Visit https://ebooknice.

com to download the full version and

explore more ebooks

(Ebook) Gulf War and health by Committee on Gulf War

and Health: Infectious Diseases, Abigail E.
Mitchell, Laura B. Sivitz, Robert E. Black ISBN
9780309101066, 0309101069
_____ Click the link below to download _____
https://ebooknice.com/product/gulf-war-and-
health-1382968

Explore and download more ebooks at ebooknice.com

Here are some recommended products that might interest you.
You can download now and explore!

(Ebook) Biota Grow 2C gather 2C cook by Loucas, Jason;

Viles, James ISBN 9781459699816, 9781743365571,
9781925268492, 1459699815, 1743365578, 1925268497
https://ebooknice.com/product/biota-grow-2c-gather-2c-cook-6661374

ebooknice.com

(Ebook) Gulf War and health by Committee on Gulf War and

Health: A Review of the Medical Literature Relative to the
Gulf War Veterans' Health ISBN 9780309101769, 030910176X
https://ebooknice.com/product/gulf-war-and-health-1382970

ebooknice.com

(Ebook) Gulf War and Health : Volume 8: Update of Health

Effects of Serving in the Gulf War by Institute of
Medicine; Board on the Health of Select Populations;
Update 2009 Committee on Gulf War and Health: Health
https://ebooknice.com/product/gulf-war-and-health-volume-8-update-of-
Effects of Serving in the Gulf War ISBN 9780309149228,
health-effects-of-serving-in-the-gulf-war-51400202
0309149223
ebooknice.com

(Ebook) Gulf War and Health. Insecticides and Solvents by

Committee on Gulf War and Health: Literature Review of
Pesticides and Solvents ISBN 9780309084581, 030908458X
https://ebooknice.com/product/gulf-war-and-health-insecticides-and-
solvents-1382972

ebooknice.com
(Ebook) Gulf War and Health : Vol. 7: Long-Term
Consequences of Traumati by Committee on Gulf War and
Health: Brain Injury in Veterans and Long-Term Health
Outcomes, Board on Population Health and Public Health
https://ebooknice.com/product/gulf-war-and-health-vol-7-long-term-
Practice, Institute of Medicine ISBN 9780309124089,
consequences-of-traumati-5396414
0309124085
ebooknice.com

(Ebook) SAT II Success MATH 1C and 2C 2002 (Peterson's SAT

II Success) by Peterson's ISBN 9780768906677, 0768906679

https://ebooknice.com/product/sat-ii-success-
math-1c-and-2c-2002-peterson-s-sat-ii-success-1722018

ebooknice.com

(Ebook) Matematik 5000+ Kurs 2c Lärobok by Lena

Alfredsson, Hans Heikne, Sanna Bodemyr ISBN 9789127456600,
9127456609
https://ebooknice.com/product/matematik-5000-kurs-2c-larobok-23848312

ebooknice.com

(Ebook) Master SAT II Math 1c and 2c 4th ed (Arco Master

the SAT Subject Test: Math Levels 1 & 2) by Arco ISBN
9780768923049, 0768923042
https://ebooknice.com/product/master-sat-ii-math-1c-and-2c-4th-ed-
arco-master-the-sat-subject-test-math-levels-1-2-2326094

ebooknice.com

(Ebook) Cambridge IGCSE and O Level History Workbook 2C -

Depth Study: the United States, 1919-41 2nd Edition by
Benjamin Harrison ISBN 9781398375147, 9781398375048,
1398375144, 1398375047
https://ebooknice.com/product/cambridge-igcse-and-o-level-history-
workbook-2c-depth-study-the-united-states-1919-41-2nd-edition-53538044

ebooknice.com
Gulf War and health 1st Edition Committee On Gulf War
And Health: Infectious Diseases Digital Instant Download
Author(s): Committee on Gulf War and Health: Infectious Diseases, Abigail E.
Mitchell, Laura B. Sivitz, Robert E. Black
ISBN(s): 9780309101066, 0309101069
Edition: 1
File Details: PDF, 1.70 MB
Year: 2006
Language: english
Abigail E. Mitchell, Laura B. Sivitz, Robert E. Black, Editors

Committee on Gulf War and Health: Infectious Diseases

Board on Population Health and Public Health Practice

 THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National
Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National
Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report
were chosen for their special competences and with regard for appropriate balance.

This study was supported by Contract V101(93)P-2155 between the National Academy of Sciences and the
Department of Veterans Affairs. Any opinions, findings, conclusions, or recommendations expressed in this
publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that
provided support for this project.

International Standard Book Number-10: 0-309-10106-9 (Book)

International Standard Book Number-13: 978-0-309-10106-6 (Book)
International Standard Book Number-10: 0-309-65706-7 (PDF)
International Standard Book Number-13: 978-0-309-65706-8 (PDF)

Library of Congress Control Number: 2006934962

Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Lockbox
285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet,
http://www.nap.edu.

For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu.

Copyright 2007 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America.

The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the
beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from
ancient Greece, now held by the Staatliche Museen in Berlin.
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars
engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their
use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has
a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone
is president of the National Academy of Sciences.

The National Academy of Engineering was established in 1964, under the charter of the National Academy of
Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the
selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal
government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national
needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf
is president of the National Academy of Engineering.

The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of
eminent members of appropriate professions in the examination of policy matters pertaining to the health of the
public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional
charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care,
research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.

The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad
community of science and technology with the Academy’s purposes of furthering knowledge and advising the
federal government. Functioning in accordance with general policies determined by the Academy, the Council has
become the principal operating agency of both the National Academy of Sciences and the National Academy of
Engineering in providing services to the government, the public, and the scientific and engineering communities.
The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr.
Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council.

www.national-academies.org

.
COMMITTEE ON GULF WAR AND HEALTH: INFECTIOUS DISEASES

ROBERT E. BLACK, MD, MPH, Edgar Berman Professor and Chair, Department of
International Health, Johns Hopkins University, Bloomberg School of Public Health,
Baltimore, MD
MARTIN J. BLASER, MD, Frederick H. King Professor of Internal Medicine, Chair of the
Department of Medicine, and Professor of Microbiology, New York University School of
Medicine, New York
RICHARD D. CLOVER, MD, Dean and Professor, School of Public Health and Information
Sciences, University of Louisville, KY
MYRON S. COHEN, MD, J. Herbert Bate Distinguished Professor of Medicine and
Microbiology, Immunology and Public Health, University of North Carolina School of
Medicine, Chapel Hill
JERROLD J. ELLNER, MD, Professor and Chair of the New Jersey Medical School at the
University of Medicine and Dentistry of New Jersey, Newark
JEANNE MARRAZZO, MD, MPH, Associate Professor, Department of Medicine, University
of Washington School of Medicine, Seattle
MEGAN MURRAY, MD, ScD, MPH, Assistant Professor of Epidemiology, Harvard
University, School of Public Health, Boston, MA
EDWARD C. OLDFIELD III, MD, Director, Division of Infectious Diseases, Eastern Virginia
Medical School, Norfolk
RANDALL R. REVES, MD, MSc, Professor, Division of Infectious Diseases, University of
Colorado Health Sciences Center, Denver
EDWARD T. RYAN, MD, Director, Tropical and Geographic Medicine Center, Massachusetts
General Hospital, and Associate Professor of Medicine, Harvard Medical School, Boston,
MA
STEN H. VERMUND, MD, PhD, Amos Christie Chair and Director, Vanderbilt University
Institute for Global Health, and Professor of Pediatrics, Medicine, Preventive Medicine,
and Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville,
TN
DAWN M. WESSON, PhD, Associate Professor, Tulane School of Public Health and Tropical
Medicine, New Orleans, LA

v
 STAFF

ABIGAIL E. MITCHELL, PhD, Senior Program Officer

LAURA B. SIVITZ, MSJ, Senior Program Associate
DEEPALI M. PATEL, Senior Program Associate
MICHAEL J. SCHNEIDER, MPH, Senior Program Associate
PETER JAMES, Research Associate
DAMIKA WEBB, Research Assistant
DAVID J. TOLLERUD, Program Assistant
RENEE WLODARCZYK, Program Assistant
NORMAN GROSSBLATT, Senior Editor
ROSE MARIE MARTINEZ, ScD, Director, Board on Population Health and Public Health
Practice

vi
 REVIEWERS

This report has been reviewed in draft form by persons chosen for their diverse
perspectives and technical expertise in accordance with procedures approved by the National
Research Council’s Report Review Committee. The purpose of this independent review is to
provide candid and critical comments that will assist the institution in making its published
report as sound as possible and to ensure that the report meets institutional standards of
objectivity, evidence, and responsiveness to the study charge. The review comments and draft
manuscript remain confidential to protect the integrity of the deliberative process. We wish to
thank the following for their review of this report:

Lawrence R. Ash, Professor Emeritus, Department of Epidemiology, University of California,

Los Angeles School of Public Health
Michele Barry, Tropical Medicine and International Health Programs, Yale University School
of Medicine
Herbert DuPont, School of Public Health, University of Texas Health Science Center at
Houston and St. Luke’s Episcopal Hospital
Robert Edelman, Travelers’ Health Clinic, University of Maryland
David Hill, National Travel Health Network and Centre, Hospital for Tropical Diseases, London
Richard T. Johnson, Department of Neurology, The Johns Hopkins Hospital
Arthur Reingold, Division of Epidemiology, University of California, Berkeley
Philip K. Russell, Professor Emeritus, Johns Hopkins School of Public Health
Mark Wallace, Independent Infectious Diseases Consultant and United States Navy, Retired

Although the reviewers listed above have provided many constructive comments and
suggestions, they were not asked to endorse the conclusions or recommendations nor did they
see the final draft of the report before its release. The review of this report was overseen by
George Rutherford, Institute of Global Health, University of California, San Francisco, and
Elaine L. Larson, School of Nursing, Columbia University. Appointed by the National Research
Council, they were responsible for making certain that an independent examination of this report
was carried out in accordance with institutional procedures and that all review comments were
carefully considered. Responsibility for the final content of this report rests entirely with the
authoring committee and the institution.

vii
 PREFACE

Infectious diseases have been a problem for military personnel throughout history. The
consequences in previous conflicts have ranged from frequent illnesses disrupting daily activities
and readiness to widespread deaths. Preventive measures, early diagnosis, and treatment greatly
limit the exposures and acute illnesses of troops today in comparison with those in armies of the
past, but infections and consequent acute illnesses still occur. In addition, long-term adverse
health outcomes of some pathogens are increasingly recognized.
The deployment of about 700,000 US troops to the Persian Gulf region in the Gulf War
of 1991 potentially exposed them to pathogens that they had not encountered at home. After
returning from that short campaign, some veterans reported symptoms and expressed the concern
that they may have been exposed to biologic, chemical, or physical agents during their service in
the Persian Gulf. In response to those concerns, the US Department of Veterans Affairs (VA)
commissioned the Institute of Medicine (IOM) to review the scientific evidence on possible
long-term adverse health outcomes of exposure to specific biologic, chemical, and physical
agents and to draw conclusions on the strength of that evidence with regard to delayed and
chronic illnesses of the veterans.
The authorizing legislation for the work of IOM included several infectious diseases
endemic in the Persian Gulf region. In the charge to our committee, VA asked that we not limit
consideration to those diseases but rather include all infectious exposures that had been
documented in troops and consider their possible long-term adverse health outcomes. It further
requested that the time and geographic dimensions of the committee’s work be widened to
include military personnel deployed as part of Operation Enduring Freedom (OEF) in
Afghanistan and Operation Iraqi Freedom (OIF) in the Persian Gulf region. OEF began in 2001,
and OIF in 2003; they continued as this report went to press. The number of military personnel
involved in the more recent conflicts now exceeds that in the 1991 Gulf War. Furthermore, they
have remained for much longer periods on the average than in the Gulf War, and many have
been deployed for more than one tour in this region. Thus, the potential for exposure to endemic
pathogens is greater in these troops than in those deployed to the Gulf War. Because the possible
exposures are relatively recent, there has been only a short time to observe long-term adverse
health outcomes. The committee needed to rely on observations from the Gulf War, information
on infectious diseases in OEF and OIF, and evidence in the scientific literature to allow
conclusions to be drawn on possible long-term adverse health outcomes. With further time to
observe the possible consequences of infectious exposures, the knowledge base will increase.
Given the continuing presence of troops in the areas and the variable nature of infectious
diseases, the exposures may change.
Valuable contributions were made to this study by a number of people who shared their
expertise on infectious diseases. On behalf of the committee, I thank several of them—K. Craig
Hyams, MD, MPH, chief consultant, Occupational and Environmental Health Strategic
Healthcare Group, VA; Michael Kilpatrick, MD, deputy director, Deployment Health Support,
Department of Defense (DOD); and Alan Magill, MD, science director, Walter Reed Army
Institute of Research, for presenting information on infectious diseases that have been diagnosed
in military personnel during the Gulf War, OIF, and OEF and Richard Reithinger, PhD,

ix
x PREFACE

infectious diseases consultant, for presenting information on infectious diseases that are endemic
in southwest and south-central Asia to the committee at its May 26, 2005 meeting. I also thank
William Winkenwerder, Jr., MD, MBA, assistant secretary for defense for health affairs, and his
staff at DOD’s Deployment Health Support for expeditiously providing information to the
committee on DOD health-related policies. Finally, the committee is grateful for the insight
provided by representatives of veteran service organizations, veterans, and others who spoke
with the committee or sent in written testimony.
I am grateful for the great expertise the committee members brought to bear on this
subject. Furthermore, the report would not have been successfully completed without the diligent
and expert contributions of the IOM staff, led by Abigail Mitchell and including Laura Sivitz,
Deepali Patel, Michael Schneider, Peter James, Damika Webb, David Tollerud, and Renee
Wlodarczyk.

