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Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
01/07/97: CMTE. REPORT
ANNOUNCEMENT
Divider Title:
SCHEDULE FOR HILLARY RODHAM CLINTON
TUESDAY, JANUARY 7, 1997
PAGE 2
00am
GULF WAR VETERANS' ILLNESSES and STAFF w/ POTUS
Oval Office
WH PHOTO ONLY
FORMAT:
The President and HRC do a group photograph
with the staff of the Presidential Advisory
Committee on Gulf War Veterans' Illnesses.
--
The President and HRC do individual photos
with members of the Presidential Advisory
Committee on Gulf War Veterans' Illnesses.
12 : 00pm-
PRIVATE MEETING
12:30pm
Residence
CLOSED PRESS
12 : 30pm-
PRIVATE MEETING
1:00pm
Residence
CLOSED PRESS
3:00pm-
PRIVATE MEETING
3:15pm
Residence
CLOSED PRESS
3 :15pm
PRIVATE MEETING
3:30pm
Residence
CLOSED PRESS
6:00pm-
WOMEN'S LEADERSHIP FORUM RECEPTION w/ POTUS
7:30pm
State Floor
CLOSED PRESS
FORMAT:
--
The President and HRC are announced from the
Green Room into the East Room and proceed to
stage.
HRC makes brief remarks and intros the
President.
The President makes remarks.
SCHEDULE FOR HILLARY RODHAM CLINTON
TUESDAY, JANUARY 7, 1997
PAGE 3
-- Upon conclusion of remarks, the President
and HRC proceed to the Blue Room for a
receiving line.
-- The President and HRC depart.
RON
The White House
WEATHER FORECAST FOR WASHINGTON, D.C.:
-Partly cloudy. Wind northwest at 10 knots. Low 30. High 45.
0046
THE WHITE HOUSE
WASHINGTON
January 6, 1997
RECEIVE FINAL REPORT
'97 JAN 6 PM9:51
PRESIDENTIAL ADVISORY COMMITTEE
ON GULF WAR VETERANS' ILLNESSES
DATE: January 7, 1997
LOCATION: Oval Office/Roosevelt Room
TIME: 10:15 - 11:00 a.m.
FROM: SAMUEL BERGER
KITTY HIGGINS
JACK GIBBONS
I. PURPOSE
To receive the final report of the Presidential Advisory
Committee (PAC) on Gulf War Veterans' Illnesses.
II. BACKGROUND
The PAC received a broad mandate in May 1995 to review
relevant research, medical treatment, outreach, risk
factors, chemical and biological agent detections and
interagency coordination. The final report is generally
positive; however, it is quite sharp in its criticism of DOD
past fact-finding related to possible chemical and
biological exposures. It recommends that further
investigation be conducted independent of DOD. The latter
recommendation and the PAC finding that stress may be a
significant contributing factor to Gulf War illnesses are
likely to get press focus.
You recently decided to extend the PAC through FY97 and
amend its charter to encompass independent oversight of the
ongoing DOD investigative process, as well as monitoring of
agency implementation of all recommendations in the final
report. You will issue a new Executive Order superseding
the initial one signed on May 26, 1995 to accomplish this.
PAC Chair Lashof has indicated that continuing the PAC in an
oversight role is consistent with their recommendation of
independent investigation.
Your remarks will highlight your commitment to Gulf
veterans, review the positive steps already taken by the
departments involved, take credit for establishing the PAC,
2
praise the PAC for its contribution, promise a full
Administration response in 60 days and announce two
immediate initiatives. The latter provide for extension of
the PAC (primarily to oversee DOD's ongoing investigation)
and direct that regulatory limits on disability benefits for
veterans with undiagnosed illnesses be revisited.
III. PARTICIPANTS (OVAL OFFICE)
The President
The First Lady
Dr. Joyce Lashof, PAC Chair
Secretary Brown
Secretary Shalala
Deputy Secretary White
Samuel Berger
Kitty Higgins
Melanne Verveer
Jack Gibbons
Adm. Paul Busick
PARTICIPANTS (ROOSEVELT ROOM)
Senator Thomas A. Daschle
Senator John D. Rockefeller, IV
Senator Arlen Specter
Representative Lane Evans
Representative Joseph P. Kennedy
Representative Bob Stump
Advisory Committee Members/Staff (See Tab C)
Representatives of Veteran's Service Organization (VSOs)
Secretary Brown
Secretary Shalala
Deputy Secretary White
Acting Direct Tenet
IV. PRESS PLAN
Oval Office - closed; Roosevelt Room - White House press
pool plus beat reporters who have been covering this issue.
