≥25. Obese participants were included in the overweight category because there were very few obese participants. The participants’ residential or deployed distance from Kuwait was queried. Distance from Kuwait was classified into 3 zones: zone1 consisted of Soldiers in Kuwait, 1 to 100 km; zone2, participants (Soldiers and civilians) 101 to 200 km from Kuwait; and zone3, participants (Soldiers and participants) between 201 to 300 km from Kuwait. Out of a total of 1200 respondents, 45 respondents were removed from the analysis because they had resided between 300 km to 860 km from Kuwait. We collected self-reported years of military experience, military status (deployed/nondeployed, Soldier/civilian) and primary job at time of the survey in 2002 and prior to 1990. Fifteen primary employment classifications were available. They were collapsed into the following categories: students, unskilled workers, Soldiers, skilled workers (farmers, self-claimed skilled workers, and clerks), and professional workers (teachers, doctors, self-claimed professionals, and those in the health profession).
The survey also included detailed questions regarding possible exposures to a range of environmental contaminants in water, food, ground, and the air, including burning oil wells. The participants were asked to respond to whether they had had any of a number of specific medical conditions during the last year. If they responded affirmatively to any of the medical conditions, they were asked whether the conditions had debuted before, during or after the Gulf War. Respondents were asked about symptoms experienced in the month before the interview. They were asked to rate to what degree they were affected by specific symptoms. Scores ranged from 1 (symptom not experienced) to 5 (extremely affected). Participants were asked if, during the last year, they had had any of 35 physical health symptoms, including fatigue, fever, inflammation, neurological symptoms, seizures and convulsion, headaches, cardiovascular symptoms, gastrointestinal symptoms, dermatological signs and symptoms, and musculoskeletal symptoms.
With regard to medical diseases/disorders, participants were presented a list of 57 specified conditions and asked if they had one or more during the last year. If so, follow-up questions related to whether the disorders had debuted before, during, or after the GW. All but 6 specific medical conditions were collapsed into broader medical history categories by body system (). These categories included hypertension, cardiovascular disease (coronary heart disease and tachycardia), headaches (recurrent headaches and migraines), respiratory disease (bronchitis, pneumonia, tuberculosis, and other lung condition), asthma, ear/nose/throat diseases (chronic sinusitis and ear infection), ulcer disease, gastrointestinal disease (gastritis, enteritis, colitis, hepatitis, cirrhosis, frequent diarrhea), diabetes, genitourinary disease (recurrent bladder infections, renal disease, and any disease of the genital organs), hematology disease (aplastic anemia, leukemia, lymphoma, and any other cancer), rheumatologic disease (arthritis, rheumatism, fibromyalgia, or fibrositis), musculoskeletal disease (lumbago and any disease of the muscles or tendons), chronic fatigue syndrome, allergy (rhinitis and any allergy), skin disorders (skin cancer, tumors, cysts, eczema, psoriasis, dermatitis, and any disease of the hair or scalp including hair loss). A category referred to as “other medical conditions” was created for medical conditions with very low reported prevalence. Other medical conditions included neurological diseases (repeated seizures, convulsions or blackouts, neuralgia or neuritis), endocrine diseases (thyroid and other endocrine disorders), infectious diseases (malaria, leishmaniasis, chronic mononucleosis, and hepatitis), chronic candidiasis, amnesia, and sleep apnea.
Reported medical history by military status: unadjusted and adjusted associations between somatic disorders and military status.
All aspects of this study were approved by the Human Investigative Committees at Basrah University and Wayne State University as a collaborative research investigation. Arnetz et al38
provide further details of study design.