Robert E. Black, MD, MPH, Chair

 CONTENTS

Summary ....................................................................................................................................1
Methodology .........................................................................................................................1
Identifying the Pathogens to Study.....................................................................................2
Development of Conclusions..............................................................................................3
Summary of Conclusions ......................................................................................................4
Sufficient Evidence of a Causal Relationship ....................................................................4
Sufficient Evidence of an Association................................................................................5
Limited or Suggestive Evidence of an Association............................................................6
Inadequate or Insufficient Evidence to Determine Whether an Association Exists...........6
Limited or Suggestive Evidence of No Association...........................................................7
Department of Defense Policies on Tuberculin Skin Testing and Predeployment and
Postdeployment Serum Collection ...................................................................................7

1 Introduction...........................................................................................................................9
Identifying the Infectious Diseases to Study.......................................................................13
The Committee’s Approach to Its Charge ..........................................................................15
Organization of the Report..................................................................................................16
References ...........................................................................................................................16

2 Methodology .......................................................................................................................19
Identifying the Infectious Diseases to Study.......................................................................19
Geographic Boundaries ....................................................................................................19
Infectious Diseases Endemic to Southwest and South-Central Asia
That Have Long-Term Adverse Health Outcomes .....................................................20
Direct Attribution to Military Service in Southwest and South-Central Asia ..................24
Timing of Appearance of Long-Term Adverse Health Outcomes ...................................27
The Infectious Diseases to Be Studied for Strength of Association
with Long-Term Adverse Health Outcomes...............................................................27
Comments on Diseases and Agents of Special Interest
to Gulf War, OEF, and OIF Veterans ..........................................................................28
Review and Evaluation of the Literature ............................................................................29
Selection of the Literature ................................................................................................29
Amassing the Literature....................................................................................................29
Reviewing the Literature ..................................................................................................29
Categories of Strength of Association.................................................................................30
Origin and Evolution of the Categories ............................................................................30
Sufficient Evidence of a Causal Relationship ..................................................................30
Sufficient Evidence of an Association..............................................................................31
Limited or Suggestive Evidence of an Association..........................................................31
Inadequate or Insufficient Evidence to Determine Whether an Association Exists.........31

xi
xii CONTENTS

Limited or Suggestive Evidence of No Association.........................................................31

References.........................................................................................................................31

3 Infectious Diseases Endemic to Southwest and South-Central Asia

That Have Long-Term Adverse Health Outcomes .............................................................35
References ...........................................................................................................................60

4 Infectious Diseases Diagnosed in US Troops Who Served in the Persian Gulf War,
Operation Enduring Freedom, or Operation Iraqi Freedom................................................61
Diarrheal Disease ................................................................................................................62
Enteric Infections in the Gulf War....................................................................................62
Gastroenteritis in Operation Enduring Freedom and Operation Iraqi Freedom ...............69
Respiratory Disease.............................................................................................................74
Mild Acute Respiratory Disease in the Gulf War.............................................................74
Severe Acute Respiratory Disease in the Gulf War..........................................................76
Respiratory Disease in Operation Enduring Freedom and Operation Iraqi Freedom ......76
Insect-Borne Diseases .........................................................................................................78
Leishmaniasis ...................................................................................................................78
Malaria..............................................................................................................................82
West Nile Fever ................................................................................................................84
Brucellosis...........................................................................................................................84
Chicken Pox (Varicella)......................................................................................................85
Meningococcal Disease.......................................................................................................85
Nosocomial Infections ........................................................................................................85
Gulf War ...........................................................................................................................85
Operation Enduring Freedom and Operation Iraqi Freedom............................................86
Q Fever................................................................................................................................88
Q Fever Contracted During the Gulf War ........................................................................89
Q Fever Contracted During Operation Enduring Freedom
and Operation Iraqi Freedom .......................................................................................89
Viral Hepatitis .....................................................................................................................90
Tuberculosis ........................................................................................................................90
Department of Defense Medical Databases ........................................................................91
Department of Defense Policy Regarding Predeployment
and Postdeployment Serum Collection ..........................................................................93
References ...........................................................................................................................94

5 Levels of Association Between Select Diseases and

Long-Term Adverse Health Outcomes .............................................................................101
Diarrheal Diseases:
Campylobacter, Non-typhoid Salmonella, and Shigella Infections .............................103
Campylobacter Infection ................................................................................................103
Nontyphoidal Salmonella Infection................................................................................108
Shigella Infection............................................................................................................110
CONTENTS xiii

Brucellosis.........................................................................................................................112
Transmission and Endemicity of Brucellosis .................................................................113
Acute Brucellosis............................................................................................................114
Treatments for Brucellosis and Related Long-Term Toxicity........................................115
Coinfection .....................................................................................................................115
Long-Term Adverse Health Outcomes of Brucellosis ...................................................115
Leishmaniasis....................................................................................................................118
Transmission of Leishmaniasis.......................................................................................119
Endemicity in Southwest and South-Central Asia..........................................................120
Acute Leishmaniasis.......................................................................................................120
Diagnosis of Leishmaniasis ............................................................................................121
Treatments for Leishmaniasis and Related Long-Term Toxicity...................................121
Coinfection by Leishmania Parasite and Human Immunodeficiency Virus ..................122
Long-Term Adverse Health Outcomes of Leishmaniasis ..............................................122
Malaria ..............................................................................................................................123
Transmission of Malaria .................................................................................................124
Endemicity in Southwest and South-Central Asia..........................................................124
Acute Malaria .................................................................................................................125
Treatments for Malaria and Related Long-Term Toxicity .............................................125
Coinfection with Plasmodium Spp. and Human Immunodeficiency Virus ...................126
Long-Term Adverse Health Outcomes of Infection with Plasmodium Spp...................126
Q Fever (Infection by Coxiella burnetii) ..........................................................................129
Transmission of Coxiella burnetii ..................................................................................129
Endemicity in Southwest and South-Central Asia..........................................................130
Acute Q Fever.................................................................................................................130
Diagnosing Q Fever........................................................................................................131
Coinfection with Coxiella burnetii and Human Immunodeficiency Virus ....................131
Long-Term Adverse Health Outcomes of Q Fever ........................................................132
Tuberculosis ......................................................................................................................135
Transmission of Tuberculosis.........................................................................................135
Endemicity in Southwest and South-Central Asia..........................................................137
Risk of Progression from Latent Tuberculosis Infection to Active Tuberculosis ..........137
Treatment for Latent Tuberculosis Infection to Prevent Active Tuberculosis ...............140
Active Tuberculosis ........................................................................................................140
Late Manifestations of Active Tuberculosis...................................................................142
Potential Relationships Between Tuberculosis and Military Service.............................144
West Nile Virus Infection .................................................................................................149
Transmission of West Nile Virus Infection ....................................................................150
Endemicity in Southwest and South-Central Asia..........................................................150
Acute West Nile Fever....................................................................................................151
Diagnosis of West Nile Fever.........................................................................................151
Treatment of West Nile Virus Infection .........................................................................152
Long-Term Adverse Health Outcomes of Infection with West Nile Virus....................152
Recommendation ............................................................................................................155
References .........................................................................................................................155
xiv CONTENTS

6 Diseases and Agents of Special Concern to Veterans of the Gulf War, Operation Iraqi
Freedom, and Operation Enduring Freedom.....................................................................181
Al Eskan Disease ..............................................................................................................181
Description of Acute Illness ...........................................................................................182
Long-Term Adverse Health Outcomes...........................................................................182
Pathogenesis ...................................................................................................................182
Treatment........................................................................................................................183
Summary.........................................................................................................................183
Idiopathic Acute Eosinophilic Pneumonia........................................................................183
Description of Acute Illness ...........................................................................................183
Long-Term Adverse Health Outcomes...........................................................................183
Pathogenesis ...................................................................................................................184
Treatment........................................................................................................................184
Summary.........................................................................................................................184
Wound and Nosocomial Infections (Including Infections with Acinetobacter Spp.) ......184
Concerns Regarding Acinetobacter baumannii ..............................................................185
Other Wound Infections .................................................................................................186
Other Nosocomial Infections..........................................................................................187
Regional Experiences in Non-Americans.......................................................................188
Summary.........................................................................................................................190
Mycoplasmas ....................................................................................................................190
Mycoplasmas and “Gulf War Illness” ............................................................................191
Summary.........................................................................................................................193
Biologic-Warfare Agents ..................................................................................................193
Summary ...........................................................................................................................194
References .........................................................................................................................194
Appendix Biographical Sketches for Members of the Committee .......................................201
Index ......................................................................................................................................205
 SUMMARY

Thousands of US veterans of the Persian Gulf War have reported an array of unexplained
illnesses since the war ended in 1991. Many veterans have believed that the illnesses were
associated with their military service in southwest Asia during the war. In response, the US
Congress legislated in 1998 that the Department of Veterans Affairs (VA) use a specific
procedure to determine the illnesses that warrant presumption of a connection to Gulf War
service (Public Law [PL] 105-277, Persian Gulf War Veterans Act). Moreover, VA must
financially compensate Gulf War veterans in whom the determined illnesses are diagnosed (PL
105-368, Veterans Programs Enhancement Act). To reach those determinations, the law states,
VA must obtain independent evaluations of the scientific evidence of associations between
illnesses and exposures to various chemical, physical, and biologic substances connected to
military service in southwest Asia during the war. The law instructs VA to obtain the scientific
evaluations from the National Academy of Sciences (NAS). NAS assigned the task of evaluating
the associations to the Institute of Medicine (IOM).
This report is the fifth volume produced by IOM for VA in response to the congressional
mandate.1 A committee of nationally recognized experts in infectious diseases was appointed and
charged with evaluating the scientific and medical literature on long-term adverse human health
outcomes associated with selected infectious diseases pertinent to Gulf War veterans. The
conclusions herein characterize the long-term adverse health outcomes associated with infection
by the following pathogens: Brucella species (spp.), the cause of brucellosis; Campylobacter
spp., nontyphoidal Salmonella spp. and Shigella spp., which cause diarrheal disease; Coxiella
burnetii, the cause of Q fever; Leishmania spp., the cause of leishmaniasis; Mycobacterium
tuberculosis, which causes tuberculosis; Plasmodium spp., the cause of malaria; and West Nile
virus, the cause of West Nile fever. The committee identified those pathogens through the
process outlined below. The committee then developed conclusions by studying the relevant
published evidence, deliberating to reach consensus, and responding to a formal process of peer
review.2

METHODOLOGY

IOM appointed the Committee on Gulf War and Health: Infectious Diseases in January
2005. The committee considered infections that US troops might have contracted in southwest
Asia during the Persian Gulf War. At VA’s request, the committee also examined infections that
might have afflicted US military personnel deployed to south-central and southwest Asia for
Operation Enduring Freedom (OEF)3 and Operation Iraqi Freedom (OIF).4 Thus, the
committee’s deliberations covered infectious diseases known to occur in Saudi Arabia, Kuwait,
Iraq, Afghanistan, and most countries along their borders (Yemen, Oman, United Arab Emirates,

1
Earlier IOM reports in this series present conclusions about long-term adverse health outcomes associated with
exposure to depleted uranium, pyridostigmine bromide, sarin, vaccines, insecticides, solvents, propellants,
combustion products, and fuels.
2
A detailed description of how IOM studies are conducted appears at www.iom.edu/?id=32248.
3
OEF began on October 7, 2001, in Afghanistan.
4
OIF began on March 19, 2003.

1
2 GULF WAR AND HEALTH

Qatar, Bahrain, Jordan, Israel, Lebanon, Syria, Iran, Turkmenistan, Uzbekistan, Tajikistan,
Kyrgyzstan, and Pakistan).

Identifying the Pathogens to Study

The committee first identified about 100 naturally occurring pathogens that could
potentially have infected US troops during their service in the Gulf War, OEF, or OIF. The
identified pathogens comprise viruses, bacteria, helminths, and protozoa that have been reported
in southwest and south-central Asia, have historically caused outbreaks of illness in military
populations, or have generated particular concern among US veterans of the Persian Gulf War.
As required by PL 105-277 and PL 105-368, the pathogens include Escherichia coli, Shigella
spp., Leishmania spp., and the Phlebovirus pathogens that cause sand fly fever.

Definition of Long-Term Adverse Health Outcome

The committee then developed a set of criteria for determining which infectious diseases
to evaluate for strength of association with specific long-term adverse health outcomes. Long-
term adverse health outcomes include secondary diseases or conditions (sequelae) caused by
primary diseases, reactivation or recrudescence of diseases, and delayed presentation of diseases.
A long-term adverse health outcome, the committee agreed, should have one or more of the
following characteristics:

• Significant interruption of normal physical and mental function outside the timeframe of acute
infection.
• Persistent organ dysfunction or damage.
• Reproductive effects in military personnel, including birth defects in their offspring.

In addition, a long-term adverse health outcome could be reversible, related to secondary

transmission,5 or both.

Development of Inclusion Criteria

Given that definition, the committee identified about 90 infectious diseases that have
long-term adverse health outcomes and that were any of the following:

• Endemic in southwest or south-central Asia during the period in question.

• Diagnosed in US troops during the three deployments under study.
• Of special concern to Gulf War, OIF, or OEF veterans.
• Historically reported among military populations.

Many of the diseases have never been reported in US military personnel in close temporal
relationship to deployment to southwest or south-central Asia for the Gulf War, OEF, or OIF.
Even so, the committee could not rule out the possibility that one or more people contracted an
unreported disease during deployment. Consequently, the committee created a tabular summary
of such diseases’ acute and long-term characteristics.