V. SEQUENCE
Briefing in Oval Office followed by meeting with the PAC
Chair, First Lady and Cabinet Members. Then proceed to the
Roosevelt Room and the formal event will begin. When event
ends proceed back to the Oval Office for photo-op session
with PAC Members/Staff.
3
VI. REMARKS
Provided by NSC speechwriter.
Attachments
Tab A E.O. 12961 of May 26, 1996,
B Final Report's Transmittal Memo and Executive Summary
C List of PAC Members and Staff
28507
Federal Register
Presidential Documents
Vol. 60, No. 104
Wednesday, May 31, 1995
Title 3-
Executive Order 12961 of May 26, 1995
The President
Presidential Advisory Committee on Gulf War Veterans'
Illnesses
By the authority vested in me as President by the Constitution and the
laws of the United States of America, it is hereby ordered as follows:
Section 1. Establishment. (a) There is hereby established the Presidential
Advisory Committee on Gulf War Veterans' Illnesses (the "Committee").
The Committee shall be composed of not more than 12 members to be
appointed by the President. The members of the Committee shall have
expertise relevant to the functions of the Committee and shall not be full-
time officials or employees of the executive branch of the Federal Govern-
ment. The Committee shall be subject to the Federal Advisory Committee
Act, as amended, 5 U.S.C. App. 2.
(b) The President shall designate a Chairperson from among the members
of the Committee.
Sec. 2. Functions. (a) The Committee shall report to the President through
the Secretary of Defense, the Secretary of Veterans Affairs, and the Secretary
of Health and Human Services.
(b) The Committee shall provide advice and recommendations based on
its review of the following matters:
(1) Research: epidemiològical, clinical, and other research concerning Gulf
War veterans' illnesses.
(2) Coordinating Efforts: the activities of the Persian Gulf Veterans Coordi-
nating Board, including the Research Coordinating Council, the Clinical
Working Group, and the Disability and Compensation Working Group.
(3) Medical Treatment: medical examinations and treatment in connection
with Gulf War veterans' illnesses, including the Comprehensive Clinical
Evaluation Program and the Persian Gulf Registry Medical Examination Pro-
gram.
(4) Outreach: government-sponsored outreach efforts such as hotlines and
newsletters related to Gulf War veterans' illnesses.
(5) External Reviews: the steps taken to implement recommendations in
external reviews by the Institute of Medicine's Committee to Review the
Health Consequences of Service During the Persian Gulf War, the Defense
Science Board Task Force on Persian Gulf War Health Effects, the National
Institutes of Health Technology Assessment Workshop on the Persian Gulf
Experience and Health, the Persian Gulf Expert Scientific Committee, and
other bodies.
(6) Risk Factors: the possible risks associated with service in the Persian
Gulf Conflict in general and, specifically, with prophylactic drugs and vac-
cines, infectious diseases, environmental chemicals, radiation and toxic sub-
stances, smoke from oil well fires, depleted uranium, physical and psycho-
logical stress, and other factors applicable to the Persian Gulf Conflict.
(7) Chemical and Biological Weapons: information related to reports of
the possible detection of chemical or biological weapons during the Persian
Gulf Conflict.
(c) It shall not be a function of the Committee to conduct scientific
research. The Committee shall review information and provide advice and
28508 Federal Register / Vol. 60, No. 104 / Wednesday. May 31, 1995 / Presidential Documents
recommendations on the activities undertaken related to the matters de-
scribed in (b) above.
(d) It shall not be a function of the Committee to provide advice or
recommendations on any legal liability of the Federal. Government for any
claims or potential claims against the Federal Government.
(e) As used herein, "Gulf War Veterans' Illnesses" means the symptoms
and illnesses reported by United States uniformed services personnel who
served in the Persian Gulf Conflict.
(f) The Committee shall submit an interim report within 6 months of
the first meeting of the Committee and a. final report. by December 31,
1996, unless otherwise provided by the President.
Sec. 3. Administration. (a) The heads of executive departments and agencies
shall, to the extent permitted by law, provide the Committee with such
information as it may require- for purposes of carrying out its functions.-
(b) Members of the Committee shall be compensated in accordance with
Federal law. Committee members may be allowed travel expenses, including
per diem in lieu of subsistence, to the extent permitted by law for persons
serving intermittently in the Government service (5 U.S.C. 5701-5707).
