Soldiers who deployed to Saudi Arabia in support of Operation Desert Shield were exposed to a wide variety of stressors. These stressors from the pre-combat phase of the deployment undoubtedly affect the current health of Gulf War veterans, but the exact mechanisms and linkages are not known. This article examines the nature of those stressors and possible effects on later health of veterans.
Over 15 years have passed since the first forces from the United States and its Coalition partners deployed to Saudi Arabia for Operation Desert Shield, which would lead to Operation Desert Storm. In evaluating the stresses of the Persian Gulf War (PGW) today, we have the benefit of hindsight. Thus, most people tend to remember primarily the massive, essentially one-sided, air war followed by a four-day ground campaign in which Coalition ground forces moved rapidly across the desert to liberate Kuwait. This rear-view mirror look at the events of 1990–1991 makes it all too easy to forget the tension and hardship of the early days of Operation Desert Shield, when soldiers prepared for war in the desert, not knowing what the outcome would be. However, any understanding of the health and well-being of PGW veterans requires consideration of the experiences, both positive and negative, during the months that preceded the opening shots of Operation Desert Storm. Rather than looking at the veterans of that war as products of events that occurred in a few weeks in January and February of 1991, we must consider the web of events that occurred over a much longer period, from the decision to send forces to Operation Desert Shield through to their homecoming.
During the Gulf War, American forces sustained 148 combat dead, 145 non-battle deaths, 21 prisoners of war and 467 wounded in action. The forecasts had been for tens of thousands of deaths, and for chemical and biological warfare attacks. The mobilization of reservists for Desert Storm was a substantial burden on small towns, that lost major figures in their communities, including business and civic leaders, teachers, health care providers and law enforcement officials. Too often we focus narrowly on the combat related stressors, forgetting that threat to life and exposure to death are not the only stressors of the combat experience. The stressors of war evolve over the time line of many different war experiences: pre-deployment, deployment, sustainment, hostilities, reunion and reintegration (Norwood & Ursano 1996).
Iraq invaded Kuwait on 2 August 1990. On 7 August, the United States began moving forces to the region. The ‘operations tempo’, reflected in the build-up of troops and supplies, was unprecedented since World War II. The number of American service members in the Gulf reached 150 000 by mid-September. By Christmas of 1990 there were over a quarter million US military personnel in the Gulf and over 300 000 by the beginning of the air war on 17 January 1991 (Norwood & Ursano 1996). In the first 90 days of World War II, the US Army had moved 138 060 people and 836 060 tons of supplies. In the same period of the PGW, 184 483 people had been moved and over 1.2 million tons of supplies (from ‘Tracking the Storm’ 1991).
This paper examines the stressors of the early deployment to the Gulf and discusses the relationship of the events of that period to the health of veterans in the years since the PGW. The primary data source for the stressors of Operation Desert Shield is interview and survey research conducted by teams from the Walter Reed Army Institute of Research (WRAIR) in Saudi Arabia beginning in September 1990, and continuing through the war until June 1991 (Marlowe 1991, 2000). Follow-up research surveys were administered between July 1991 and November 1991, after units had returned to the United States. The nature of the Southwest Asia theatre of operations made well controlled, rigorous scientific research impossible, especially during the early days of the deployment, but the data from the WRAIR teams provide insights into the state of mind of soldiers in the initial defensive phase and the build-up to combat, as well as in the months following combat.
1. Research during Operations Desert Shield and Desert Storm
The methods used by the WRAIR research team have been described elsewhere (Gifford et al. 1992; Wright et al. 1996; Marlowe 2000). Interviews were conducted in small groups of soldiers of the same rank and from the same unit. Senior commanders and non-commissioned officers (NCOs) were typically interviewed individually. Leaders were never present when subordinates were interviewed (and vice versa). Whenever possible, interviews were conducted with soldiers at different levels of the same unit, e.g. within an infantry battalion, the battalion commander, the command sergeant major, company commanders and first sergeants, platoon leaders and platoon sergeants, squad leaders and squad members would be interviewed in succession. The ordering of the interviews from senior to junior was intentional, so that soldiers would not have interviewers they had just confided in going directly to the same leaders the soldiers might have spoken about.