5
In this context, secondary transmission means the spread of a pathogen directly from a primary human host to one
or more other humans.
SUMMARY 3

The committee further defined its infections of focus according to the likelihood that the
primary infection would be subacute or the infected person would be asymptomatic for days to
years, and the adverse health outcome would begin months to years after infection. In such cases,
diagnosis of the long-term adverse health outcome during military service in Asia would be
unlikely, and such infections were candidates for in-depth review and conclusions. In contrast,
military medical personnel would probably diagnose adverse health outcomes that are manifest
during the acute illness or shortly after a person’s deployment.
Finally, the committee examined the likelihood that the candidate infections would have
occurred specifically during military deployment to southwest and south-central Asia during the
three operations in question. The risk of contracting the disease in the theater of operations must
have been equal to or greater than the risk of contracting it in the United States. Moreover, given
the natural history of the disease or infection, it must have been diagnosed in US troops in
appropriate temporal relationship to deployment.
By applying those criteria to the dozens of infectious diseases recognized initially, the
committee identified the group that required in-depth evaluation and conclusions: brucellosis,
Campylobacter infection, leishmaniasis, malaria, Q fever, salmonellosis, and shigellosis. Two
other diseases did not meet all the criteria but still merited in-depth evaluation: tuberculosis and
West Nile virus infection.
Tuberculosis (TB) could cause long-term adverse health outcomes in US troops and
veterans deployed to southwest and south-central Asia, where TB is highly endemic. TB has a
long history of activation and transmission in military settings. Moreover, about 2.5% of military
personnel deployed to OEF and OIF and given predeployment and postdeployment skin tests for
TB converted from negative to positive; that is, these troops acquired new TB infections during
deployment.6 Therefore, although the committee found no published reports of active TB cases
among the troops in question, conclusions about the long-term adverse health outcomes of TB
infection are quite pertinent.
Unlike TB, West Nile virus (WNV) has been reported in troops deployed to southwest
and south-central Asia, where the virus is endemic. The long-term adverse health outcomes
associated with WNV infection are usually manifest during the acute illness—a characteristic
that disqualified other diseases from comprehensive evaluation in this report. Nevertheless,
dramatic changes in the epidemiology of WNV since the mid-1990s led the committee to make
an exception for WNV and to review it in depth.
In addition, a small set of biologic agents, infections, and diseases that failed to meet the
committee’s inclusion criteria nevertheless raised serious questions that merited discussion: Al
Eskan disease, biowarfare agents, idiopathic acute eosinophilic pneumonia, mycoplasmal
infection, and wound infection (including wound infection caused by Acinetobacter baumanii,
the most notable pathogenic colonizer of wounds during OEF and OIF).

Development of Conclusions

Identifying the Literature to Review and Evaluate

Conducting extensive searches of the biomedical and epidemiologic peer-reviewed
literature on the diseases identified for study yielded about 20,000 potentially relevant

6
Kilpatrick ME. 2005. Presentation to IOM Committee on Gulf War and Health: Infectious Diseases. Washington,
DC.
4 GULF WAR AND HEALTH

references. On closer examination, some 1,200 references appeared to provide the requisite types
and quality of scientific evidence for this study.

Assessing the Strength of the Evidence

By evaluating the evidence in the published scientific literature, the committee
determined the relationships between each of the nine diseases of interest and specific adverse
health outcomes that might appear weeks to years after the primary infection. Those relationships
are conceived in terms of the strength of association between the primary infection and a specific
long-term adverse health outcome.
The committee framed its conclusions in categories, described below, that qualitatively
rank the strength of the evidence of an association. Used by many previous IOM committees,
including those in the Gulf War and Health series, this five-tier framework was adapted from the
system used by the International Agency for Research on Cancer to evaluate evidence of the
carcinogenicity of various agents.

SUMMARY OF CONCLUSIONS

Sufficient Evidence of a Causal Relationship

The evidence is sufficient to conclude that there is a causal relationship

between exposure to a specific agent and a specific health outcome in
humans. The evidence is supported by experimental data and fulfills the
guidelines for sufficient evidence of an association (defined below). The
evidence must be biologically plausible and must satisfy several of the
guidelines used to assess causality, such as strength of association, a dose–
response relationship, consistency of association, and a temporal
relationship.
The committee concludes that there is sufficient evidence of a causal relationship between

• Coxiella burnettii infection (Q fever) and osteomyelitis.

• Malarial infection and
o Ophthalmologic manifestations, particularly retinal hemorrhage and scarring,
recognized for the first time months or years after the infection.
o Hematologic manifestations weeks or months later, particularly anemia after
falciparum malaria and splenic rupture after vivax malaria.
o Renal disease, especially the nephrotic syndrome that may occur weeks to months
after acute infection.
o Late presentation of disease (Plasmodium malariae) or relapse of disease
(Plasmodium ovale or Plasmodium vivax) months to years after acute infection.
• Mycobacterium tuberculosis infection and occurrence of active TB months to decades after
infection.
SUMMARY 5

Sufficient Evidence of an Association

The evidence from available studies is sufficient to conclude that there is

an association. A consistent association has been observed between
exposure to a specific agent and a specific health outcome in human
studies in which chance and bias, including confounding, could be ruled
out with reasonable confidence. For example, several high-quality studies
report consistent associations and are sufficiently free of bias, including
adequate control for confounding.
The committee concludes that there is sufficient evidence of an association between

• Brucellosis and
o Arthritis and spondylitis; arthritis usually is manifest within 12 months of the acute
illness, and spondylitis might be manifest later.
o Hepatic abnormalities, including granulomatous hepatitis.
o Chronic meningitis and meningoencephalitis.
o Uveitis.
o Orchioepididymitis and infections of the genitourinary system.
o Cardiovascular, nervous, and respiratory system infections.
• Campylobacter jejuni infection and Guillain-Barré syndrome (GBS) if GBS is manifest within
2 months of the infection.
• Campylobacter infection and reactive arthritis (ReA) if ReA is manifest within 3 months of
the infection; most cases of ReA are manifest within 1 month of the infection.
• Coxiella burnetii infection (Q fever) and
o Endocarditis years after primary infection.
o Vascular infection years after primary infection.
o Chronic hepatitis years after primary infection.
• Plasmodium malariae infection and manifestation of immune-complex glomerulonephritis
years to decades later.
• Plasmodium falciparum infection and recrudescence weeks to months after the primary
infection, but only in the case of inadequate therapy.
• Nontyphoid Salmonella infection and ReA if ReA is manifest within 3 months of the
infection.
• Shigella infection and
o Hemolytic-uremic syndrome (HUS) if HUS is manifest within 1 month of the
infection; most cases of HUS are manifest within 10 days of the infection.
o ReA if ReA is manifest within 3 months of the infection; most cases of ReA are
manifest within 1 month of the infection.
• Active TB and long-term adverse health outcomes due to irreversible tissue damage from
severe forms of pulmonary and extrapulmonary TB.
• Visceral leishmaniasis (kala-azar) and
o Delayed presentation of the acute clinical syndrome.
o Reactivation of visceral leishmaniasis in the context of future immunosuppression.
o Post-kala-azar dermal leishmaniasis (PKDL) if PKDL occurs generally within 2 years
of the initial infection.
6 GULF WAR AND HEALTH

• West Nile virus infection and variable physical, functional, or cognitive disability, which may
persist for months or years or be permanent.

Limited or Suggestive Evidence of an Association

The evidence from available studies suggests an association between

exposure to a specific agent and a specific health outcome in human
studies, but the body of evidence is limited by the inability to rule out
chance and bias, including confounding, with confidence. For example, at
least one high-quality study reports an association that is sufficiently free
of bias, including adequate control for confounding. Other corroborating
studies provide support for the association, but they were not sufficiently
free of bias, including confounding. Alternatively, several studies of less
quality show consistent associations, and the results are probably not due
to bias, including confounding.
The committee concludes that there is limited or suggestive evidence of an association
between

• Brucellosis and
o Myelitis-radiculoneuritis, demyelinating meningovascular syndromes, deafness,
sensorineural hearing loss, and GBS.
o Papilledema, optic neuritis, episcleritis, nummular keratitis, and multifocal
choroiditis.
o Fatigue, inattention, amnesia, and depression.
• Campylobacter jejuni infection and development of uveitis if uveitis is manifest within 1
month of infection.
• Coxiella burnetii infection and post-Q-fever chronic fatigue syndrome years after the primary
infection.
• Plasmodium falciparum infection and neurologic disease, neuropsychiatric disease, or both
months to years after the acute infection.
• Plasmodium vivax and Plasmodium falciparum infections and demyelinating polyneuropathy
and GBS.

Inadequate or Insufficient Evidence to Determine Whether an Association Exists

The evidence from available studies is of insufficient quantity, quality, or

consistency to permit a conclusion regarding the existence of an
association between exposure to a specific agent and a specific health
outcome in humans.
For some potential long-term adverse health outcomes of the nine identified diseases, the
evidence of an association is inadequate, insufficient, or both. The committee presents these
potential long-term adverse health outcomes and their characteristics in tabular form in the body
of the report.
SUMMARY 7

Limited or Suggestive Evidence of No Association

Evidence from well-conducted studies is consistent in not showing an

association between exposure to a specific agent and a specific health
outcome after exposure of any magnitude. A conclusion of no association
is inevitably limited to the conditions, magnitudes of exposure, and length
of observation in the available studies. The possibility of a very small
increase in risk after exposure cannot be excluded.
For many potential long-term adverse health outcomes of the nine identified diseases,
there is no evidence of an association. In this report, the committee focused on identifying
positive associations between specific infectious diseases and specific long-term adverse health
outcomes and did not present the numerous long-term adverse health outcomes for which there is
no association.

DEPARTMENT OF DEFENSE POLICIES ON TUBERCULIN SKIN TESTING AND

PREDEPLOYMENT AND POSTDEPLOYMENT SERUM COLLECTION

Each branch of the US military has polices regarding tuberculin skin testing and
treatment of latent TB infection (LTBI). The most effective way to mitigate TB transmission and
activation is to identify and treat for LTBI. In addition, the only way to determine whether
military personnel and reservists have become infected with M. tuberculosis during their service
is to test all personnel for TB shortly before and after deployment. Such testing would make it
possible to trace cases of active TB to periods of military service if that is when infection
occurred.
Department of Defense (DOD) policy specifies that predeployment serum specimens for
medical examinations will routinely be collected within 1 year of deployment and that
postdeployment serum specimens for medical examinations will be collected no later than 30
days after arrival at the demobilization site, home station, or in-patient medical treatment facility.
The committee agrees with DOD’s overall policy regarding collection and use of serum
specimens. However, for banked serum specimens to be most useful for determining whether
infectious exposures occurred during deployment, the predeployment specimens need to be
collected before travel. Current policy allows for collection of predeployment serum specimens
up to 1 year after deployment. If the collection of serum is not done until after deployment, it
would be difficult to ascertain whether any signs of infection found in the “predeployment”
specimen are due to exposure during the current deployment or before it.
 1

INTRODUCTION

Five days after the Iraqi invasion of Kuwait on August 2, 1990, the United States
deployed troops to Operation Desert Shield (ODSh). The United States attacked Iraqi armed
forces by air on January 16, 1991, and this marked the beginning of Operation Desert Storm
(ODSt). The ground war began on February 24, 1991, and ended 4 days later. The official cease-
fire took effect on April 11, 1991, and the last troops to participate in the ground war arrived
back in the United States on June 13, 1991. In this report, ODSh and ODSt are also referred to
collectively as the Gulf War.
About 697,000 US troops were deployed to the Persian Gulf during ODSh and ODSt.
Figure 1.1 depicts the size of the US military presence in the Persian Gulf from August 1990
through June 1991. The war was considered to be a successful military operation, and there were
few injuries and deaths.
Shortly after returning to the United States, a number of veterans started reporting a
variety of symptoms—fatigue, headache, muscle and joint pain, sleep disturbances, and
cognitive difficulties (Persian Gulf Veterans Coordinating Board 1995). The veterans were
concerned that they might have been exposed to chemical, biologic, or physical agents during
their deployment to the Persian Gulf and that those exposures might be responsible for their
unexplained illnesses.

9
 10

Approximate Number of Troops Deployed

(Thousands)
600

500

400

300

200

100

0
Operation Desert Shield (ODSh) Period of Combat

August September October November December January February March April May June July
1990 1991
8/7/90: First US troops arrive in 1/16/91: 4/11/91: 6/13/91: Last US troops
Arabian Peninsula for Operation Desert Operation Desert Official to participate in ground
Shield Storm (ODSt) cease-fire war arrive back in US
begins takes effect

FIGURE 1.1 Operation Desert Shield and Operation Desert Storm: key dates and size of US military presence in theater.
SOURCE: DOD 2006; IOM 2000; PAC 1996.
INTRODUCTION 11

In response to the concerns of the Gulf War veterans about their unexplained illnesses,
the US Department of Veterans Affairs (VA) asked the Institute of Medicine (IOM) to conduct a
study to evaluate the scientific literature on chemical, biologic, and physical agents to which
military personnel in the gulf were potentially exposed and possible long-term adverse health
outcomes. In addition, Congress passed two laws in 1998—the Persian Gulf War Veterans Act
(PL 105-277) and the Veterans Programs Enhancement Act (PL 105-368)—that called for the
review of the scientific literature on specified agents with regard to long-term adverse health
outcomes. That legislation directs IOM to study a number of diverse chemical, biologic, and
physical agents (listed in Box 1.1). IOM divided the task into several reviews. It has completed
four reports: Gulf War and Health, Volume 1: Depleted Uranium, Pyridostigmine Bromide,
Sarin, Vaccines (IOM 2000); Gulf War and Health, Volume 2: Insecticides and Solvents (IOM
2003); Gulf War and Health Volume 3: Fuels, Combustion Products, and Propellants (IOM
2005); and Gulf War and Health, Volume 4: Health Effects of Serving in the Gulf War (IOM
2006). The present report is the fifth volume in the series. An additional, related report has also
been published: Gulf War and Health: Updated Literature Review of Sarin (IOM 2004).
Since VA asked IOM to conduct the above-mentioned study and PL 105-277 and PL
105-368 were enacted, the United States has again entered into military conflicts in southwest
and south-central Asia—Operation Enduring Freedom (OEF) and Operation Iraqi Freedom
(OIF). Therefore, VA has asked IOM to make this report relevant to the military personnel
serving in OEF and OIF in addition to those who served in the 1991 Gulf War.
12 GULF WAR AND HEALTH