(c) To the extent permitted by law, and subject to the availability of
appropriations, the Department of Defense shall provide the Committee with
such funds as may be necessary for the performance of its functions.
Sec. 4. General Provisions. (a) Notwithstanding the provisions of any other
Executive order, the functions of the President under the Federal Advisory
Committee Act that are applicable to the Committee, except that of reporting
annually to the Congress, shall be performed by the Secretary of Defense,
in accordance with the guidelines and procedures established by the Admin-
istrator of General Services.
(b) The Committee shall terminate 30 days after submitting its final report:
(c) This order is intended only to improve the internal management of
the executive branch and it is not intended to create any. right, benefit
or trust responsibility, substantive or procedural, enforceable at law or equity
by a party against the United States, its agencies, its officers, or any person
THE WHITE HOUSE,
May 26, 1995.
IFR Doc. 95-13484
Filed 5-30-95: 10:36 am]
Billing code 3195-01-P
FinalReport
PRESIDENTIAL
ADVISORY
COMMITTEE ON
GULF WAR
VETERANS' ILLNESSES
For sale by the U.S. Government Printing Office
Superintendent of Documents. Mail Stop: SSOP. Washington. DC 20402-9328
ISBN 0-16-048942-3
Presidential Advisory Committee on Gulf War Veterans' Illnesses
MEMORANDUM
Chair
TO:
Secretary William Perry, Department of Defense
Joyce C. Lashof, M.D.
Secretary Donna Shalala, Department of Health and Human Services
John Baldeschwieler, Ph.D.
Secretary Jesse Brown, Department of Veterans Affairs
Arthur Caplan, Ph.D.
RE:
Major Thomas P. Cross
Final Report
Admiral Donald Custis, M.D. (Ret.)
DA:
December 31, 1996
David A. Hamburg, M.D.
James A. Johnson
On behalf of the Presidential Advisory Committee on Gulf War Veterans' Illnesses, I am pleased to
Major Marguerite Knox, M.N.
transmit our Final Report. Over the past 16 months, the Committee has analyzed the full range of the
Philip Landrigan, M.D.
government's outreach, medical care, research, chemical and biological weapons, and coordination
Elaine L. Larson, Ph.D.
Rolando Rios, Esq.
activities pertinent to Gulf War veterans' illnesses. We also investigated short- and long-term health
effects of Gulf War risk factors.
Andrea Kidd Taylor, Dr.P.H.
Together with our February 1996 Interim Report, we make several recommendations we believe can
Executive Director
Robyn Y. Nishimi
improve our government's approach to addressing the concerns of the men and woman who served our
country during Operations Desert Shield/Desert Storm. We emphasize, however, that in the main these
Deputy Director/Counsel
are suggestions to fine-tune the government's programs on Gulf War health matters. The Committee
Holly L. Gwin
has concluded that in all areas save one, the government has responded with a comprehensive series
of measures to address Gulf War veterans' illnesses.
Many veterans clearly are experiencing medical difficulties connected to their service in the Gulf War.
First and foremost, continuing to provide clinical care to evaluate and treat veterans' illnesses is vital.
At the same time, however, a causal link between a single factor and the symptoms Gulf War veterans
currently report remains elusive. And while the Committee finds that stress is likely to be an important
contributing factor to Gulf War veterans' illnesses, the story is by no means complete: Veterans, their
physicians, and policymakers clearly stand to benefit from the broad array of ongoing research.
This benefit can only be achieved with a thoughtful, inclusive dialogue between veterans and your
Departments. In light of public skepticism arising from recent revelations related to chemical weapons,
the Committee strongly believes that a sustained risk communication effort is the only way to repair
what many believe has been a breach of the government's compact with Gulf War veterans. This effort
cannot begin soon enough.
The Committee is pained by the current atmosphere of government mistrust that now surrounds every
aspect of Gulf War veterans' illnesses. It is regrettable-but also understandable. Our investigation of
the Department of Defense's efforts related to chemical weapons led us to conclude these early efforts
have strained public trust in our government. Hence, evidence of possible chemical warfare agent
exposures during the Gulf War must be thoroughly evaluated by a group independent of DOD. This
process must be conducted in an open manner and include veterans. The Committee recognizes that
in November 1996 DOD announced it was expanding its efforts related to low-level CW agent exposure.
