A final victory in the Persian Gulf War may be won far from Iraq's desert and the burning oil wells whose smoke darkened Kuwait for weeks.
American troops fought in one of the most chemically active combat zones in the history of U.S. warfare. And now as many as 4,000 veterans have Gulf War Syndrome, an illness that so far has defied diagnosis.
Victims complain of many problems, including fatigue, memory disorders, mood swings, body pain and insomnia.
With the war's shift from the battlefield to the field of clinical research, Claudia S. Miller, MD, an allergist and immunologist at the Health Science Center, finds herself on the front line of a politically-charged medical mystery. In January, the Defense Department pledged $1.2 million for a research project similar to that first proposed by Dr. Miller to test the sick veterans for "multiple chemical sensitivity," or MCS.
"Her work has great potential importance as a possible etiology for the illnesses," said Maj. Gen. Ronald R. Blanck, DO, commander of Walter Reed Army Medical Center in Washington, D.C., and head of the Defense Department's clinical task force on the gulf veterans' illnesses.
"More significantly, it has a tremendous potential benefit to society, which is increasingly being exposed to low levels of a variety of chemicals in the environment," Dr. Blanck said.
The Gulf War mystery fell in Dr. Miller's lap in 1992. She had become nationally known for her research into chemical exposure and its relationship to human illnesses. The Department of Veterans Affairs hired her as a consultant to examine its Gulf War patients and try to find a diagnosis.
"I noticed that the symptoms of some of the veterans were strikingly similar to multiple chemical sensitivity, a controversial condition that civilian patients had reported having before the war," she said.
In 1993, Dr. Miller was appointed to the VA's blue-ribbon scientific panel on the Gulf War illnesses. She acknowledged that MCS was unproven but pressed for clinical research on the subject.
MCS is a condition that has stirred controversy since it was first described 40 years ago. Victims say they are "sensitized" by intense or long-term chemical exposures and thereafter become sick when exposed to low levels of any number of chemicals.
Dr. Miller had studied related issues involving indoor air pollution and pesticide exposure, but said it was unknown whether exposure to low levels of environmental chemicals could affect previously sensitized individuals. She proposed building an "environmental medical unit," a set of ultraclean rooms to test patients for chemical sensitivities. Her approach began to win support from the military, veterans' organizations, scientists and congressmen.
In November, Congress appropriated $300,000 in defense funds for the unit. Defense officials announced in January they would supply the additional $920,000 needed to build and operate it. There was no immediate announcement about where the unit would be located, but congressmen who campaigned for its funding want it to be in San Antonio.
During a December visit to the Health Science Center, Rep. G.V. "Sonny" Montgomery, D-Miss., chairman of the Veterans Affairs Committee, and committee member Rep. Frank Tejeda, D-Texas, endorsed Dr. Miller's proposal for the unit and said it should be built in San Antonio.
MCS causes no known changes in antibodies, a fundamental clue in diagnosing allergies. How it affects the body, if it affects the body, is unclear. The American Medical Association has deferred recognizing MCS as a clinical diagnosis, citing a lack of research. Skeptics in medicine and science argue that Gulf War Syndrome, and MCS for that matter, are ill-defined and probably psychological in nature.
Dr. Miller acknowledges a gap in scientific proof, but says MCS could be the most logical explanation for the Gulf War illnesses.
"If I have any advocacy, it's not for one side or the other in this dispute. It's advocacy for careful research. Knowledge about chemical sensitivities is lagging far behind the pressing health care needs of the veterans. Without studies, we cannot define the mechanism and without a mechanism, treatments are just guesses," she said.
Dr. Miller's name and work have been cited by the New York Times, USA Today, the prestigious journal Science and other publications. In 1993, she testified before the House Veterans Affairs Subcommittee on Oversight and Investigations and began to win allies in her call for MCS research.
"She took a very courageous stand," said Iris Bell, MD, PhD, a leading researcher in the effects of environmental exposures on the brain. Dr. Bell is a psychiatrist at the University of Arizona and the VA hospital in Tucson.
The environmental medical unit would have eight beds in four rooms where the indoor air is filtered for optimum purity. Porcelain walls and special furnishings would minimize "out- gassing," the release of low-level chemicals common in plastics and other synthetic materials.
After several days in the unit, away from their usual home and work environment, patients would be given very low concentrations of the chemicals they would breathe, ingest or somehow encounter in daily living. These "challenges" would be blinded. In other words, substances would be presented so that patients could not smell or taste them. Patient reactions would be measured and analyzed.
The environmental unit is critical to ending the debate about whether MCS is real or imagined, said Sanford A. Miller, PhD, no relation to Dr. Miller, who is dean of the Health Science Center's Graduate School of Biomedical Sciences and a former high ranking executive in the U.S. Food and Drug Administration.