BOX 1-1 Agents Specified in PL 105-277 and PL 105-368

• The following organophosphorus pesticides:

o Chlorpyrifos
o Diazinon
o Dichlorvos
o Malathion
• The following carbamate pesticides:
o Proxpur
o Carbaryl
o Methomyl
• The carbamate pyridostigmine bromide used as nerve-agent prophylaxis
• The following chlorinated hydrocarbons and other pesticides and repellents:
o Lindane
o Pyrethrins
o Permethrins
o Rodenticides (bait)
o DEET (repellent)
• The following low-level nerve agents and precursor compounds at exposures below those which produce
immediately apparent incapacitating symptoms:
o Sarin
o Tabun
• The following synthetic chemical compounds:
o Mustard agents at exposures below those which cause immediate blistering
o Volatile organic compounds
o Hydrazine
o Red fuming nitric acid
o Solvents
• The following sources of radiation:
o Depleted uranium
o Microwave radiation
o Radio frequency radiation
• The following environmental particulates and pollutants:
o Hydrogen sulfide
o Oil fire byproducts
o Diesel heater fumes
o Sand micro-particles
• Diseases endemic to the region (including the following):
o Leishmaniasis
o Sand fly fever
o Pathogenic Escherichia coli
o Shigellosis
• Time compressed administration of multiple live, ‘‘attenuated’’ and toxoid vaccines
INTRODUCTION 13

IDENTIFYING THE INFECTIOUS DISEASES TO STUDY

In accordance with PL 105-277 and PL 105-368, IOM appointed the Committee on Gulf
War and Health: Infectious Diseases and tasked it to review, evaluate, and summarize the peer-
reviewed scientific and medical literature on long-term adverse health outcomes associated with
selected infectious diseases pertinent to service in the Gulf War. The infectious diseases can
include, but are not limited to, pathogenic Escherichia coli infection, shigellosis, leishmaniasis,
and sand fly fever.
VA is also concerned about potential long-term adverse health outcomes of infectious
diseases in veterans of OEF and OIF. As of October 2005, about 1.2 million US troops have been
deployed to OEF or OIF (see Figure 1.2). VA asked IOM to evaluate infectious diseases
pertinent to service in OEF and OIF.
It should be noted that the charge to IOM was not to determine whether a unique Gulf
War syndrome or Gulf War illness exists or to make judgments about whether individual
veterans were exposed to specific pathogens. Nor was the charge to focus on broader issues, such
as the potential costs of compensation for veterans or policy regarding compensation; such
decisions are the responsibility of the secretary of veterans affairs.
 14

Approximate Number of Troops Deployed

(Thousands)

450

400

350

300

250

200

150

100

50

September January May Sept January May Sept January May September January May September
2001 2002 2003 2004 2005

10/7/01 3/19/03
Operation Enduring Operation Iraqi
Freedom begins Freedom begins

FIGURE 1.2 Operation Enduring Freedom and Operation Iraqi Freedom: key dates and size of US military presence in theater.
SOURCE: Personal Communication, Michelle Rudolph, Branch Chief, Defense Manpower Data Center, December 15, 2005.
INTRODUCTION 15

THE COMMITTEE’S APPROACH TO ITS CHARGE

A brief overview of how the committee approached its charge is presented here. A more
comprehensive explanation is provided in Chapter 2.
The committee identified numerous infectious diseases to which Gulf War, OIF, and OEF
military personnel might have been exposed during their deployment. Dozens of infectious
diseases are endemic to southwest and south-central Asia, which includes Iraq, Kuwait, and
Afghanistan. The committee then determined which of the endemic infectious diseases are
known to have long-term adverse health outcomes. To determine which infectious diseases to
review in depth, the committee took several factors into account, including which ones were
diagnosed in military personnel who served in the Gulf War, OEF, or OIF and in veterans after
they returned home, as well as the prevalence of the infectious diseases in southwest and south-
central Asia compared with their prevalence in the United States.
Overall, the incidence of infectious diseases among Gulf War military personnel was low
(Hyams et al. 1995). Acute diarrheal and acute respiratory diseases were the major causes of
morbidity from infectious diseases (Hyams et al. 1995; Hyams et al. 2001). The outbreaks of
diarrhea were due primarily to enterotoxigenic Escherichia coli and Shigella sonnei. Some 12
cases of viscerotropic leishmaniasis and 20 cases of cutaneous leishmaniasis were diagnosed in
Gulf War military personnel (Hyams et al. 1995; Hyams et al. 2001). Other reported infectious
diseases included Q fever (three cases), West Nile fever (one case), and malaria (seven cases)
(Hyams et al. 1995; Hyams et al. 2001).
Infectious diseases reported in troops who served in OEF and OIF as of December 2005
are visceral and cutaneous leishmaniasis, malaria, diarrheal disease, respiratory disease,
tuberculosis infection (but not active tuberculosis), Q fever, brucellosis, and Acinetobacter
baumannii infection (Kilpatrick 2005). Chapter 4 reviews the literature on infectious diseases
that have been diagnosed in military personnel during or shortly after returning from the Gulf
War, OIF, or OEF.
The committee identified for comprehensive evaluation nine infectious diseases known to
have long-term adverse health outcomes that were diagnosed in military personnel who served in
the Gulf War, OEF, or OIF. Some information is presented on a number of other infectious
diseases as well because they are endemic to southwest and south-central Asia, although there
have been no reported cases in military personnel through December 2005. It is possible that
military personnel have become infected but that no diagnosis was made either because no acute
symptoms were present or because the symptoms were mild and the soldier who had them did
not seek medical care. We also present information on diseases and agents of special concern to
veterans of the Gulf War, OEF, and OIF (Al Eskan disease, acute eosinophilic pneumonia,
Acinetobacter baumannii infection, mycoplasmas, and biological warfare agents).
After determining which infectious diseases it would evaluate, the committee had to
identify the relevant literature for review. The committee relied primarily on peer-reviewed
published literature in developing its conclusions. It also consulted other material, such as
surveillance reports, technical reports, and textbooks, and it obtained additional information from
experts in infectious diseases of southwest and south-central Asia, from Deployment Health
Support at the Department of Defense (DOD), from Walter Reed Army Institute of Research,
from the VA Occupational and Environmental Health Strategic Healthcare Group, and from
veteran service organizations and Gulf War veterans. The committee focused on medical and
16 GULF WAR AND HEALTH

scientific data on long-term adverse health outcomes related to the infectious diseases it selected
for study.
The final step in the committee’s evaluation process was to weigh the evidence on the
infectious diseases and their long-term adverse health outcomes and to develop conclusions
about the strength of the evidence. The conclusions are assigned to categories of association,
which range from sufficient evidence of a causal relationship to insufficient or inadequate
evidence of an association.
This report includes discussion of acute diseases with potential long-term adverse health
outcomes caused by known pathogens. The committee acknowledges that there might be
clinically important pathogens that cannot be detected with available cultivation techniques
(Relman 2002). Because the extent to which such pathogens might contribute to acute illnesses
in military personnel is unknown, it is not possible to define a relationship between them and an
acute illness or long-term adverse health outcome.

ORGANIZATION OF THE REPORT

Chapter 2 lays out the committee’s process for selecting the infectious diseases to study
and reviewing and evaluating the evidence on them. Chapter 3 presents, in tabular format, the
endemic infectious diseases of southwest and south-central Asia that are known to have long-
term adverse health outcomes. Chapter 4 summarizes the body of literature on infectious diseases
that have been diagnosed in military personnel serving in the Gulf War, OIF, and OEF. The
committee’s comprehensive evaluations of selected infectious diseases are presented in Chapter
5, which also contains the committee’s conclusions. The final chapter, Chapter 6, presents
information about diseases and agents of special concern to veterans of the Gulf War, OIF, and
OEF that have an infectious component or have been implicated as a cause of “Gulf War
illness”.

REFERENCES

DOD (Department of Defense). 2006. US Department of Defense Official Website. [Online].

Available: http://www.defenselink.mil/ [accessed March 2006].
Hyams KC, Hanson K, Wignall FS, Escamilla J, Oldfield EC, 3rd. 1995. The impact of
infectious diseases on the health of US troops deployed to the Persian Gulf during operations
Desert Shield and Desert Storm. Clinical Infectious Diseases 20(6):1497-1504.
Hyams KC, Riddle J, Trump DH, Graham JT. 2001. Endemic infectious diseases and biological
warfare during the Gulf War: A decade of analysis and final concerns. American Journal of
Tropical Medicine and Hygiene 65(5):664-670.
IOM (Institute of Medicine). 2000. Gulf War and Health, Volume 1: Depleted Uranium, Sarin,
Pyridostigmine Bromide, Vaccines. Washington, DC: National Academy Press.
IOM. 2003. Gulf War and Health, Volume 2: Insecticides and Solvents. Washington, DC: The
National Academies Press.
IOM. 2004. Gulf War and Health: Updated Literature Review of Sarin. Washington, DC: The
National Academies Press.
INTRODUCTION 17

IOM. 2005. Gulf War and Health, Volume 3: Fuels, Combustion Products, and Propellants.
Washington, DC: The National Academies Press.
IOM. 2006. Gulf War and Health, Volume 4: Health Effects of Serving in the Gulf War.
Washington, DC: The National Academies Press.
Kilpatrick ME. 2005. Presentation to IOM Committee on Gulf War and Health: Infectious
Diseases. Washington, DC.
PAC (Presidential Advisory Committee). 1996. Presidential Advisory Committee on Gulf War
Veterans’ Illnesses: Final Report. Washington, DC: US Government Printing Office.
Persian Gulf Veterans Coordinating Board. 1995. Unexplained illnesses among Desert Storm
veterans. A search for causes, treatment, and cooperation. Persian Gulf Veterans
Coordinating Board. Archives of Internal Medicine 155(3):262-268.
Relman DA. 2002. New technologies, human-microbe interactions, and the search for previously
unrecognized pathogens. Journal of Infectious Diseases 186(2 Suppl):S254-S258.
 2

METHODOLOGY

This chapter articulates the committee’s approach to its task. Of the dozens of pathogens
known to exist in southwest and south-central Asia, the committee identified the ones that are
known to cause long-term adverse health outcomes and infected at least one US veteran who
served in southwest or south-central Asia in the period 1991-December 2005. The committee
then oversaw a formal, comprehensive literature review that identified about 1,200 peer-
reviewed studies about the late complications and latent and chronic infections that might be
associated with primary infection by each of the pathogens. Those studies constituted the
evidence from which the committee drew conclusions about the relationship between each
primary infection and specific long-term adverse health outcomes in humans. Finally, the
committee ranked the strength of the relationships through the five-category system presented at
the end of this chapter.

IDENTIFYING THE INFECTIOUS DISEASES TO STUDY

Geographic Boundaries

As required by law, the committee considered infectious diseases that might have
afflicted US troops who served in the 1991 Gulf War (PL 105-277 and PL 105-368).
Additionally, in response to a request by the Department of Veterans’ Affairs, the committee
considered infectious diseases that might have afflicted US troops during Operation Enduring
Freedom (OEF) or Operation Iraqi Freedom (OIF). Thus, the committee’s preliminary
deliberations covered infectious diseases known to occur specifically in Iraq, Kuwait, and
Afghanistan and in the geographic region that includes the Arabian Peninsula, Syria, Lebanon,
Israel, Iran, Qatar, Pakistan, Tajikistan, Kyrgyzstan, Uzbekistan, and Turkmenistan (Figure 2.1).
The term southwest and south-central Asia refers to that region throughout this report.

19
20 GULF WAR AND HEALTH

Uzbekistan
Kyrgyzstan

Turkmenistan
Tajikistan

Lebanon Syria
Iraq Afghanistan
Israel Iran
Jordan

Kuwait Pakistan

Qatar
Bahrain Qatar
Saudi United
Arabia Arab
Oman Emirates

Yemen

FIGURE 2.1 Southwest and South-Central Asia. The committee’s preliminary deliberations covered infectious
diseases known to occur specifically in Iraq, Kuwait, and Afghanistan and in the geographic region that includes the
Arabian Peninsula, Syria, Iran, Qatar, Pakistan, Tajikistan, Kyrgyzstan, Uzbekistan, and Turkmenistan.
SOURCE: The National Academies Press.

Infectious Diseases Endemic to Southwest and South-Central Asia That Have Long-Term
Adverse Health Outcomes

The committee approached its task by first identifying infectious diseases that could have
affected US troops deployed to southwest and south-central Asia. The committee members drew
upon their collective knowledge of infectious diseases, which stems from both professional
experience (Appendix A) and information gathered specifically for this study. The committee
acquired information from numerous sources about illnesses diagnosed in troops deployed to
southwest and south-central Asia, infectious diseases known to occur in that region, and
conditions of special interest to veterans. The information came from peer-reviewed journal
articles, surveillance and technical reports, presentations by physicians and scientists, and
veterans and representatives of veterans’ groups.
METHODOLOGY 21

Approximately 100 infectious diseases were identified for preliminary consideration

(Table 2.1), including the four diseases specified in the legislation that directs the committee’s
work (Box 2.1).

