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8 March 1997
THE LATE Michael Shepherd, Professor of Psychiatry at the Maudsley Hospital, London, told me that he had once tried to get the World Health Assembly to pass the resolution that "War is bad for health". The delegates immediately began to ask him (as he knew they would) which war he was referring to: they were evidently under the impression that the wars on which their own countries were currently engaged were of the health-giving variety. He was quite unable to convince them (as he knew he would be) that war as such is deleterious to health.

But as wars go, the Gulf war was comparatively healthy, at least for the victors. Unfortunately, a medical condition has come back to haunt the self-congratulatory war ministries of the allied world: the Gulf war syndrome. This consists of a collection of generally rather vague symptoms whose existence as a definite disease entity, let alone whose cause, has proved difficult to prove.

Governments have been left with an impossible task: to prove a negative. When they deny the existence of a specific Gulf war syndrome, no one believes them: after all, we most of us lie when it is in our interests to do so, and clearly it is in the interests of our governors to lie on this particular question, as on many others. Why should we believe them? The more frequent and vehement their denials, the less they are believed.

People whom most of us are disinclined to believe for a priori reasons are now in the invidious position of having to prove to the public's satisfaction the non-existence of an illness. But why should such non-existence be so difficult to prove?

In the first place, however much research is done it is always possible that something has been overlooked, and that further research will uncover something hitherto unsuspected. In the second place, if two groups of people are studied in enough detail it is inevitable that some differences which appear not to have arisen as the result of chance will be discovered. If the health of a group of people who shop at Sainsbury's were to be compared in enough detail with that of a group of people who shop at Tesco's, eventually evidence of a post-Sainsbury's or post-Tesco's syndrome would emerge. The search would then be on for environmental factors to explain the difference.

Of course, Gulf war syndrome is much more serious than this analogy might suggest. Many servicemen - who appear to have joined up imagining that war was a thing of the past, and that armies are now purely ornamental or a form of disguised unemployment - returned home from the Gulf deeply traumatised psychologically. Their concentration and memory were impaired, they felt fatigued, their libido decreased, they slept poorly and had nightmares reliving scenes from the war, they felt depressed, and were irritable and nervous. War is a terrible business, and no amount of training can prepare everyone fully for its reality.

But several factors have profoundly muddied the waters. First, the wide publicity given to the existence of a supposed syndrome might in itself have affected the incidence of the syndrome itself. La Rochefoucauld said that most people would never have fallen in love if they had never heard of it; and this is a psychological mechanism which, a fortiori, might well apply in a case such as this.

Worse still, the question of compensation and pensions has arisen. Nothing prevents the elucidation of cause and effect in clinical problems like the Gulf war syndrome more than the hope of monetary gain. This is especially sad, since the payment of compensation in any case rarely leads to happiness or to a resolution of symptoms, even where they are completely psychological in origin. This is because the compensated person feels a moral obligation to continue to be ill, otherwise he stands revealed in his own eyes as a fraud. People who enter the search for compensation are often entering a kind of purgatory from which they rarely emerge.

A principally or wholly psychological explanation of the Gulf war syndrome will not satisfy those who suffer it, for two reasons: first, it will force upon them a view of themselves which is less than flattering to their self-esteem. Soldiers more than others like to believe that they are tough and equal to anything which they can experience. Second, it is likely that, unless a physical cause for the syndrome can be established with reasonable certainty, public sympathy and support will ebb away.

No mealy-mouthed attempt to prove that there is no philosophically valid difference between the physical and psychological causation of symptoms will do. The public is likely to take the view that, in the absence of a physical cause of the Gulf war syndrome, those members of the armed forces who are content to draw their pay in peace must be prepared to pay the price in war.

The symptoms reported by veterans of the Gulf war are not dissimilar in kind to those reported by veterans of other wars, including the American Civil War and the Vietnam War. Moreover, they are not dissimilar from those reported in such strange disorders as the sick building syndrome, in which large numbers of workers in certain buildings experience various complaints and attribute them to something in the building: its ventilation, the radon its walls emit, and so forth.

It is important to keep an open mind, of course. The fact that the Gulf war syndrome does not conform to any known disease pattern does not mean that it does not exist: acccording to an old adage, absence of proof is not proof of absence. But it is certainly not beyond the bounds of possibility that while some cases are "genuine" (that is to say, have been caused by exposure to a pathologenic agent), others are the result of fear, publicity and the hope of gain.

Whatever the medical truth about the Gulf war syndrome - which may not emerge for many years, for such controversies have a considerable life-expectancy of their own - the episode does tell us quite a lot about ourselves. For what the Gulf war teaches is that governments of liberal democracies such as ours can no longer cavalierly - or even justifiably - send thousands of young men and women off to war, in the hope and expectation that, once the war is over, their condition may safely be forgotten.

On the contrary, veterans will insist on being heard, and they will insist on compensation if they suffer any harm whatever. The stiff upper lip has gone for good; and there is no cannon fodder any more.

This, no doubt, represents a considerable advance in civilisation; though whether the enemies of civilisation itself will show a similar squeamishness when it comes to making war may be doubted.