"Claudia Miller wants to apply scientific standards to define what this disorder is and she has been remarkably objective. If she were anything but neutral in this debate, the last thing she would want is that environmental unit because it could just as well prove that she is wrong as prove she is right," he said.
Findings from the environmental unit could have a profound effect on medicine, consumer products and the way Americans live if evidence emerges to link illness with low-level chemical exposures.
Dr. Claudia Miller contends that Americans encounter many of the same chemicals suspected of making the Gulf War veterans ill. She said more doctors are seeing patients with similar problems and the number of cases of reported chemical sensitivity appears to have risen sharply in the past decade.
In addition, patients with primary diagnoses of asthma, migraine, depression and chronic fatigue report many of the same kinds of chemical exposures that MCS patients say trigger their symptoms.
Years ago, miners kept caged canaries nearby to warn them if they were breathing dangerous gas. They would flee if a bird died. "Some people feel these chemically sensitive people are our canaries," Dr. Miller said. "I don't know, but we need to find out."
Military personnel in the Gulf War encountered a potent brew of chemicals. "The use of environmental agents was far greater in this war than in Vietnam," Dr. Blanck said.
There were pesticides to kill desert insects. Ammunition and armor made with depleted uranium, a heavy metal that is toxic as well as radioactive. Pyridostigmine bromide pills to protect against a poison-gas attack. Smoky, fuel-burning tent heaters. Diesel oil doused on roadways, runways and even inside tents to stop sand from blowing. One veteran said the diesel wicked up his tent's canvas siding. Others reported diesel odor and smoke in their tents and other areas.
Iraqi forces torched Kuwait's oil fields. Smoke from the fires was visible from space. The air turned foul, the sky turned dark and it rained a black, oily residue. Water became contaminated. "We all took showers in oily water," a former Army medic from San Antonio said.
In 1993, reports surfaced that some military personnel may have been exposed to low levels of Iraqi chemical warfare agents. Investigators for Sen. Donald Riegle, D-Mich., said it was possible the chemicals escaped when U.S. warplanes bombed Iraq's nerve-gas plants.
Iraqi leader Saddam Hussein had threatened to use chemical weapons. Several GIs reported becoming ill on or after Jan. 17, 1991, the day Baghdad's official government newspaper said Iraq would unleash a secret weapon that "will astonish our enemies and fascinate our friends."
Defense officials have examined the possibility of low-level gas exposure, but report finding no evidence to support it.
Dr. Miller's role in solving the Gulf War mystery began in 1992. The VA's Houston Regional Referral Center hired her to examine some of the sickest Gulf War veterans who had been sent there from across the nation. She has since completed more than 20 comprehensive evaluations.
In the '70s, she distinguished herself as an industrial hygienist. Determined to pursue an interest in health effects of low -level chemical exposure, Dr. Miller enrolled in the Health Science Center's School of Medicine in the '80s. Later, her work became widely read. In 1991, she wrote the acclaimed book Chemical Exposures: Low Levels and High Stakes, which won an award from the World Health Organization.
Her co-author, Nicholas A. Ashford, PhD, JD, professor of technology and policy at Massachusetts Institute of Technology, said the book brought MCS into the mainstream of medical inquiry. Issues involving chemical sensitivity had become clouded by the unconventional treatment techniques of its chief proponents, clinical ecologists. Some ecologists prescribed vitamins or sweating in a sauna.
"It's important not to throw out the baby with the bathwater," Dr. Miller said. "We don't have to believe in all of the therapies these patients try in order to find out whether people are ill from low-level exposures to chemicals."
The respected Journal of the American Medical Association gave the book a favorable review. Soon the National Academy of Sciences and the Association of Occupational and Environmental Clinics sponsored national workshops on the subject. Participants seemed to agree that research was needed. Even skeptics acknowledged a need for the type of studies proposed by Drs. Ashford and Miller.
Dr. Ashford, who has known her for 20 years, said, "Claudia Miller understands the problem of chemical sensitivity better than anyone else in the world. She does not overstate what the evidence shows. She is clear about where the facts end and the speculation begins."
Dr. Miller grew up in Milwaukee. Her mother was a reading teacher; her father, a patent attorney. In the early '60s, she was the first girl at her high school to win the annual Bausch & Lomb science award.
She went to college amid the anti-war protests of the '60s. Dr. Miller was Phi Beta Kappa at the University of Wisconsin, where she received her bachelor's degree in molecular biology in 1968. She obtained her master's degree in public health a year later from the University of California at Berkeley.