TABLE 2.1 Diseases and Etiologic Agents Considered by the Committee for Evaluation
Disease Etiologic Agent
Bacterial diseases
Acinetobacter infection Acinetobacter baumanii and other Acinetobacter species
Actinomycosis Actinomyces spp.
Anthrax Bacillus anthracis
Bartonellosis Bartonella spp.
Cat-scratch disease B. henselae
Trench fever B. quintana
Botulism Clostridium botulinum
Brucellosis Brucella spp.
Campylobacteriosis Campylobacter spp.
Capnocytophaga infection Capnocytophaga spp.
Chlamydia
Genital infections Chlamydia trachomatis
Pneumonia Chlamydia pneumoniae
Cholera (including vibrio infections) Vibrio spp.
Diphtheria Corynebacterium diphtheriae
E. coli gastroenteritis Escherichia coli
Enterotoxigenic E. coli
Shiga toxin-producing E. coli
Enteroaggregative E. coli
Enteroinvasive E. coli
Enterohemorrhagic E. coli
Enteropathogenic E. coli
Ehrlichioses Ehrlichia spp.
Enteric fever
Paratyphoid fever Salmonella enterica serovar Paratyphi A,B,C
Typhoid fever Salmonella enterica serovar Typhi
Enterococcal infection (vancomycin-resistant) Enterococcus spp.
Gas gangrene Clostridium perfringens
Hemophilus meningitis Haemophilus influenzae
Helicobacter infection Helicobacter pylori
Klebsiella infection Klebsiella spp.
Legionnaire’s disease Legionella spp.
Leptospirosis Leptospira spp.
Listeriosis Listeria monocytogenes
Lyme disease Borrelia burgdorferi
Melioidosis Burkholderia pseudomallei
Meningococcal infection Neisseria meningitidis
Moraxella infection Moraxella catarrhalis
22 GULF WAR AND HEALTH

Disease Etiologic Agent

Mycoplasma infection Mycoplasma spp.
Nocardiosis Nocardia spp. or aerobic actinomycetes
Nontuberculous mycobacterial infection Mycobacteria spp. (except M. tuberculosis complex)
Pasteurella infection Pasteurella spp.
Pertussis (whooping cough) Bordetella pertussis
Plague Yersinia pestis
Plesiomonas shigelloides infection Plesiomonas shigelloides
Pneumococcal disease Streptococcus pneumoniae
Pseudomonas infection Pseudomonas aeruginosa
Q fever Coxiella burnetii
Rat bite fever Spirillum minus
Relapsing fever Borrelia spp.
Rickettsioses
Boutonneuse fever Rickettsia conorii
Louse-borne typhus Rickettsia prowazekii
Marine typhus Rickettsia typhi
Ehrlichiosis Ehrlichia chafeensis
Anaplasmosis Anaplasma phagocytophilum
Salmonellosis (non-typhoid) Salmonella spp. (except serovar Typhi)
Shigellosis Shigella spp.
Staphylococcal infection Staphylococci spp.
Methicillin-resistant Staphylococcus aureus S. aureus (methicillin-resistant)
(MRSA) infection
Stenotrophomonas infection Stenotrophomonas maltophilia.
Streptococcal infection (group A) Streptococcus pyogenes
Tetanus Clostridium tetani
Tuberculosis Mycobacterium tuberculosis
Tularemia Francisella tularensis
Yaws (nonvenereal treponemal infection) Treponema pertenue
Yersiniosis Yersinia enterocolitica
Fungal diseases
Aspergillosis Aspergillus spp.
Cryptococcus Cryptococcus spp.
Histoplasmosis Histoplasmosis capsulatum
Mucormycosis Fungi of the order Mucorales
Helminthic diseases
Ascariasis Ascaris lumbricoides
Echinococcosis Echinococcus spp.
Enterobiasis Enterobius vermicularis
Filariasis Wuchereria bancrofti
Hookworm disease Necator americanus and Ancylostoma duodenale
Onchocerciasis Onchocerca volvulus
Schistosomiasis Schistosoma mansoni and S. haematobium
METHODOLOGY 23

Disease Etiologic Agent

Strongyloidiasis Strongyloides stercoralis
Tapeworm disease (taeniasis) Taenia spp. and Diphyllobothrium latum
Cysticercosis T. solium (Cysticercus cellulosae)
Trichinosis Trichinella spiralis
Trichuriasis Trichuris trichiura
Protozoan diseases
Amebiasis Entamoeba histolytica
Cryptosporidiosis Cryptosporidium parvum
Cyclosporiasis Cyclospora cayetanensis
Giardiasis Giardia lamblia
Isosporiasis Isospora bella
Leishmaniasis Leishmania spp.
Malaria Plasmodium spp.
Microsporidiosis Microsporidia spp.
Toxoplasmosis Toxoplasma gondii
Viral diseases
Adenoviral infection Adenovirus
Avian influenza Influenza virus H5N1
Chickenpox (varicella) Human herpesvirus 3 (varicella-zoster virus)
Crimean-Congo hemorrhagic fever Crimean-Congo hemorrhagic fever virus, genus
Nairovirus
Dengue Dengue virus, genus Flavivirus
Dengue fever
Dengue hemorrhagic fever, dengue shock
syndrome
Hantavirus hemorrhagic fever with renal syndrome genus Hantavirus
and hantavirus pulmonary syndrome
Influenza Influenza virus
Rabies Rabies virus
Retroviral diseases Human T-cell lymphotropic virus I (HTLV-I), HTLV-II,
human immunodeficiency virus (HIV)-1
Rift Valley fever Rift Valley fever virus, genus Phlebovirus
Sand fly fever Sand fly virus, genus Phlebovirus
Sindbis virus disease Sindbis virus, genus Alphavirus
Viral enteritis Various viruses
Rotavirus infection group A Rotavirus
Norovirus infection Norovirus
Viral hepatitis Hepatitis viruses
West Nile fever West Nile virus, genus Flavivirus
Miscellaneous diseases
Acute eosinophilic pneumonia Origin undetermined; not necessarily infectious
Idiopathic enteropathy Origin undetermined; not necessarily infectious
Madura foot (mycetoma)
Actinomycetoma Various actinomycetes bacteria
24 GULF WAR AND HEALTH

Disease Etiologic Agent

Eumycetoma Various fungi
Nosocomial infection Acinetobacter baumannii and other pathogens
Sexually transmitted diseases (STDs) Haemophilus ducreyi, herpes simplex virus, HIV, human
papillomavirus, HTLV, chancroid, Chlamydia
trachomatis, Neisseria gonorrhoeae, Treponema pallidum,
Trichomonas vaginalis, and others
Wound-associated bacterial infection Acinetobacter baumannii, Staphylococcus aureus, and
other pathogens
NOTE: The term infection refers to a primary infection that leads to disease.
SOURCE: CDC 2005; Heymann 2004; Mandell et al. 2005.

BOX 2.1 The Four Diseases Specified in PL 105-277 and PL 105-368

Leishmaniasis
Sand fly fever
Pathogenic Escherichia coli infection
Shigellosis

Though present in southwest or south-central Asia, some of the diseases on the

committee’s preliminary list do not have long-term adverse health outcomes. The committee’s
next step was to identify infectious diseases endemic in southwest and south-central Asia that
have potential long-term adverse health outcomes, including secondary diseases or conditions
(sequelae) caused by primary diseases, reactivation or recrudescence of diseases, and delayed
presentation of diseases. Only diseases with known or possible long-term adverse health
outcomes were selected from Table 2.1 for further evaluation.
The process began with the development of consensus on the meaning of long-term
adverse health outcomes. Such health outcomes, the committee agreed, should have one or more
of the following characteristics:

• Substantial interruption of normal physical and mental functioning occurring outside the
timeframe of acute infection.
• Organ dysfunction or damage with a persistent effect.
• Reproductive effects in military personnel, including birth defects in offspring of military
personnel.

A long-term adverse health outcome may be reversible. The committee also considered the
potential for secondary transmission of the pathogen.
The application of these criteria to the infectious diseases listed in Table 2.1 generated
the infectious diseases contained in Box 2.2: infectious diseases that are endemic to southwest
and south-central Asia and have long-term adverse health outcomes.

Direct Attribution to Military Service in Southwest and South-Central Asia

The committee examined the likelihood that the candidate infections would have
occurred specifically during military deployment to southwest and south-central Asia during the
METHODOLOGY 25

three operations in question. The risk of contracting a disease in the theater of operations must
have been equal to or greater than the risk of contracting it in the United States. Moreover, given
the natural history of the disease or infection, it must have been diagnosed in US troops in
appropriate temporal relationship to deployment.
Chapter 4 comprises a review of infectious diseases that have been reported in US troops
in close temporal relationship to the operations under study. On the basis of that review, the
committee determined that many of the diseases in Box 2.2 have never been reported in US
military personnel in close temporal relationship to deployment to southwest or south-central
Asia during the Gulf War, OEF, or OIF. Nevertheless, it is impossible to prove that US troops
did not contract any of the unreported diseases during deployment. Thus, the committee
summarizes the acute and long-term characteristics of these unreported diseases in tabular form
in Chapter 3 and excludes them from further analysis.

BOX 2.2 Infectious Diseases That Are Endemic in Southwest and South-Central Asia and Have Long-Term
Adverse Health Outcomes
Type of Etiologic Agent
Bacterium Virus Protozoan Helminth
More prevalent in southwest or More prevalent in More prevalent in More prevalent in
south-central Asia than in the southwest or south- southwest or south- southwest or south-
United States central Asia than in the central Asia than in central Asia than in
Anaplasmosis United States the United States the United States
Anthrax Crimean-Congo Amebiasis Ascariasis
Boutonneuse fever hemorrhagic fever Cryptosporidiosis Cysticercosis
Brucellosis Dengue fever Cyclosporiasis Echinococcosis
Campylobacter infection Dengue hemorrhagic fever Giardiasis Enterobiasis
Chancroid Dengue shock syndrome Isosporiasis Filariasis
Cholera Hepatitis A Leishmaniasis Hookworm disease
E. coli gastroenteritis Hepatitis B Malaria Onchocerciasis
Ehrlichiosis Hepatitis C Microsporidiosis Schistosomiasis
Enteric fever Rift Valley fever Toxoplasmosis Strongyloidiasis
Helicobacter infection Sand fly fever
Leptospirosis Sindbis
Lymphogranuloma venereum
Melioidosis Potentially more
Plague prevalent among troops
Q fever in war theater than
Rat bite fever among US adult
Relapsing fever population
Salmonellosis (nontyphoid) Adenovirus infection
Shigellosis Avian influenza
Syphilis Hantaviral hemorrhagic
Tuberculosis fever with renal
Typhus group (louse-borne and syndrome
murine) Hantavirus pulmonary
Yaws syndrome
Yersinia enterocolitica infection Influenza
Viral enteritis
Potentially more prevalent among West Nile fever
troops in war theater than among
US adult population
Gonorrhea
Trichomoniasis
Exploring the Variety of Random
Documents with Different Content
home to a musical journal in Berlin that music 'lies still in the cradle
here and nourishes herself on sugar-teats.'

The sentimental strain in German vocal music of the period made it

more popular than German instrumental music, in that the American
palate had been prepared for sentimentality by a saccharine sort of
psalmody and secular music which was being sprinkled over the
country by a second generation of Yankee music teachers of the
Billings order. Elijah K. Prouty and Moses E. Cheney were leading
representatives of this class. Prouty was a peddler, singing teacher,
and piano tuner. Cheney was a leader of a church choir. In 1839 they
organized and conducted a musical 'convention' at Montpelier, Vt., at
which, with shrewd perception of popular interest in novelty and
variety, they practised 'unusual tunes, anthems, male quartets, and
duets and solos for both sexes.' For the secular music they used the
'Boston Glee Book and Social Choir,' compiled by George Kingsley. In
order to attract the attendance of non-musical people, in the
intervals between performances short debates were held between
the local ministers, lawyers, and other prominent citizens.

In May, 1848, another musical convention was held in Chicago,

which discussed the general question of musical education and the
specific one of music in the public schools. Four years later William
B. Bradbury led a similar but larger convention. At this convention
the 'Alpine Glee Singer,' a compilation by Bradbury, was used for
secular music, indicating the strong influence which the elementary
sentimentality of German popular music exerted upon Americans.
Sugared American psalmody, flavored with German sentimentality,
and colored with a crudity of technique almost aboriginal produced
that sort of musical candy which we know as the Sunday-school
song. Bradbury was a pioneer in the composition and publication of
such music, although, to do him justice, the especially deleterious
coloring of the mixture was added by his successors, among whom
Ira D. Sankey and P. P. Bliss may be mentioned as chief offenders.
The collections of this school of musical composers must be
reckoned by thousands in editions and millions in numbers of copies.
Bradbury alone compiled more than fifty singing books, containing
many of his own compositions. Of these collections 'The Jubilee,'
published in 1857, sold 200,000 copies; 'Fresh Laurels' (1867),
1,200,000 copies; and a series known as the 'Golden Series,'
2,000,000 copies.

This flood of sentimentality, completely inundating the Sunday-

school, poured into the public school, and almost swamped the ark
of juvenile education in music which careful hands had just
committed to that great stream of popular culture. When music
became recognized as an essential element of education, it was
inevitable that the only available juvenile songs, those of the
Sunday-school, should be introduced in the public schools. Indeed,
the singing of anything in the schools was preferable to the entire
absence of song, and so this order of music, representing, as it did,
the popular taste of the time, marks, although we are loath to say it,
an important step forward.

Dr. Lowell Mason was the chief assistant at an event which marks an
epoch in American musical education, namely, the birth of the
normal musical institute from the so-called musical convention. This
occurred in 1856 at North Reading, Mass., where an annual musical
convention of the usual sort was converted into a school of a
fortnight's duration for instructing its members, particularly teachers,
in both musical theory and practice. The example was followed all
over the country to the great benefit of musical pedagogy.
Associated with Dr. Mason in this work of popularizing music was
George F. Root, who journeyed over the country conducting
conventions, lecturing, etc.[58]

V
During the second half of the nineteenth century the teaching of
music passed in large measure from the hands of single,
independent teachers into the direction of music masters associated
in institutions for class instruction, which are generally known as
conservatories, although this term in its European signification of a
large, completely equipped and nationally endowed school of music
is misleading. Indeed, the pretense seems to have been deliberate.
Dr. Frank Damrosch, in an address on 'The American Conservatory,'
before the Music Teachers' National Association at Oberlin, Ohio, in
1906, said:

'The so-called conservatory, college, or university of music ... may

be found in every American community.... It is usually organized
by an individual whose commercial instincts are stronger than his
musical conscience, and who, banking on the dense ignorance of
the average citizen in matters of art, offers what seems to be a
great bargain in the acquisition of musical ability in one form or
another.... There are many such schools which seemingly flourish
by the glittering, if empty, promises which they advertise. Some of
them confer degrees; ... one of the first musical doctor degrees
conferred by the director of one of these schools was on himself!'