Approximately 500 soldiers were interviewed during the early phase of Operation Desert Shield (September–October 1990) and over 800 were interviewed during the build-up to combat in November–December 1990. Interviews were 60–90 min and included discussion of the stressors of each stage of the deployment from initial notification to the present, as well as individual coping mechanisms, unit supports, and leader actions the soldiers found helpful in adapting to the stresses of the deployment. Interviews were open-ended, and soldiers were encouraged to bring up any issues they saw as important, both in describing stress points and in evaluating coping and adaptation measures.
Information from the initial interviews was used to develop a pre-combat survey. The survey was administered in late November and early December of 1990. During this time, soldiers prepared for combat that they knew could commence as early as 15 January 1991, the deadline the Coalition had set for Iraqi withdrawal from Kuwait. The questionnaire, approximately 45 min long, was administered at the units' field sites where the soldiers lived and worked. The questionnaire included demographic items, items measuring the soldiers' belief about Army family support, measures of unit cohesion, perceptions of leaders, ratings of the stressfulness of various aspects of the deployment, the effectiveness of different coping techniques and the Brief Symptom Inventory (BSI), a measure of psychological distress (Derogatis & Spencer 1982). Approximately 1300 surveys were administered. In January 1991, a shortened version of this survey, which omitted items about deployment stressors, was administered to another 1600 soldiers in units about to go to combat.
The research was requested by the Chief of Staff of the United States Army in order to gather information on soldier adaptation and coping during the deployment. The information was to assist the Army Staff in decisions about needed support for the deployed soldiers. All interviews and surveys were with US Army soldiers. The preponderance of both interviews and surveys were conducted in combat arms and divisional support units. For this reason, most of the sample was male. The samples for both interviews and surveys were opportunity samples. However, the research teams attempted to obtain a wide geographical, unit and rank sample, collecting data throughout the theatre and interviewing soldiers ranging in rank from private to major general. Thus, the sample did capture a broad range of the US Army forces in the theatre.
Although the WRAIR research teams concentrated on US Army forces, there is no reason to believe that the experience of the many other Coalition forces deployed to Southwest Asia differed substantially, or that they reacted differently to the stressors of deployment. Members of the research teams had numerous casual interactions with members of forces from the several other nations, including the United Kingdom, Canada and France, as well as with non-Army components of the United States forces. None of these interactions led to any observation that suggested that soldiers from other nations or other components of the US forces had divergent perspectives on the situation they were in (R. K. Gifford 1991, unpublished work).
2. Stressors of the early Persian Gulf War
Importantly, on the whole, most soldiers reported coping well in a difficult deployment, despite being under considerable stress. As in all wars, the nature of the stressors changed during the course of the deployment. The main stressor identified in September–October 1990 (see table 1) was the uncertainty of the tour length, since soldiers had no idea whether they would be there for a few more weeks or, at the other extreme, possibly a year or more. They had been sent to deter further Iraqi aggression, and when Iraq had not invaded Saudi Arabia, they wanted to know whether they were going to liberate Kuwait or whether they were going to stay in the desert in a long-term face-off with the Iraqi Army. There was a decided distaste for the latter option. More than one soldier said words to the effect ‘Send us north or send us home!’ That statement, in its various forms, was more than macho posturing. It was an expression of a genuine feeling that at this stage of the operation, their skills were being wasted in static positions, and also of frustration with what they saw as their ambiguous role, unsure whether they were in a pre-combat phase or whether they were establishing a garrison force.
This feeling of frustration at being stranded in the desert with no clear end in sight was combined with a general lack of information about what was occurring at higher levels, what plans were being made and what the overall status of the operation was. Indeed, soldiers had a hard time getting any information about the world outside of their units. Most soldiers did not have access to current newspapers or magazines, and there was no television access. Some soldiers were able to get news from radio stations such as the BBC, but they were a minority. Mail service was slow, with letters typically taking weeks. Opportunities for telephone calls were infrequent. Thus, information deprivation became a stressor in its own right, as did the rumours that inevitably developed in the absence of information. Soldiers heard many rumours about dates they were due to be sent home. When the dates came and there was no re-deployment, they were disappointed. They also heard various rumours about problems that might affect their families back home, such as crime in the largely deserted military housing areas. Without the ability to communicate with their families in anything approximating real time, soldiers found these rumours worrisome and stressful. Another effect of the lack of information was that many soldiers were not aware of the overwhelming public support for their service. Soldiers were still greatly affected by the legacy of the Vietnam War, and wondered, with considerable apprehension, what the American public thought of them and how they would be seen when they returned to the United States.