These initiatives-combined with independent, vigorous oversight-could begin to restore public
confidence in the government's investigations of possible incidents of CW agent exposure.
In closing, the Committee notes that in preparing this report, we relied on the generosity of hundreds of
citizens committed to addressing concerns about Gulf War veterans' health. We gratefully acknowledge
the significant time and effort that individuals within and outside government devoted to our effort-their
contributions were invaluable.
Lastly, the Committee has been fortunate to have a talented and dedicated staff: This Final Report
would not have been possible without them. The Committee members, staff, and I thank you for the
unique opportunity to contribute to this critically important issue.
Joyce C. Lashaf
Joyce C. Lashof, M.D.
Committee Chair
EXECUTIVE
SUMMARY
President Clinton established the Presidential Advisory Committee on Gulf War Veterans' Illnesses
in May 1995 to ensure an independent, open, and comprehensive examination of health concerns
related to Gulf War service. The Committee, a 12-member panel made up of veterans, scientists,
health care professionals, and policy experts, held 18 public meetings between August 1995 and
November 1996. We heard invited testimony and received public comment at each meeting. Staff
held in-house consultations, received briefings, conducted literature reviews, interviewed veterans,
and reviewed government documents throughout our tenure. We analyzed information on the full
range of activities specified in our research, coordinating efforts, medical treatment, out-
reach, reviews conducted by other governmental and nongovernmental bodies, risk factors
(exposure and health effects), and chemical and biological weapons- to reach our findings and rec-
ommendations. The Final Report presents the Committee's conclusions in three major parts:
an evaluation of the government's response to Gulf War veterans' illnesses;
an evaluation of available data on the nature of Gulf War veterans' illnesses; and
an evaluation of available data on the health effects of Gulf War risk factors.
Findings and recommendations specific to the needs of Gulf War veterans appear throughout the
Final Report and are summarized here.
The Committee's primary focus was on Gulf War veterans' illnesses, but parallels with the health
concerns of Vietnam veterans became increasingly obvious over time. Thus, the Committee also
decided to include in its analysis, recommendations on how to anticipate and avoid post-conflict
health concerns.
ADDRESSING GULF WAR VETERANS' ILLNESSES
Overall, the Committee is encouraged by the government's response to the range of health-related
problems experienced by Gulf War veterans. We found the Vet Centers and Persian Gulf Family
Support Program established by the Department of Veterans Affairs (VA) to be effective outreach
programs and recommend that these field-based initiatives serve as models for health education
and risk communication campaigns.
The Committee agrees with the Institute of Medicine's conclusion that the clinical evaluation pro-
grams of the Department of Defense (DOD) and VA are excellent for the diagnosis of Gulf War veterans'
illnesses. We found some shortcomings in the availability of treatment, particularly with regard to mental
health and reproductive health, and recommend better follow-up care in these areas.
Presidential Advisory Committee
The Committee found that the government's research portfolio is appro-
priately weighted toward epidemiologic studies and studies on stress-related -
disorders that are likely to improve our understanding of Gulf War veterans'
illnesses. To close gaps in the current knowledge base, we recommend addi-
tional research on the long-term health effects of low-level exposures to chem-
ical warfare agents and on the synergistic effects of pyridostigmine bro-
mide - a chemical warfare agent pretreatment- with other Gulf War risk fac-
tors. We also recommend more emphasis on basic and applied research on
the body's physical response to stress.
The existing knowledge base, including results from epidemiologic studies
of Gulf War veterans, data from clinical evaluation and treatment programs
for Gulf War veterans, and published literature from decades of toxicologic
research, enabled the Committee to reach some conclusions about the nature
and causes of Gulf War veterans' illnesses. We found that:
among the subset of the Gulf War veteran population examined
in the ongoing clinical and research programs, many veterans
have illnesses likely to be connected to their service in the Gulf.
current scientific evidence does not support a causal link between
the symptoms and illnesses reported today by Gulf War veterans
and exposures while in the Gulf region to the following environ-
mental risk factors assessed by the Committee: pesticides, chemi-
cal warfare agents, biological warfare agents, vaccines, pyri-
dostigmine bromide, infectious diseases, depleted uranium, oil-
well fires and smoke, and petroleum products.
stress is known to affect the brain, immune system, cardiovascu-
lar system, and various hormonal responses. Stress manifests in
diverse ways, and is likely to be an important contributing factor
to the broad range of physical and psychological illnesses cur-
rently being reported by Gulf War veterans.