While there are hundreds of conservatories of the class described by

Dr. Damrosch scattered over the Union, a number of institutions are
to be found which rank in thoroughness and comprehensiveness of
instruction with the best European conservatories. These have been
in every instance of slow growth, the most pretentious in chartered
plans having made early and signal failures in the province of
musical education, though some of them won success in other
musical activities. A typical example of this order is the Academy of
Music of New York, whose career is recorded in Chapter VI.

The earliest American conservatory worthy of its name is the

Conservatory of Music of the Peabody Institute, Baltimore, which
was founded in 1857. Its chief contribution to American musical
education has been the Peabody concerts, a series of eight
performances having been given annually since 1865. From 1872 to
1898 Asger Hamerick, the Danish composer, was director. He
organized an orchestra of fifty performers, which became, under his
intelligent training, a highly efficient instrument for the rendition of
the most advanced music. The programs of his concerts were
formed of overtures, symphonies, concertos, suites, and vocal solos.
He gave especial attention to works by American, English, and
Scandinavian composers, performing for the first time in America
many notable compositions, among them a number of his own. The
good work of the Peabody concerts, attracting, as it has done, the
respectful attention of foreign masters, should be a matter both of
encouragement and pride to those who have the cause of American
music at heart. It points the way to high attainment in our musical
appreciation and notable achievement in native composition.

The year of 1867 is notable in American musical history for the

establishment of five leading conservatories or musical colleges: the
New England Conservatory in Boston; the Boston Conservatory; the
Cincinnati Conservatory; the Oberlin Conservatory; and the Chicago
Academy of Music, later known as the Chicago Musical College.

The New England Conservatory was founded by Eben Tourjée,

whom Sir George Grove, in his 'Dictionary of Music and Musicians,'
denominates the 'father of the conservatory or class system of
instruction in America.' The nature of this system and its advantages
have been well expressed by Felix Mendelssohn-Bartholdy, who said:
'The class system has the advantage over the private instruction of
the individual in that, by the participation of several in the same
lessons and studies, a true feeling is awakened; and in that it
promotes industry, spurs to emulation, and is a preservative from
one-sidedness of education and taste.'

Dr. Tourjée, in 1851, at the age of seventeen, formed classes at his

home, Fall River, Mass., for instruction in vocal and instrumental
music. In 1859 he founded a musical institute at East Greenwich,
where he greatly developed his method. In 1863 he visited Europe
to gain information concerning the conduct of European
conservatories, and upon the ideas thus secured he established the
Providence Conservatory of Music, and in 1867 the New England
Conservatory of Music in Boston. For a time he conducted both
schools, then devoted himself exclusively to the latter. From its
beginning the Boston institution secured the best masters available
and gave a maximum of musical instruction at a minimum of cost. It
has sent forth over the country thousands of accomplished pianists,
organists, and vocalists, and, what is even more pertinent to the
present subject, music teachers, trained in Tourjée's methods. After
the founder died (in 1890), Carl Faelten acted as director, until in
1897 he founded a school of his own for instruction in the piano. No
school of its kind stands higher in America.

In 1897 George W. Chadwick, the professor of harmony,

composition, and orchestration, was made director of the New
England Conservatory. For several years Mr. Chadwick had conducted
the annual musical festivals at Springfield and Worcester, Mass., and
his special attention was thereby directed toward great orchestral
and choral performances by the students, whose number was
mounting into the thousands. By the generosity of patrons of the
Conservatory, especially Eben D. Jordan, president of the trustees, a
large building was erected in 1902, containing facilities for
instruction superior even to those of European conservatories, and
an auditorium, Jordan Hall, whose large size and fine acoustic
properties render it one of the important concert halls of the country,
use as such being frequently made of it by visiting artists, to the
great advantage of the students as well as the general public. The
instrumental equipment of the conservatory is large, the collection of
organs, including the pipe organ in Jordan Hall, which is one of the
largest in the world, being especially notable.

The conservatory possesses one of the best working musical libraries

in the country, a unique feature being the choral library of the
Boylston Club (founded 1872) and its successor, the Boston Singers,
which contains many copies of manuscript treasures in European
collections. This library was a gift to the conservatory by George L.
Osgood. The Boston Public Library nearby contains the Allen A.
Brown collection of musical books and manuscripts, which is excelled
in America only by the Congressional Library at Washington.
Accordingly, the pupils of the conservatory have at hand every
facility for acquiring a musical education which the most ardent
student could desire. It is not surprising that among its three
thousand and more students every one of the forty-eight states of
the Union is represented, as well as a dozen foreign countries, even
distant Russia and Turkey.

The curriculum of the conservatory has been generally described by

Frederick W. Colburn in 'The Musical Observer' for July, 1913. Mr.
Colburn, after mentioning special features, such as the conservatory
orchestra of seventy-five members, affording the training and
routine indispensable to professional performers whose ranks it is
annually supplying, says: 'While the new is studied, the
fundamentals are not lost sight of. All the courses have been
planned to avoid turning out narrow and one-sided specialists. The
management realizes that the professional musician has need of
very broad and very correct culture. The students listen to lectures
on the history and theory of music from such authorities as Louis C.
Elson and Wallace Goodrich. The modern languages and English
diction are taught by experts, several of whom are authors of their
own text-books. The pianoforte instruction follows approved
methods; it shows much of the influence of the late Carl Baermann,
one of the most eminent of the German musicians who have settled
in this country. The vocal instruction is along the lines of the old
Italian method which has formed the voices of most of the world's
great singers. The teaching of the organ accords with the practice of
the best German and French organists. In all departments there is
present the idea of thoroughly grounding the student in the
essentials of musical art and of avoiding easy, ready-made and get-
culture-quick methods.'

The Boston Conservatory, second in the list of five founded in 1867,

was organized by Julius Eichberg, a distinguished German violinist
and composer, who had been, since 1859, director of the orchestra
at the Boston Museum. This speedily won and long maintained a
high reputation, particularly for instruction in the violin, on which
subject Eichberg prepared a number of valuable text-books.

The Cincinnati Conservatory of Music was founded by Clara Bauer,

who still is active in its management, having charge of the home for
the female pupils. This was the first conservatory in the country to
establish a residence department—indeed, its group of buildings and
park-like grounds give the conservatory a truly academic aspect
possessed by few institutions of its kind that are situated in cities.
Miss Bauer, however, recognized from the beginning that the all-
important element of a conservatory was its teaching force. She
secured representative talent in the various branches of music from
the various European musical centres, thereby securing warm
approbation of the institution from foreign musical artists and critics.
The faculty now numbers sixty members; it contains artists notable
for excellence in every branch of musical arts and pedagogy. General
cultural studies, such as dramatic art, literature, and modern
languages, are conducted with special application to their relation to
music.

The Cincinnati Conservatory was the first to conduct a summer

music school. The sessions have been uninterrupted since 1867.
Attended largely by music teachers, they have greatly advanced the
cause of musical education in the territory tributary to the city.

The Oberlin Conservatory of Music, at Oberlin, presents so many

object lessons of musical pedagogy that it demands rather extended
treatment here.

In the first place, the institution had a natural origin: it was formed
to teach psalmody to a religious community and, in growing beyond
this limited field by adding one musical feature after another as the
developing taste of the people demanded, it typifies the history of
music in the nation. Secondly, the conservatory has a proper
environment. It was planted in a soil already enriched by culture,
Oberlin being the seat of a college distinguished for progressive
ideas and high ideals, the reaction of which upon musical work is
always inspiring—indeed, is essential to the highest achievement.
Thirdly, the Oberlin Conservatory has a proper organization. It is a
social democracy and thereby calculated to produce that free and
fraternal spirit which is the soul of art. Young men and women meet
on equal terms and there are no distinctions among them based on
wealth or nationality or even race, Oberlin having been the first
college to include negroes among its students. Lastly, the
conservatory has a sound program and is living up to this as well as
could be expected in view of the pressure exerted on all 'schools of
the people,' to supply immediate demands. It believes in
constructive work, in learning by doing. Thus it regards a practical
knowledge of the science of musical composition as necessary to an
intelligent appreciation of musical masterpieces, and to this end has
established a course in theory and composition which requires four
years of hard study and assiduous practice. The class system of
instruction is the one adopted as the chief method, it being
supplemented by private instruction.

Dr. Florens Ziegfeld, a distinguished German pianist, still conducts

(1915) the conservatory which he founded in Chicago—the last of
the five started in 1867—under the name of the Chicago Academy of
Music, and which is now called the Chicago Musical College. The
institution was burned out in the great fire of 1871, but with
indomitable courage Dr. Ziegfeld at once secured new quarters and
continued his classes. The course of study was steadily enlarged
until now it includes every department of music and the principal
modern languages, the faculty being one of the strongest in the
country, comparing favorably with those of European conservatories.
By authority of the State of Illinois the college grants music teachers'
certificates and confers musical degrees. The college is finely
situated on Michigan Boulevard, overlooking Lake Michigan and
Grant Park. It contains a concert hall seating 1,000. A student
orchestra of seventy members is maintained, affording practical
training in conducting and ensemble playing.
In 1871 a conservatory of music was established in Jacksonville, Ill.,
the seat of Illinois College. Its founder was Professor W. D. Sanders,
a leading Western educator, and its first director was I. B. Poznanski,
a violinist and composer who later became instructor at the Royal
Conservatory, London. In 1903 the conservatory was merged with
the college. The Cleveland Conservatory of Music was also founded
in 1871. It adopted the European conservatory method of
instruction.

In 1873 Northwestern University at Evanston, Ill., became a co-

educational institution and at once established a 'Conservatory of
Music' that began, and for many years thereafter remained, on a low
plane of instruction. The university authorities, in the manner of old-
time monarchs, 'farmed out' to the director of the conservatory the
privilege of running the business for a percentage of the receipts,
and gave him a free hand and full responsibility. Naturally the
conservatory was conducted in a way to produce the greatest
immediate returns.

In 1891 Prof. P. C. Lutkin was put in charge of the conservatory. He

insisted that the title be dropped and that the school be made a
department of the university, directly under control of the university
authorities; and that its director should receive a full professorship
with a fixed salary, in order that educational ideals should not be
compromised by financial considerations. These changes were
authorized, and Professor Lutkin radically revised and extended the
curriculum to make it conform to academic standards. By 1895 a
four-years course was developed, to correspond with that of the
Liberal Arts department. The 'Department of Music' then assumed
the title of 'School of Music' and became a coördinate division of the
university, like the School of Law, the School of Mines, etc., with its
own dean and faculty. Its pupils, of course, retained all the
opportunities for general culture afforded by the college of Liberal
Arts.
In an address delivered before the Music Teachers' National
Association at Oberlin in 1906, Professor Lutkin said: 'The exact
point where general education should give way to the study of music
is a much discussed one, and we will not stop to consider it here,
except to say that we have placed it at the point of entrance-
requirements in the College of Liberal Arts. The fact that the
students are able to pursue advanced work in history of music,
harmony, counterpoint, analysis, etc., is of itself a clear index as to
their mental capacity, and places them, without doubt, upon a plane
of mentality quite up to that required of college students.' The music
department of the Northwestern University now ranks with the best
conservatories in the country.

Concerts have always formed the leading element in developing

American appreciation of music. The enthusiasm created by the
festivals conducted in Cincinnati by Theodore Thomas in the early
seventies led directly to the establishment in 1878 of the Cincinnati
College of Music by Miss Dora Nelson. The institution was planned
along the lines of European conservatories, with a close relation to
superior public performances in the city, the patrons of which were
patrons of the college. With a fine faculty the institution has retained
to the present the high reputation it won at the outset. Theodore
Thomas was the first musical director of the school, and among his
successors is Frank Van der Stucken.

Of the important Chicago schools of music the earliest was the

Chicago Conservatory, established in 1884. Quite a typical institution
is the American Conservatory of Chicago. It was founded in 1886 by
its present head, President John J. Hattstaedt, with the assistance of
several of Chicago's music-loving citizens. Its quarters were in Weber
Hall Building, corner of Wabash Avenue and Jackson Street, which
were retained for ten years, when the conservatory was removed to
the adjoining building—Kimball Hall, where it still remains.
From a small institution it has grown to be one of America's largest
schools of music, registering about 2,000 students annually. The
faculty numbers seventy-five, and contains many teachers of
national reputation. A modern and thorough curriculum includes all
branches of instrumental and vocal music, theory and composition,
dramatic art, expression, physical culture, and modern languages.
Special features are: a complete and well-established Normal School,
a student's orchestra, a musical bureau and a carefully arranged
series of faculty and pupils' recitals.

In 1885 two conservatories, the American Institute of Applied Music

and the National Conservatory of Music, were established in New
York. Miss Kate S. Chittenden was the founder of the Institute, Mrs.
Jeannette M. Thurber of the Conservatory. Both are flourishing to-
day under control of the founders and with excellent faculties and
ample musical facilities.

The National Conservatory, because of certain philanthropic features,

is deserving of special mention as a type of institution which is not
wholly commercial in its ends, and which has prepared the way for a
type that is purely artistic in its purposes. It offers musical
instruction to every applicant without regard to race, sex, or creed,
the sole condition being that he shall give proof of a natural talent
for music; this instruction it imparts without cost to those unable to
pay.

The title of National Conservatory is formally justified by the fact

that it was chartered in 1891 by a special act of Congress, the
official home being designated as Washington. A far better claim to
the title could be based on the facts that names of even more than
national fame appear on the roll of its faculty from the beginning,
when such musicians as Rafael Joseffy, Camilla Urso, and Victor
Herbert were connected with the institution, down through Dvořák's
brilliant régime to the present day.
The Conservatory at its outset secured experts in special lines of
music as instructors. For three years (1892-95) Dr. Antonin Dvořák
was its director. Under his management liberal prizes were awarded
for original compositions, and the works, a symphony by Henry
Schoenefeld, a piano concerto by Joshua Phillen, a suite for string
orchestra by Frederick Bullard, and a cantata by Horatio W. Parker,
were performed in public concert. Under the direction of the
distinguished composer the National Conservatory orchestra became
notable not only for artistic excellence, but, what pertains more to
the present subject, for the superior training it afforded poor young
men of talent, and the places this enabled them to obtain in leading
American orchestras. This work, of course, did not cease with Dr.
Dvořák's retirement.