The sense of isolation that soldiers felt was compounded by stressful living conditions. Soldiers lived in a variety of situations, but almost all were austere. Those who were in the desert lived in tents (although some had to do without tents for several weeks because they had not arrived) in intense heat and with fine-grained sand working its way into everything they owned. Other units, especially headquarters units, lived in fixed structures that, at first glance, appeared relatively luxurious compared to living in the sand. However, that appearance of luxury was an illusion in most cases, because people lived and worked in extremely crowded conditions. Often cots were crowded together only inches apart, sometimes with hundreds of people living in a warehouse. Indeed, crowded living conditions forced some units to use ‘hot cots’: two soldiers, working different shifts, would be assigned to the same cot, one for sleeping during the day and one at night.
Soldiers, except those fortunate enough to have duties that required them to travel, generally had almost no opportunity to go outside of their immediate unit areas. They spent most of their time in crowded camps, working long hours and with very little to entertain them in the rare times off. They were constantly in the company of their fellow unit members and their chain of command. While this enforced togetherness provided an opportunity that many units used to train and work in ways that enhanced cohesion, it was also stressful for both soldiers and leaders. As time went on, the lack of privacy and constant presence of the chain of command was wearing. Soldiers felt that they were always under scrutiny by their leaders, while leaders, especially NCOs at the squad and platoon levels, felt the pressure of always being in the leadership role, with no time to relax among peers. Furthermore, they felt the pressures of being isolated in a foreign culture, with which most of them had no opportunity to interact. Sensitivity to Saudi mores led to a number of regulations that soldiers found irritating, such as restrictions in dress (e.g. female soldiers' not being allowed to work in t-shirts), perceived limitations on expression of religion, restrictions on reading material that contained pictures depicting nudity or scanty attire, and a total ban on alcoholic beverages. Some complained that these restrictions, which they saw as imposed on behalf of a nation they had come to rescue, were unnecessarily depriving them of personal liberties they were accustomed to.
There were few amenities for soldiers in the early days of the operation. The need to get people and combat equipment to the theatre as rapidly as possible precluded bringing morale, welfare, and recreation (MWR) equipment in the early shipments, so any sports or games were conducted with improvised equipment, and, at first, there were few amusements such as books or movies available. Many soldiers had only the Army's pre-packaged MRE (meals ready to eat) rations, because the heavily burdened supply system had not delivered fresh rations to their units. Soldiers could cope with discomforts and shortages, and indeed many took pride in the fact that they did without comforts that people back in the United States take for granted. However, the presence or absence of minor amenities also took on symbolic importance, and relative deprivation became an issue. If the unit down the road got better rations than one's own unit, in the eyes of many soldiers it was because that unit's leaders cared more about their soldiers.
Over time, soldiers' concerns changed. By November–December, soldiers had begun to adapt to life in the desert, and their field sites became ‘home.’ The enhanced infrastructure of the maturing theatre meant that living conditions were less austere. Living spaces had improved for most, and there was much wider access to MWR equipment, recreational opportunities, and even small post exchanges where soldiers could purchase snacks, soft drinks and personal items. Life was still difficult compared to being back in the United States, and the desert was still a harsh environment, but by November of 1990 most soldiers were in much more pleasant living conditions. Amenities were important, not because soldiers need soft drinks and junk food to survive, but because they provided assurance that someone back home cared. Of course, soldiers were still entering the theatre at a great rate, and the newer arrivals did not always appreciate how much better daily life was than it had been for the earlier arriving soldiers. But for those that had been there, improvements raised spirits considerably. The outpouring of public support also helped soldiers realize that they did not need to worry that they would suffer the fate of their predecessors in Vietnam, coming home to an indifferent or even hostile public.