Currently, the extent of service-connected illness among Gulf War vet-
erans is unknown, but the Committee anticipates results from the large,
population-based epidemiologic studies now underway will shed light on
this issue. In addition to the government's existing research, the Commit-
tee also recommends that mortality studies of Gulf War veterans con-
tinue, since some health effects, such as cancer, would not be expected to
appear until a decade or more after the end of the Gulf War.
Although somewhat slow to act at the end of the Gulf War, the govern-
ment is now providing appropriate medical care to Gulf War veterans and
has initiated research in the areas most likely to illuminate the causes of
their illnesses. The Committee identified ways to fine-tune those efforts,
but found that, for the most part, the government has acted in good faith
to address veterans' health concerns.
The Committee takes issue with the government's performance in one
key area: investigation of possible exposures of U.S. troops to chemical
Final Report
and biological warfare agents in the Gulf. We found substantial evidence of
site-specific, low-level exposures to chemical warfare agents. Moreover, we
found DOD's investigations to date superficial and unlikely to provide credi-
ble answers to veterans' and the public's questions. DOD's failure to seriously
investigate chemical warfare agent exposures also adversely affected deci-
sions related to funding research into possible health effects of low-level ex-
posures to chemical warfare agents. At the Committee's final meeting in
November 1996, DOD announced plans to revamp its investigatory and re-
search programs related to low-level chemical warfare agent exposure. The
Committee believes these efforts-combined with independent, high-quality
oversight-could begin to restore public confidence in the government's in-
vestigations of possible incidents of chemical warfare agent exposure. Given
that these steps come too late for the Committee to evaluate, however, we
emphasize the importance of the following recommendation:
To ensure credibility and thoroughness, further investigation of
possible chemical or biological warfare agent exposures during
the Gulf War should be conducted by a group independent of
DOD. Openness in oversight activities-including public access
to information and veteran participation-public notice of meet-
ings, opportunity for public comment, and regular reporting are
essential. Full public accountability is critical.
The government has a significant amount of ground to recover with Gulf
War veterans and the American public, who have come to question whether
a lack of data-on possible chemical warfare agent exposures, on the pre- or
post-deployment health of veterans, or on the location of troops in-
theater-indicates a lack of commitment to veterans' health. We recognize
the many laudatory actions taken to address the concerns of Gulf War veter-
ans, but the Committee believes the government can do a better job of antici-
pating and avoiding these types of problems. We offer the following find-
ings and recommendations in that spirit.
AVOIDING POST-CONFLICT HEALTH CONCERNS
The Committee was impressed by the professionalism of the individuals re-
sponsible for the government services we evaluated. We believe the exper-
tise needed to improve technical performance and implement policy and
procedural changes resides within the government, but we also believe that
DOD and VA have much to learn from their peers in other agencies. There-
fore, the Committee recommends that:
A Presidential Review Directive (PRD) be issued to instruct the
National Science and Technology Council (NSTC) to develop an
interagency plan to address health preparedness for and readjust-
ment of veterans and families after future conflicts and peacekeep-
ing missions. The President's Committee of Advisors on Science
and Technology and other nongovernmental experts, as appropri-
ate, should be asked to review the plan 12 months after the PRD is
Presidential Advisory Committee
issued and again at 18 months to ensure national expertise is brought
to bear on these issues.
The NSTC's agenda should include the following recommendations
for better communication, data, and services, which were developed
during the Committee's evaluation of issues related to Gulf War veter-
ans' illnesses (see Final Report, chapters 2-4).
Better Communication
Clearly, the volunteers who serve in defense of our Nation deserve complete
and accurate information about the risks they face. An open democracy de-
mands that the public, as well, has the opportunity to engage in policy de-
bates that accompany the commitment of troops abroad. Therefore, the Com-
mittee recommends that:
DOD and VA immediately develop and implement a comprehen-
sive risk communication plan. This effort should move forward in
close cooperation with agencies that have a high degree of public
trust and experience with risk communication, such as the Agency
for Toxic Substances and Disease Registry and the National Institute
for Occupational Safety and Health.
FDA solicit timely public and expert comment on any rule that per-
mits waiver of informed consent for use of investigational products
in military exigencies. Among the areas that specifically should be
revisited are: adequacy of disclosure to service personnel; adequacy
of recordkeeping; long-term followup of individuals who receive in-
vestigational products; review by an institutional review board out-
side of DOD; and additional procedures to enhance understanding,
oversight, and accountability.