An institution incorporating in a systematic and substantial way the

public and philanthropic spirit which has called into existence so
many of our conservatories and schools of music is the Institute of
Musical Art of the City of New York. This is the model institution of
its kind in America; and, as there is promise that its example will be
followed in other cities of the Union, leading to the establishment of
musical education on a high and uniform plane, it deserves special
notice.

Recognizing that schools of music, inaugurated with fine ideals and a

sound program to attain these, have almost without exception been
forced by the need of funds to lower their standard and modify their
curricula to suit the popular demand for easy and flashy courses, Dr.
Frank Damrosch determined to found an institution wherein
commercial considerations would not enter. In James Loeb, a New
York banker, he found a patron of art in thorough sympathy with the
project. By a fund of a half million dollars, given in memory of his
mother, Betty Loeb, Mr. Loeb put the splendid idea into concrete
form, and in 1905 established and endowed the Institute of Musical
Art with Dr. Damrosch as its director.
The purpose of the Institute is to provide thorough and
comprehensive courses in music, each of which is planned to include
every study necessary for mastering a particular branch of music,
and all of which taken together cover the whole art. The Institute is
enabled to execute this plan inflexibly because it is independent of
tuition fees, since the revenue from these is supplemented by the
interest of the funds. Accordingly the fees have been fixed at
moderate and uniform rates, while no expense is spared in securing
the best talent available as a teaching and training force.

The roll of the faculty contains seventy-seven names. The faculty

council which directs the policy of the Institute consists of the
director and five other experts. Since operatic and concert managers
agree that individual instruction and criticism cannot be too carefully
given in the case of students intending to make the performance of
music a profession, and, as this thorough system of education is
equally beneficial to the amateur, it has been adopted by the
Institute. Theoretical subjects are the only ones taught in class.

In addition to the direct personal teaching which the student

receives, he is surrounded by artistic and educational influences
calculated to broaden his general knowledge and culture and to
improve his taste and discrimination. The discipline which is an
essential principle of the Institute, and which is lacking in private
instruction, where the pupil often demands and obtains relaxing
modifications of the instructor's system to suit his inclinations, since
he is paying for his education, is of the highest value in developing
character. Students of an art which in its nature tends to
overstimulate the emotional nature need a corrective cultivation of
the powers of the intellect and the will which students of other
subjects do not so much require, since, from their studies,
intellectual development is acquired directly and, reason being the
governor of the will, control of this great moral force is indirectly
imparted.
Like the National Conservatory the Institute is open to students of
both sexes, irrespective of creed or race. The only demand is that
they give proof of general intelligence, musical ability and serious
purpose. Every regular student is required to follow a prescribed
course not only in the specific branch which he has selected, but, in
order to provide a proper foundation for this, in the subject of music
in general. The student begins the course at the stage for which his
attainments and abilities have prepared him, as these are indicated
by three tests: as to his general knowledge of music; as to his sense
of musical hearing; as to his vocal or instrumental talent.

The departments of study are singing, piano, organ, stringed

instruments, orchestra, public school music and theoretic course.
The courses are divided into seven grades, the last four being post-
graduate. The post-graduate diplomas are of two types, called
teachers' and artists'. For the teachers' diploma two grades of
pedagogy and advanced work in theory and technique are required;
for the artists', either two or three grades in theory, technique, and
ear training, according to the proficiency of the student, which is
tested not only by work done in the Institute, but by a public recital
before musicians not connected with the Institute. The work of the
seventh grade in the artists' course is confined to the study of
composition in the various forms of complete sonata, chamber
music, vocal forms, overture and orchestration. A prize sufficient to
provide for a year of European life and experience is given annually
to that graduate in any of the artists' courses, or in composition,
whom the faculty and trustees think most deserving of the award
and distinction.

The leading schools of music in Canada are the Toronto

Conservatory of Music and the Conservatorium of Music in McGill
University at Montreal.
The Toronto Conservatory was founded by the late Dr. Fisher in 1886
and opened in 1887. In the thoroughness of its courses and the
completeness of its equipment it ranks with the best conservatories
in Europe. In 1897 it purchased its present centrally located site, in
close proximity to the cluster of educational and public buildings,
and began the erection of the structures which now form its
commodious home. Its music hall is architecturally one of the finest
edifices of the kind and its auditorium is acoustically one of the most
satisfactory halls in Canada for chamber music and other recitals. It
contains a three-manual concert organ which is a masterpiece of
Canadian workmanship. The main hall is supplemented by smaller
ones for lectures and recitals and by practice rooms equipped with
two-manual organs. The musical equipment in general is ample and
comprehensive, meeting the needs of the 2,500 pupils in
attendance.

On the death of Dr. Fisher in 1913, Dr. A. S. Vogt, whose work as

conductor of the Mendelssohn Choir of Toronto is well known, and
who had been for many years teacher of piano in the Conservatory,
was advanced to the position of director. The faculty consists of 139
professors and instructors. It is almost exclusively British in
composition, in striking contrast to the faculties of leading
conservatories in the United States, on whose roll Continental
European names abound, often to the point of a majority. However,
many of the instructors have received their education at foreign
conservatories.

The Conservatory is divided into eleven departments, schools for the

piano, the voice, the organ, the violin, and other stringed
instruments, theoretical instruction, embracing harmony,
counterpoint, composition, orchestration, musical history and
acoustics, orchestral and band music, expression (including
education, physical culture, etc.), modern languages, piano tuning,
and kindergarten music method. The extremely practical elements of
this curriculum indicate the attention paid to the fundamental needs
of the public.
The Conservatory maintains an orchestra for practice in routine and
training for students sufficiently advanced to justify their assignment
to places in the organization. Frank E. Blatchford, of the violin
faculty, who is also concert master of the Toronto Symphony
Orchestra, is the conductor.

The Conservatory is affiliated with its near neighbor, the University of

Toronto. Students who pass the conservatory examinations in
musical theory are exempted from corresponding examinations by
the University for the degree of Bachelor of Music. In its desire to
spread at least a measure of musical knowledge and appreciation
among the people, the conservatory conducts correspondence
courses in musical theory, and, for the convenience of practice,
especially in the piano, maintains eleven branches in the outlying
residential districts of Toronto.

The McGill University Conservatorium was opened in 1904. The

Conservatorium, however, was then only in its experimental stage
and it was not until October, 1908, that the connecting link between
the University and the Conservatorium was completed by the
appointment as director of Dr. Harry Crane Perrin, professor of music
in the University. In 1909 the orchestra was formed, which was
composed of students of the Conservatorium, and in February of
that year they gave their first orchestral concert.

VI
Henry Dike Sleeper, professor of music in Smith College, a women's
college of the first rank, has made an interesting analysis of the
character of musical instruction given in the leading universities and
colleges where the subject is taught. He says that there are four
ideals of study:
1. Musical composition: Great emphasis is laid on this at the
University of Pennsylvania, and it is a predominant, though lesser
element in the schemes of Harvard and Yale.

2. Public performance: This is the chief feature of education in the

conservatories affiliated with, but not a part of the regular academic
course. These conservatories are founded largely in the West and
South, and are connected with colleges that either are for women or
are co-educational.

3. Culture: Amherst, Beloit, Cornell, and Tufts are examples of

institutions where the music courses tend chiefly to imparting
musical appreciation.

4. A balance of the three: composition, concerts, culture. Examples

of where this ideal of rounded development is sought for are the
women's colleges, Smith and Mount Holyoke, and co-educational
institutions, such as Oberlin and Ohio Wesleyan, and the State
Universities of Michigan, Wisconsin, and Nebraska.

In the light they throw on the status of musical education in

American universities the following authoritative statistics, the latest
of the kind compiled, are illuminating:

In a monograph on 'Music Instruction in the United States,' prepared

by Arthur L. Manchester after exhaustive inquiry and published by
the United States Bureau of Education in 1908, the enrollment of
students of music in 151 colleges and universities was 18,971, of
whom 5,257 were men and 13,714 were women. There was an
average attendance in each institution of about 125.

Dr. Rudolf Tombo, registrar of Columbia University, in an article in

'Science' for December 25, 1908, and January 1, 1909, stated that
from statistics supplied him by twenty-five leading universities, not
counting summer schools conducted under their auspices, ten had
departments of music and five had courses of music. In a total
attendance in all departments of all the twenty-five universities
amounting to 35,885, the students of music numbered 1,940, which
is only 5.4 per cent. of the total.

When the great popular interest in music, as exhibited by the

attendance at operas, concerts, and musical festivals, is taken into
consideration, this low percentage would indicate that the
universities are not adopting attractive methods of musical
instruction. Evidently the cause of higher musical education will be
more readily served by improving the character of instruction in the
conservatories, where enthusiasm among the students prevails, than
by attempting to wake up university men from their indifference to
music—for enthusiasm is a prerequisite in all studies and pursuits.

The pioneer in creating a department of music in American

universities was John K. Paine, teacher of music in Harvard in one
capacity or another from 1862 until 1905, when he retired on a
pension. Although practical music courses, piano-playing and
singing, were taught in women's colleges, notably Vassar, before Mr.
Paine began his work in Harvard, he was the first teacher to direct
his energies toward establishing music as an academic study, on an
equality with all the other branches, counting like them for the arts
degrees of A. B. and A. M.

The history of music is obviously an academic study, and Mr. Paine

judiciously began his campaign by securing permission in 1870 to
deliver a university course of lectures on the subject. In 1870 he had
persuaded the faculty to introduce harmony and counterpoint in the
curriculum, counting for the bachelor of arts degree. After this vital
concession, the faculty could not well deny to music full standing in
the university. In 1875 Mr. Paine was appointed professor of music.

The indifference of the students to the art, and their prejudice

against music as an academic study, were harder to contend with.
For twenty years Prof. Paine carried on his work without assistance
in instruction and with small classes. Then the students seemed
suddenly to wake up to the fact that a department of music
conducted on the high plane of Oxford and the great German
universities was a matter to be proud of, and they began in
increasing numbers to embrace the rare advantage extended to
them. When Prof. Paine retired he had three assistants in his work
and over two hundred students in his classes.

Prof. Walter R. Spalding, Mr. Paine's successor, aided by able

teachers, such as Edward Burlingame Hill, instructor in musical
history, have continued the good work of the founder. The course is
essentially theoretical; it includes harmony, counterpoint, musical
form, musical history, and the higher branches of composition,
including orchestration. In 1912 the students of the department
established the 'Harvard Musical Review,' a publication of high ideals.

Professor Paine, and Professors Parker and MacDowell, his

contemporaries at Yale and Columbia, respectively, achieved fame as
practical exponents of the art in its highest realm. Professors of
music in European universities as a rule are learned theorists and
historians, but not composers. It is a moot question which class of
instructors is the better. In behalf of instruction by a creative genius
it is claimed that it inspires students with pride in their teacher and,
if training is afforded in composition, with desire to emulate his
achievements. In behalf of the academic drill-master it is urged that
the thorough grounding which he imparts develops that all-round
ability in music which, when the purpose is in time realized by
students, will itself generate enthusiasm. The respective merits of
the two systems may thus be summed up: the American early
develops musical appreciation, the European musical knowledge.
Since these qualities have reciprocal influence, it would seem that
the two systems should be combined, at least in America, where
musical appreciation on the part of the student can not always be
assumed, as in Europe.

Of the departments of music in women's colleges, that in Wellesley

may be considered the most academic. A school of music was
established in 1875, its pupils being drawn chiefly from the special
students, who lacked preparation for the regular college studies and
so were limited to the so-called 'accomplishments' of music and
drawing, with a smattering of literature. As it became increasingly
evident that the emphasis in the school of music was on
performance—the development of highly specialized skill—and that
the predominating interests in the college were intellectual rather
than vocational, the school was seen to be out of place. The
students diminished in members to less than 100 in 1895. In 1896-7
the school was converted into a regular department of the college,
the curriculum in music being made mainly theoretical, the courses
being harmony, counterpoint, musical form, history of music, and
free composition. The director since 1897 has been Hamilton C.
Macdougall. There are eight other professors in the department
faculty, and students number over two hundred. In 1907 Billings Hall
was erected for the use of the department. While practice in music
has been subordinated to theory, it has been retained and even
improved since the school became the department. Indeed, in 1897
a college orchestra was organized.

The four leading women's colleges in the East, Vassar, Wellesley,

Smith, and Mt. Holyoke, have much the same curriculum in music,
instruction being given in both theory and practice with mutual
benefit resulting from the reacting influence one on the other. In this
respect it would seem that these institutions have a decided
advantage over such universities as Harvard, where there is no
training in musical performance.

In the same year that music was made a part of the curriculum of
Harvard (1875), classes in music were inaugurated at the University
of Pennsylvania under Professor Hugh A. Clarke. As has already been
stated, the attention paid to composition is the distinguishing feature
of the course.

In 1894 the department of music was established in Yale University,

and Horatio W. Parker, Mus. D., was placed at its head. At present
there are nine other professors and instructors in the faculty of the
department. The aims of Dr. Parker and his assistants are to provide
adequate instruction for those who desire to become musicians by
profession, either as teachers or as composers, and to afford a
course of study for those who intend to devote themselves to
musical criticism and the literature of music. Accordingly the work of
the department is divided into practical and theoretical courses. The
practical courses consist of instruction in pianoforte, organ, violin,
and violoncello playing, in singing, and in chamber music (ensemble-
playing). No student is admitted to a practical course other than
singing and violoncello playing unless he is also taking at least one
of the theoretical courses.

The theoretical courses are subdivided into elementary and

advanced. The former class includes harmony, counterpoint, and the
history of music; the latter class instrumentation, advanced
orchestration and conducting, and strict and free composition. Both
courses in composition are under the immediate direction of Dr.
Parker, whose special fitness has been commented upon in another
chapter. Dr. Parker requires every student in the composition courses
to produce an extended original work. This usually takes the form of
a sonata. The students are incited to excel in original composition as
well as in artistic performance by the Sandford Fellowship, which
gives two years' study abroad to the most gifted performer who shall
also show marked ability as a composer.