Furthermore, major political events had changed the nature of the previous top stressor (i.e. uncertainty of tour length). First, the Secretary of Defense announced that American soldiers would not be rotated out of the theatre—they were there until Iraqi forces were out of Kuwait. This was followed shortly by a deadline of 15 January 1991, for Iraq to get its forces out of Kuwait or face military action by Coalition forces to achieve that end. Thus, while soldiers still did not have a fixed date to return home, they now knew what events must occur before that could happen, and, psychologically, that was an important boost. Soldiers also knew that they would be training for possible offensive combat operations for the next several weeks. While the question of whether they would actually face combat obviously left them with major uncertainty, the general feeling soldiers expressed in interviews was that now they knew what was going to happen and they could get to work preparing for the operation ahead.
In this later stage, with the emphasis on preparation for combat, morale went up, at least based on the subjective comments made in interviews. Some positive aspects of the stressful deployment were becoming evident. In units that had functioned well before deployment, the intensive training and close living enhanced confidence and cohesion. Soldiers also felt pride in having adapted successfully to life in the desert, and appeared to have developed skills in living together in constant proximity and resolving interpersonal problems.
Fatigue and lack of sleep were still problems, since soldiers worked long hours. Support units were particularly stressed, often working 15–16 h days six or seven days a week, as they built the infrastructure to prepare the force for combat and support and sustain the force once combat began. The deployment factors cited as most stressful on the survey (see table 2) were not having the companionship of the opposite sex, flies, lack of contact with family back home, lack of private time, not being allowed to ‘act like Americans’, eating MREs a lot of the time, people in other units having things better, leaders around too much of the time, lack of adequate MWR and lack of alcoholic drinks.
Soldiers' top concern about combat was the threat of attack with chemical or biological weapons. Considerable publicity was given to this possibility, and many medical soldiers were given a special in-theatre course in care of chemical combat casualties. The combat trauma soldiers cited fearing most was the possibility of a friend getting killed or wounded, followed, in order, by the possibility of themselves getting killed or wounded, not getting adequate medical care if hit and losing a leader (table 3). Killing or wounding the enemy was low on their list of anticipated stresses, although we know from data collected after the war that those who actually killed enemy soldiers often found it stressful (Marlowe 2000).
The fear of losing friends, and of getting killed or wounded oneself, was very realistic, since the units had been told to expect thousands of casualties. While today we remember the relatively small number of casualties as one of the hallmarks of the PGW, the psychological reality for American soldiers at the time was an expectation of high casualties. This expectation continued until practically the end of the war. Furthermore, in the weeks leading up to ground combat, there were frequent alarms for chemical attacks and Scud missile attacks. The former were virtually always false alarms, but they were powerful stressors nonetheless. As soldiers entered ground combat, they had no way of knowing that there would be no massive Iraqi chemical attack and that the combat would be a very lopsided contest. To them, this was an extremely dangerous operation with a high risk of death and injury.
3. Post-war research on soldier health
Considerable research has been conducted on the health of PGW veterans, and several of these studies are mentioned below. This body of research tells us quite a bit about the overall health of veterans; unfortunately, despite the best efforts of researchers, there is little evidence to link specific stressors from the PGW to specific health outcomes, and almost all of the research that has been conducted has, given the absence of pre-deployment or immediate post-combat data other than the WRAIR surveys, necessarily relied on retrospective surveys to rate exposure to stressors. As Southwick et al. (1997) and Wessely et al. (2003) have noted, recall of wartime experiences is unstable over time, with potential for both exaggeration and minimization of exposure. Southwick et al. specifically found a positive correlation between increases in post-traumatic stress disorder (PTSD) scale scores and number of wartime traumatic events recalled.