Graduating from Berkeley, Dr. Miller became an industrial hygienist, and worked in the field for 12 years; first for the University of California Medical Center in San Francisco, then the Occupational Safety and Health Administration (OSHA) and finally for the United Steelworkers union.
In the mid-'70s, she helped solve unexplained illnesses at an electronics assembly plant in Pennsylvania. Dozens of solderers, mostly women, complained of headaches, nausea and difficulty concentrating. Federal investigators blamed the illnesses on psychological causes, but Dr. Miller had doubts.
"The women were breathing a cloud of organic and inorganic chemicals from the solder fumes. Some of us wondered if the cause might not be from these low-level chemical exposures. Our thinking was that maybe levels that meet OSHA standards still aren't always safe for everybody," she said.
Dr. Miller recommended adding exhaust hoods to ventilate the soldering area. The company installed the units and the illnesses went away.
Dr. Ashford, then chairman of OSHA's advisory committee, was impressed. "Everyone was calling this case mass psychogenic illness, but Claudia Miller thought they were jumping to conclusions and suggested the idea of systemic poisoning. She was right on the money, and that was 20 years ago."
Her colleagues describe her as tenacious, incisive and adept at analyzing complex problems.
"Claudia Miller is a dedicated scientist who is devoted to unraveling the mysteries behind the symptoms displayed by Persian Gulf veterans and others," said James Young, PhD, dean of the Health Science Center's Medical School and himself a former career soldier. "If she is given the necessary resources to establish an environmental unit and to conduct the appropriate research, I am confident that she will play a pivotal role in finding the root causes of these troubling conditions and pointing the way to their treatment."
Dr. Miller's dedication seems to be nourished by her years examining occupational health issues, particularly those affecting blue-collar workers. She said:
"I have been through a much different experience than most physicians. I've been in mines, smelters, foundries, steel mills and manufacturing plants of all kinds. It was a very compelling and eye- opening experience. I realize what people must do to make a living, and what they are exposed to in the process.
"I wouldn't have gone to medical school if I hadn't been an industrial hygienist first and seen a problem that I felt was important enough for me to spend nine years in medical school and in training."
Dr. Miller teaches environmental and occupational health in the Health Science Center's department of family practice. On campus, she collaborates in research with Howard C. Mitzel, PhD, assistant professor of family practice, and Leonid Bunegin, assistant professor of anesthesiology. She also is an adjunct faculty member in the School of Public Health and teaches aerospace medicine residents from Brooks Air Force Base in San Antonio.
National debate about "sick building" syndrome, hazardous waste sites and the Gulf War illnesses has focused growing public attention on chemical sensitivity.
Several state and federal agencies have been pulled into the debate, but none so directly as the Environmental Protection Agency (EPA), which was sensitized itself by an embarrassing incident in 1987.
About 200 EPA employees became sick when the agency remodeled its headquarters in Washington. Workers had repainted office space and installed 27,000 square yards of new carpet.
Several dozen employees have since claimed they have MCS. Some have sued. They have complained that they are unable to tolerate perfume, engine exhaust, tobacco smoke and low levels of other substances that never bothered them before the incident.
Dr. Miller says Americans are exposed to more low-level chemicals than ever before, and cites three reasons:
+ Increased use of synthetic organic chemicals. "These include solvents, pesticides, adhesives -- substances that find their way into our buildings, our clothing, our consumer products, the equipment we use and the fragrances we wear."
+ Lack of fresh air indoors. "We 'tightened' our buildings and insulated them well to conserve energy after the Arab oil embargo in the mid-'70s. As a result, the average home has about half as much fresh air coming into it as the older homes did."
+ Modern lifestyles. "On average, we spend 90 percent of our day indoors. Most of us get our highest exposure to chloroform when we get into a spa or take a hot shower. Our greatest exposure to benzene occurs when we fill our car with gasoline. Homes with an attached garage also have a higher level of benzene that those with a detached garage."
Business and industry have paid close attention to incidents that seem to be associated with chemicals in products.
"The struggle here is between psychosocial issues and science. In other words, when is a smell an irritant, and when is it just a smell most of us don't like?" said Mark Stuart of the National Association of Manufacturers in Washington, a trade organization.
"The truth is there is no way to tell in black and white that any smell is directly related to an illness," Stuart said.
Real or imagined, illness associated with low-level chemicals from the Gulf War or elsewhere appears to be a frontier for medical research in the '90s. Amid the controversy, Dr. Miller said she keeps in mind a lesson her parents taught her years ago.
"They patiently read stories to me as a child, encouraged my interest in science, and taught me to keep the two separated," she said. "You have to remember that stories are about belief. Science is 'guess and test.' It's not about belief. It's about facts."