Better Data
Many of the health concerns of Gulf War veterans may never be resolved
fully because of the lack of data. The Committee identified problems related
to missing medical records, the absence of baseline health data, inaccurate
records of troop locations, and incomplete data on the health effects of what
should have been viewed as reasonably anticipated risks. To help prevent
similar problems in the future, we recommend that:
DOD officials at the highest echelons, including the Joint Chiefs of Staff
and the Commanders in Chief, assign a high priority to dealing with the
problem of lost or missing medical records. A computerized central
database is important. Specialized databases must be compatible with
the central database. Attention should be directed toward developing a
mechanism for computerizing medical data in the field (including classi-
fied information, if and when it is needed). DOD and VA should adopt
standardized recordkeeping to ensure continuity.
Final Report
the Persian Gulf Veterans Coordinating Board and other appropri-
ate departments and agencies be charged to develop a protocol to
implement the following recommendation, which was made in the
Committee's Interim Report: Prior to any deployment, DOD should
undertake a thorough health evaluation of a large sample of troops
to enable better postdeployment medical epidemiology. Medical
surveillance should be standardized for a core set of tests across all
services, including timely postdeployment followup.
the government develop more accurate and reliable methods of
recording troop locations to facilitate post-conflict health research.
DOD should make full use of global positioning technologies.
the government plan for further research on possible long-term
health effects of low-level exposure to organophosphorus nerve
agents such as sarin, soman, or various pesticides, based on studies
of groups with well-characterized exposures, including: a) cases of
U.S. workers exposed to organophosphorous pesticides; and b)
civilians exposed to the chemical warfare agent sarin during the
1994 and 1995 terrorist attacks in Japan. Additional work should
include followup and evaluation of an appropriate subset of any
U.S. service personnel who are presumed to be exposed during the
Gulf War. The government should begin by consulting with ap-
propriate experts, both governmental and nongovernmental, on
organophosphorus nerve agent effects. Studies of human popula-
tions with well-characterized exposures will be much more reveal-
ing than studies based on animal models, which should be given
lower priority.
the government continue to collect and archive serum samples
from U.S. service personnel when feasible.
research on possible causes and methods of prevention of ex-
cess mortality from external causes among veterans receives
high priority.
the government consider methods for routinely sampling military
populations regarding reproductive health so that an appropriate
baseline exists for evaluating reproductive outcomes following de-
ployment. In particular, DOD should consult with the National
Center for Health Statistics and strongly consider implementing its
National Survey of Family Growth and related methodologies for
collecting data.
the entire federal research portfolio place greater emphasis on ba-
sic and applied research on the physical effects of stress and on
stress-related disorders.
Presidential Advisory Committee
Better Services
The Nation has long provided care to veterans for service-connected
health problems. Unfortunately, the government continues to give short
shrift to veterans' legitimate concerns about reproductive health, and soci-
ety at large continues to stigmatize mental health concerns. Therefore, the
Committee recommends that:
the government conduct a thorough review of VA's policies concern-
ing reproductive health and seek statutory authority to treat veterans
and their families for service-connected problems. When indicated,
genetic counseling should be provided-either via VA treatment fa-
cilities or referral - to assist veterans and their families who have re-
productive concerns stemming from military service.
the government continue and intensify efforts to develop stress
reduction programs for all troops, with special emphasis on de-
ployed troops.
CONCLUSION
Approximately 697,000 men and women answered the call to serve in Opera-
tions Desert Shield/Desert Storm. In many important ways - through medi-
cal care, outreach, and research - the Nation has begun to pay its debt to these
service members. It is essential, now, to move swiftly toward resolving Gulf
War veterans' principal remaining concerns: How many U.S. troops were
exposed to chemical warfare agents, and to what degree?
A continued and sustained commitment to a healthy future for Gulf
War veterans - for all current and future veterans - is a priority for all
Americans. This Final Report represents the Committee's contribution to
that goal. We have given our full dedication to President Clinton's charge
and have appreciated the opportunity to serve Gulf War veterans and
their families.
148
Presidential Advisory Committee
APPENDIX C - ADVISORY COMMITTEE MEMBERS
Joyce C. Lashof, M.D., Committee Chair
Former Dean and Professor Emerita of the School of Public Health at the University of
California at Berkeley, Dr. Lashof was Assistant Director of the Office of Technology
Assessment from 1978-81 and Deputy Assistant Secretary for Health Programs and Deputy
Assistant Secretary for Population Affairs at the Department of Health, Education, and Welfare
from 1977-78. She served as President of the American Public Health Association from 1991-92.