The WRAIR studies included surveys conducted six to nine months after soldiers returned from the combat zone, and there were 1293 soldiers for whom both pre-combat (but not pre-deployment) and post-combat BSI scores were available (Marlowe 2000). Marlowe did not find any general elevation of symptom scores at that point, and the most striking finding was that the soldiers who reported the highest levels of symptoms in the post-combat survey tended to be those who had reported the highest levels before combat, in the December 1990 survey. Some individuals whose BSI scores went up between the pre-combat and post-combat surveys did report high levels of combat exposure. Unfortunately, as Marlowe points out, we have no data on any of the sample before deployment. Even though they had not been in combat yet, they were already under considerable stress when initially surveyed. Further, different levels of reported symptoms on the BSI, while an important finding, do not equate to differential health outcomes. The WRAIR studies did not include clinical data, and the best evidence available from interviews conducted in conjunction with the surveys suggested that even those who endorsed items reflecting symptoms were still basically healthy at that point.
Despite Marlowe's finding of a high overall level of health among PGW veterans shortly after return from Southwest Asia, there were soldiers in the WRAIR sample who reported a number of symptoms. Studies of veterans' health that were conducted longer after return from the war have consistently found that PGW veterans are more likely to report a number of health problems than are various control groups. Studies looking specifically at the health of PGW veterans have found that those who served in the Gulf War are more likely to report a variety of symptoms and illnesses than various comparison groups who did not serve in the Persian Gulf (Iowa Persian Gulf Study Group 1997; Joseph 1997; Wolfe et al. 1998; Kang et al. 2000; Stuart et al. 2002). The complaints most associated with PGW service include musculoskeletal pain, fatigue, cognition and memory complaints, depression, anxiety, sleep disturbance and gastrointestinal complaints. While these studies have also reported numerous stressors, there has been no strong evidence to date tying specific stressors to particular symptoms. None of the symptoms are unique to Gulf War veterans. Hyams et al. (1996) discuss the appearance of several of these symptoms in various conflicts throughout history. So, whatever causes the increased symptoms found among Gulf War veterans, it is probably not unique to the specific circumstances of the PGW.
Stimpson et al. (2003) reviewed 20 studies of the mental health of PGW veterans and found that, despite variations among studies, the consistent finding was the PGW veterans were more likely than comparison groups to report PTSD or common mental disorder (depression, or anxiety based on recognized standard assessment instruments). The effect was stronger for PTSD, with an odds ratio of 3.2 compared to an odds ratio of 2.0 for common mental disorder. Stimpson et al. noted that it is not clear how this finding relates to physical problems reported by PGW veterans.
Unwin and colleagues (Unwin et al. 1999, 2002) reported that UK veterans of the PGW were more likely to report a variety of symptoms than either soldiers serving at the same time who had not deployed to the Gulf or a comparison group who had deployed to Bosnia. Unwin et al. (1999) further noted that although the PGW veteran group in their sample had greater likelihood of meeting criteria for PTSD, chronic fatigue, or multisymptom syndrome, there was no evidence of increased frequency of objective outcomes such as birth defects, cancers, or death.
Other researchers have found that reports of PTSD symptoms correlate positively with self-reports of other health symptoms (Engel et al. 2000; Wagner et al. 2000). As Engel et al. concluded, ‘PTSD diminishes the general health perceptions of care-seeking Gulf War veterans. Clinicians should carefully consider PTSD when evaluating Gulf War veterans with vague, multiple, or medically unexplained physical symptoms.’ In a population-based nested case–control study, Ismail and colleagues found that physically disabled UK Gulf War veterans had consistently higher rates of mental disorders than non-disabled Gulf War veterans (Ismail et al. 2002). The investigators cautioned, however, that only a minority of Gulf veterans with physical disabilities had a comorbid mental disorder. Thus, we can conclude from the available literature that PGW veterans report both more psychological symptoms and more physical ailments than comparison groups who did not serve in the PGW, but we cannot confidently assert the role of particular deployment stressors in these elevated levels of symptom reporting.