Allied with the department is the New Haven Symphony Orchestra, a

complete and well-equipped organization of seventy players, which
gives a series of concerts during the winter. It affords opportunity to
the students of orchestration to hear their work actually and
adequately played, and, when its quality warrants, to have the
composition publicly performed. Several original works are thus
produced every year. They are commonly overtures, but piano
concertos and other works have occasionally been presented.

The orchestra also opens to the student a gateway into professional

life by admitting to it those whose performance on the violin or
violoncello has been approved. Students of the piano, as well as of
the violin, are allowed to rehearse with the orchestra and even to
perform publicly if their fitness to do so has been demonstrated. The
students give informal recitals from time to time and, toward the end
of the college year, a concert, accompanied by the Symphony
Orchestra.

This insistence on the study of the theory of music and the

demonstration of the theoretical principles by original composition as
the only proper foundation of education in the art are the
distinguishing characteristics of the Yale department of music, and
the practical achievements of Dr. Parker and his students would
seem to justify the soundness of the idea.

In 1896 Edward MacDowell, the composer, was called to the chair of

music in Columbia University. Mr. MacDowell, either because of his
temperament or the limitations imposed by the university on his
work, did not find the position so congenial as Dr. Parker has done at
Yale. Instead of being inspired by teaching to greater feats of
composition, Mr. MacDowell seemed hampered, and, to the great
loss of American music, produced fewer and fewer of those fine
works which cause him to be acclaimed as the greatest of American
composers. He resigned the position in 1904, two years before his
death.

In 1906 the department of music which had developed

independently in the Teachers' College was combined with the
department in the university to form the Columbia School of Music.
Cornelius Rübner, Mus. D., is the present head. The declared aims of
Prof. Rübner and his four associates in the faculty of the school are
to treat music historically and æsthetically, as an element of liberal
culture; to teach it scientifically and technically, with a view to
training musicians who shall be competent to teach and compose;
and to provide practical training in orchestral music. There are a
university chorus and an orchestra (the Columbia Philharmonic) in
connection with the school, which present much the same
opportunities to the students as those afforded by the New Haven
Symphony Orchestra to the Yale students. The school holds two
annual concerts of original compositions by its students and
conducts many other concerts as well as public lectures and recitals.

The various courses may be counted toward the degrees of bachelor

of music, of arts, of science, and master of arts. The curriculum
includes the history of music, conducted by Prof. Daniel Gregory
Mason; harmony, counterpoint, sight-singing and playing;
composition, orchestration, and symphonic form, conducted by Prof.
Rübner. The school also offers courses in teaching and supervising
music at the Teachers College. The equipment of the school is large
and comprehensive. The department of music in the University
Library contains a well-selected working collection not only of
treatises but also of compositions. The private library of Anton Seidl,
consisting of 1,220 scores, which was presented to the university,
has been placed in the rooms of the School of Music.

The University School of Music at Ann Arbor, which is conducted by

the Musical Society of the University of Michigan, was founded by
Prof. Henry S. Frieze, and its membership is restricted to officers,
graduates, and students of the university. In 1888 the present head
of the school, Albert A. Stanley, took charge. He greatly
strengthened the technical and theoretical work. Under his direction
the policy of the school has been to train a few students thoroughly
rather than many superficially. The courses are those generally given
in schools of music connected with American universities: harmony,
single and double counterpoint; canon and fugue; history of music;
analysis and criticism; musical appreciation.

Since our Western State universities form each the summit of public
education in its state, such institutions as Michigan pay much
attention to training teachers of music in the public schools. The
University of Wisconsin goes much further than this. In connection
with its admirable University School of Music, which is one of the
best in the country in that not only the theory of music is taught in
the most approved academic fashion, but practice is also afforded in
choral and instrumental music, and it has established a 'university
extension' division for educating the whole people of the state in
music.

As stated in a bulletin of the university, the School of Music stands

ready to assist any community in strengthening its musical life by
the following means:

1. It gives advice to communities desiring such aid, by sending to it an expert

who studies the situation, and, with local representatives, prepares a plan of
action.

2. It supplies lists of materials, names of persons and books that would be

helpful to the plan.

3. It rents out at low cost such materials, including chorus music and material for
bands and orchestras.

4. It supplies at reasonable prices musical attractions of high quality and wide

variety, such as concerts and lecture recitals—singly or in series.

5. It assists in providing competent music teachers to communities which are too

small to support them unaided. These teachers direct the music in the public
schools and assist in general community music, both vocal and instrumental,
and in the music of churches and social organizations.

6. Through the coöperation of the Wisconsin University School of Music, the

American Federation of Music, and other organizations, it assists in building up
bands and orchestras throughout the State by supplying organizers and
teachers.

7. It conducts correspondence courses in which experts give advice in solving the

various problems which arise in connection with school and church music,
bands, orchestras, choruses, and concerts.

Truly an extensive program and one worthy of emulation.

VII
The introduction of music into the public schools has already been
discussed. It is a great tribute to the soundness of the pedagogic
principles laid down by Mason and Woodbridge, the pioneers in
juvenile musical education, that, despite the many new methods
which have been tried, music in the public school is largely
conducted along the original lines. Singing in chorus with use of
specially prepared and successively graded exercises printed on
charts or written on the blackboard and song books, and, most
important of all, under the leadership of a teacher with winning
personality and knowledge of the childish mind, has been found to
produce the best results. So great proficiency has been achieved in
the training of juvenile choruses for musical festivals that the only
really satisfactory choruses given by a great multitude of persons are
the choruses of children, some of which have exceeded three
thousand voices.

The basis of juvenile instruction in music is marked rhythm and

simple melody, with a short range of pitch, which are best taught in
unison. The voices of the children with a good natural ear being
fortunately in a large majority they tend to correct the defective
auditory perception of the minority.

When the voices of the children are sufficiently trained by singing

together simple rote songs, musical analysis is begun. The notes are
taught to be recognized first by the ear, and then by the eye, and a
practical application of this knowledge is made by exercises and
songs. The same general process is pursued until, by the time the
pupil reaches the higher grades, he has acquired an ability to sing at
sight any new song which a non-professional musician is likely to be
called on to render.

In small American towns the regular teachers in the public schools

carry on musical exercises. But they are not without easy access to
knowledge of approved methods, for this is published in a special
magazine, 'The School Music Monthly,' which was established in
1900. Many other magazines, educational as well as musical, contain
articles and even departments on the subject.

Furthermore, there exists a great and influential organization, the

Music Teachers' National Association, which was founded in 1876
with Dr. Eben Tourjée as its president. This uses every means in the
power of an extra-governmental association to keep up the standard
of musical education in the country. It holds annual sessions wherein
methods in musical pedagogy are presented and discussed. In many
states similar associations are found whose membership is confined
to music teachers in the state. These are not affiliated with the
National Association, and their activities are less general in scope,
although of more immediate interest to the members because
applied to matters of special concern.

Cities of from 8,000 to 200,000 inhabitants usually employ a special

teacher to direct instruction in music in the public schools. Larger
cities have a number of these teachers and one or more supervisors
or directors of public school music. New York, for example, has one
director, one assistant director and fifty-six special teachers. From
the vastness and complexity of the situation in the largest cities,
musical education has of necessity become highly systematized and
correspondingly efficient.

New York perfected its system about 1900. The capstone may be
said to be the public musical lectures and performances given in
connection with the evening lecture courses presented in the public
schools and other public buildings under the general auspices of the
Board of Education and the special supervision of Dr. Henry M.
Leipziger.

Indeed, it is only since the beginning of the century that the country
in general has come to recognize at all adequately the supreme
importance of musical culture to community or civic life. As a result
of this recognition there has been a general movement in the central
and western states, and in encouragement of the study of music to
add the forces of private instruction to public by giving credit in the
schools for musical work done outside of them, which credit many
state universities have in turn accepted by admitting high school
graduates upon their certificates.

A more spectacular expression of appreciation of the value of music

to community life is the growing use of children's singing for musical
festivals, concerts, and pageants. In many cities the performance by
public school children of concerts ranging from simple unison songs
to part songs, cantatas, and even light operas has become a regular
feature of community life. In many cases school orchestras and
bands have accompanied the choruses. In this way the public
schools have become foreshadowings of the conservatories and the
university schools of music. In time the weak spot in our higher
musical curricula, the course in 'musical appreciation' which so many
idlers follow as a 'royal road' to a musical education (although it is
found in none of the Royal Conservatories of Europe), will have no
excuse for being retained, for our high school pupils will already
possess it in sufficient measure to pursue with zest the hard
technical courses the mastery of which is necessary to the making of
a real musician.

VIII
While the American people have shown themselves opposed to the
conduct or subsidization of music by the national government, as
this has been often proposed in plans for a national conservatory, we
have seen, in the case of Wisconsin, that this does not apply to the
state governments, at least in respect to the feature of popular
education in music. Still less does it apply to the conduct of music by
the municipal government. For many years the 'city fathers' of most
American municipalities have provided band concerts in the public
parks during the summer season. The programs of these concerts,
however, until quite recently, were planned with little regard to
education of the people in appreciation of the best music—the
selections being of the so-called 'popular' order, the prevalent
opinion of the directors being that the mass of the American people
did not enjoy music of a high order.

A few far-seeing men, whose prescience was based on long and

intimate acquaintance with the musical taste of every class in the
community, had a confident faith that if selections of the best music
were placed on the programs of the park concerts the public would
become rapidly educated to prefer them to the other selections. This
was done, and the result showed that the proposers of the
innovation had been, if anything, too reserved in their prophecy.
From the very beginning the new selections met with favor. Music
lovers, many attending for the first time, crowded into the parks to
hear the concerts and, by their intense interest during the
performance and enthusiastic hand-clapping at its close, they not
only silenced opposition, but even converted it into approval.

Said Arthur Farwell, supervisor of municipal music in New York from

1910 to 1913, in 'The Craftsmen' (Nov., 1910): 'The little comedy of
resistance to classical music on the part of the average American
man ends when he finds himself one of fifteen thousand similar
persons—as happened repeatedly in New York this summer—
listening in perfect silence to the great musical imaginings of the age
by that most wonderful of instruments, the modern orchestra in the
hands of a capable leader.'

New York is the acknowledged leader of American cities, and in

many respects is their model in this development of municipal music
from the most defective of instrumentalities for educating the people
in musical appreciation into possibly its most effective one.
Accordingly the story of the regeneration wrought in this
municipality will indicate better than any other account the
movement in the same direction all over the country. And for
purposes of record it is well to quote Mr. Farwell, who in his official
position was mainly responsible for the revolution:
'Municipal music in New York falls within the province of two
departments, the Department of Parks and the Department of Docks
and Ferries. It has been customary in the past to have frequent
band and orchestral concerts at the Mall in Central Park with
organizations of some size, and to have weekly concerts by smaller
bands of twenty-one men and a leader in a number of the other
parks. It has also been customary to have concerts nightly on all of
the nine recreation piers on the North and East Rivers.

'Without describing the status of most of the music in the past, it

may at least be said that the administrations supporting it let the
work out to many independent band leaders, without requiring the
upholding of musical standards, or having the means to uphold
them, and without even suggesting such standards.

'The task of the new department heads, Charles B. Stover,

Commissioner of the Department of Parks, and Calvin Tomkins,
Commissioner of the Department of Docks and Ferries,[59] was
therefore to place the work of providing municipal music upon a
basis admitting of musical standards, and thus to make possible the
systematic carrying out of new and progressive ideas.

'In the Park Department, Commissioner Stover's first act in

extending the scope and influence of the municipal music was to
increase the number of music centres. Most important of all, he
increased the number of symphony orchestras to two, and opened a
new music centre for orchestral music at McGowan's Pass in the
upper end of the park, where there is a natural amphitheatre. The
crowds from the upper East Side that frequent this portion of the
park are made up of persons who for the most part have never
heard a symphony orchestra. It is an interesting fact that at the first
concert given them there was much curiosity, but little real response,
up to the performance of a movement from a Beethoven symphony,
which brought forth prolonged and enthusiastic applause until an
encore number was played. The concerts at McGowan's Pass have
grown steadily and rapidly in popularity, eager audiences of from
four to six thousand, or more, assembling at every performance....

'One other feature of fundamental importance in any truly national

development, a feature wholly new, has marked the season's
concerts in Central Park. This is the establishment by Commissioner
Stover of a rule that each of the two orchestras shall perform one
new or little-heard composition by an American composer each
week. This is a step of the utmost moment, not so much in the mere
gaining of a hearing for the works now performed, as in the
recognition of the composers of our own land as a factor in the
creation of America's dawning musical democracy.

'On the recreation piers the band concerts provided by the Dock
Department have been enjoyed by many thousands. An innovation
there has been to classify the program, and give the concerts
distinctive character on different evenings—an Italian Opera Night,
American Night, Wagner Night, Folk Songs and Dances, German-
Slavonic Night, etc....

'In these activities of only a single summer, it will be seen what a

vista of possibilities has been revealed. If these developments have
any meaning whatsoever, they have a meaning of the deepest sort
for every American city and village. The magnitude of New York's
operations is not the most important point. We are most deeply
concerned with the spirit of these progressive activities, a spirit
which may find its appropriate expression wherever there exists a
community, large or small, which senses the upward trend of
American humanity and democracy.'

M. M. M.
Welcome to our website – the ideal destination for book lovers and
knowledge seekers. With a mission to inspire endlessly, we offer a
vast collection of books, ranging from classic literary works to
specialized publications, self-development books, and children's
literature. Each book is a new journey of discovery, expanding
knowledge and enriching the soul of the reade

Our website is not just a platform for buying books, but a bridge
connecting readers to the timeless values of culture and wisdom. With
an elegant, user-friendly interface and an intelligent search system,
we are committed to providing a quick and convenient shopping
experience. Additionally, our special promotions and home delivery
services ensure that you save time and fully enjoy the joy of reading.

Let us accompany you on the journey of exploring knowledge and

personal growth!

ebooknice.com