John Baldeschwieler, Ph.D.
Professor of Chemistry and former Chair of the Division of Chemistry and Chemical
Engineering at the California Institute of Technology, from 1971-73, Dr. Baldeschwieler served
as Deputy Director of the White House Office of Science and Technology Policy. He is an expert
on national security issues, having served on numerous scholarly panels, commissions, and
committees.
Arthur Caplan, Ph.D.
Director of the Center for Bioethics at the University of Pennsylvania, Dr. Caplan was
Director of the Center for Biomedical Ethics and Professor of Philosophy and Professor of
Surgery at the University of Minnesota from 1987-94. He is an authority on ethics and medicine,
and served as the first President of the American Association of Bioethics.
Thomas P. Cross
Currently a Major in the United States Marine Corps Reserve, Mr. Cross was activated
during Operation Desert Shield/Desert Storm. He was an Assistant Operations Officer for the
6th Marine Regiment in the Gulf, where he participated in the initial attack across the Kuwaiti
border in February 1991. He is the recipient of the Navy Commendation Medal with Combat
"V", the Combat Action Ribbon, and the Kuwait Liberation Medal. Mr. Cross earned a B.S. in
marketing from Central Connecticut State University and is continuing his education. He is
currently a sales representative for Bell Industries in Meriden, Connecticut.
Donald Custis, M.D.
Senior Medical Advisor to the Health Policy Department of the Paralyzed Veterans of
America, Dr. Custis served from 1980-84 as Chief Medical Director for the Veterans Administration,
having joined VA in 1976. During his career, he served as Commanding Officer of the Naval Combat
Hospital in Danang, Vietnam (1969), followed by command of the National Naval Medical Center in
Bethesda, Maryland. He retired in 1976 as the U.S. Navy Surgeon General, with the rank of Vice
Admiral.
David A. Hamburg, M.D.
President of the Carnegie Corporation, Dr. Hamburg was President of the Institute of
Medicine, National Academy of Sciences from 1975-80, and Director of the Division of Health
Policy Research and Education and John D. MacArthur Professor of Health Policy at Harvard
University from 1980-82. He served as President, then Chairman of the Board, of the American
Association for the Advancement of Science, between 1984-86.
Final Report
149
James A. Johnson tattending
Chairman and Chief Executive Officer of FANNIE MAE in Washington, DC,
Mr. Johnson was a managing director at Lehman Brothers from 1985-90, and Executive
Assistant to Vice President Walter Mondale from 1977-81. He is Chairman of the John F.
Kennedy Center for the Performing Arts, and Chairman of the Board of Trustees of the
Brookings Institution. He also serves on the Boards of the Carnegie Endowment for
International Peace and the Carnegie Corporation.
Marguerite Knox, M.N., R.N.C., C.C.R.N.
Clinical Assistant Professor at the College of Nursing of the University of South Carolina
in Columbia, Ms. Knox is nationally certified as an Adult/Acute Care Nurse Practitioner. She
is a Major in the South Carolina Army National Guard and served with the U.S. Army Nurse
Corps during Operations Desert Shield/Storm; she was stationed with the 251st Evacuation
Hospital at King Khalid Military City in Saudi Arabia. From 1985-1993, she worked in critical
care and vascular nursing at the William Jennings Bryan Dorn Veterans Hospital in Columbia,
South Carolina.
Philip J. Landrigan, M.D., M.Sc.
Ethel T. Wise Professor and Chairman, Department of Community Medicine and
Professor of Pediatrics at the Mount Sinai School of Medicine in New York, Dr. Landrigan is an
expert on toxic environmental and occupational exposures. He is Editor-in-Chief of the
American Journal of Industrial Medicine and former Editor-in-Chief of Environmental Research. In
1988, he served as Chair of the science committee that reviewed the health effects of Agent
Orange for the American Legion. Dr. Landrigan served as an epidemiologist with the Centers
for Disease Control and Prevention from 1970-1985. He is a Lieutenant Commander in the
United States Naval Reserve.
Elaine L. Larson, Ph.D., R.N., F.A.A.N., C.T.C.