Stuart et al. (2003) examined belief in exposure to chemical agents (mustard or nerve gas) among veterans of the PGW in the Department of Defense's Comprehensive Clinical Evaluation Program registry (Joseph 1997). Stuart et al. found that those who believed they had been exposed to chemical agents reported more current physical symptoms than those who did not believe they had been exposed. Since there is no evidence that the majority of those who reported exposure were actually exposed to any chemical agents (although some of those in the sample may have been exposed during postwar destruction of Iraqi stockpiles), the critical factor in later health may be belief in exposure, rather than exposure per se. This study is important because it draws our attention to belief as an important area to study to complement our knowledge of the effects of actual exposure. Understanding how beliefs form and are shared in combat and post-combat settings is important to our learning more about the association of post-combat symptoms and pre- and during combat experiences. There are undoubtedly individual differences in how beliefs are formed and interpreted. At present, we do not know how such individual differences affect post-combat symptoms; however, there are reports in the literature that suggest that how a person processes information and forms beliefs correlates with reports of symptoms after combat. For example, Bartone et al. (1992) and Sutker et al. (1995) report that veterans who score higher on measures of personal resiliency, which in part measure how a person forms beliefs about life events, have lower scores on scales that predict PTSD.
Another difficulty in linking specific stressors to later outcomes for veterans, as documented in the WRAIR studies, is the sheer complexity and changing over time of the array of stressors which soldiers face. In addition to the pre-combat and combat stressors, many soldiers had additional stressors to cope with as part of the homecoming process. Besides the inherent difficulties in reintegrating into civilian life or returning to peacetime garrison life, many soldiers faced economic difficulties, either from the economic recession in the United States at the time or from the downsizing of the military that had been planned even before the war began. Some returned to family situations that were stressful. Newspapers at the time featured many accounts of marriages failing. The role of the deployment in the breakup of these marriages is not clear. Nearly 9% (8.9%) of soldiers surveyed in December of 1990 reported moderate or major family problems (J. S. Stuart 2005, personal communication). The relationship of those problems to post-war family adjustment is unknown. Post-war, a common theme in interviews was that the marriages that broke up were ones that had been in difficulty before the war, and some soldiers reported that the experience of going to war had actually strengthened their marriages (Marlowe 2000). Nevertheless, family re-adjustment must be considered a major stressor for at least some soldiers.
A wide variety of stressors affected soldiers before combat ever occurred, and, in fact, before it was certain that any combat would occur. The relevant question for our understanding of PGW veterans today is how these stresses affected the later lives of soldiers. It seems certain that the lives of these soldiers were significantly altered by their participation in Operation Desert Shield and would have been even if the combat phase of Operation Desert Storm had never been launched. There is no way to estimate how many soldiers would have found their later lives enriched by their participation in the deployment and how many would have suffered negative consequences, some of which might have been attributed to Operation Desert Shield. Research from other deployments suggests that there would have been substantial numbers in each group (Newby et al. 2005).
In addition to the economic problems and family adjustment stress noted above, other events that happen to veterans in the years after deployment probably interact in complex ways with the deployment and combat stressors they have already experienced. The solider faces stressors across the time line of garrison to combat to return to reintegration to civilian life: pre-deployment, deployment, sustainment, hostilities, reunion and reintegration. The individual soldier faces the web of war and life stressors across time and space.
Thus, in order to comprehend health outcomes after combat, we need to understand the relationship of pre-, during and post-combat stressors to health outcomes: the burden of going to war, the burden of war and the burden of return from war. Responses of resilience, distress, behaviour change and psychiatric illness are to be expected. Indeed, most PGW veterans are healthy, based on all the studies conducted so far. However, no one goes through such experiences without life changing. The challenge lies in determining what differentiates those individuals who have been resilient and those who need post-combat health care.
While this is a daunting task, some recent efforts have demonstrated methodologies that could make progress toward this goal. The Mental Health Advisory Team sent to Iraq in 2003 by the US Army (Department of the Army 2003) did both interviews and surveys during the course of the operation, and made recommendations for data collection efforts that would provide pre-deployment, deployment and post-deployment data on soldiers currently serving in Iraq. A recent review of psychiatric care in the post 9/11 war on terrorism has reached similar conclusions (Ursano et al. 2004). If these recommendations are implemented, they can enhance our ability to understand the complex individual factors that determine soldiers' responses to the experience of deployment and combat, and to provide the care and assistance that they need.
One contribution of 17 to a Theme Issue ‘The health of Gulf War veterans’.
- © 2006 The Royal Society