Dean of the Georgetown University School of Nursing and Associate Director of
Nursing, Georgetown Hospital, Dr. Larson also currently serves on the Governing Council of
the Institute of Medicine and as Editor of the American Journal of Infection Control. From
1985-92, she was Professor and Nutting Chair in Clinical Nursing and Director of the Center for
Research at Johns Hopkins University School of Nursing. Dr. Larson has been a consultant in
infection prevention and nursing in Australia, Brazil, Egypt, Ghana, Jordan, Kuwait, Peru,
Singapore, and Spain.
Rolando Rios
Personal injury and civil rights attorney in private practice in San Antonio, Texas,
Mr. Rios served in the U.S. Army from 1969-72. He earned the rank of First Lieutenant and was
disabled while serving in Cam Ranh Bay during the Vietnam War.
Andrea Kidd Taylor, Dr.P.H.
An industrial hygienist and occupational health policy consultant for the International
Union, United Automobile, Aerospace and Agricultural Implement Workers of America
(UAW) in Detroit, Michigan, Dr. Taylor also is a health representative on the National Advisory
Committee for Occupational Safety and Health. From 1984-87, she was an industrial hygiene
consultant for the Maryland Committee on Occupational Safety and Health.
150
Presidential Advisory Committee
APPENDIX D - ADVISORY COMMITTEE STAFF AND CONSULTANTS
Executive Director
Robyn Y. Nishimi, Ph.D.
Deputy Director/Counsel
Holly L. Gwin, Esq.
Director of Public Affairs
Gary L. Caruso
Research Staff
Joseph S. Cassells, M.D., M.P.H. - Senior Advisor for Medical and Clinical Affairs
Kathi E. Hanna, M.S., Ph.D. - Senior Advisor for Policy and Reproductive Health
Kelley A. Brix, M.D., M.P.H. - Senior Policy Analyst
Mark A. Brown, Ph.D. - Senior Policy Analyst
Miles W. Ewing - Special Assistant and Coordinator, Public Affairs¹
Lois M. Joellenbeck, Dr.P.H. - Senior Policy Analyst
Michael E. Kowalok, M.A. - Policy Analyst and Coordinator, Subcommittee Affairs
John D. Longbrake - Research Analyst and Coordinator, Public Affairs
Thomas C. McDaniels, Jr. - Policy Analyst
Joan P. Porter, M.P.H., D.P.A - Senior Policy Analyst
Nicole M. Stern - Research Analyst
James C. Turner, Esq. - Senior Policy Analyst
Administrative Staff
Carol A. Bock, Executive Assistant
Barbara A. Bradley - Conference and Travel Services/Technical Editor
Michael R. Brown - Administrative Services
Philip B. Jackson - Telecommunications and Computing Services²
Barbara V. Ketchum - Administrative Secretary
Vincent E. McCall, Jr. - Telecommunications and Computing Services
Debra J. McCurry - Information and Reference Services
M. Cecile Parker - Administrative Officer
Linda S. Rayford - Desktop Publishing/Word Processing Specialist
Tracy C. Smith - Administrative Secretary
Other Contributors
Mary Lou Higgs
Susan J. Hoffmeyer
Timothy E. Phillips, Esq.
Jonathan B. Tucker, Ph.D. not attending
I Through August 1996
2 Through April 1996
January 6, 1997
MEMORANDUM TO THE FIRST LADY
FROM:
MELANNE VERVEER
RE:
GULF WAR SYNDROME EVENTS
You have participated in the following events/meetings concerning
the Gulf War Illnesses and the establishment of the President's
Advisory Committee:
Jan., Feb., and March 1995: You convened meetings with:
Secretaries Deutch and Brown; senior Administration officials
from the Departments of Health and Human Services, Veterans
Affairs, and Defense; representatives from VFW and the American
Legion; and the National Security Council.
February 16, 1995: You visited Washington's VA Hospital with
Secretary Jesse Brown and held a discussion with veterans.
February 22, 1996: You visited Walter Reed Army Medical Center
with Secretary Deutch, held a discussion with veterans and
attended a meeting of the Gulf War Research Committee.
February, 1995:
You reported to the President on your
activities concerning the issue of Gulf War illnesses. (Memo
attached)
August 14, 1995:
You testified before the PAC on Gulf War
Veterans Illnesses at its first meeting.
DRAFT
February 10, 1995
MEMORANDUM FOR THE PRESIDENT
FROM:
THE FIRST LADY
You asked me to look into the issue of Gulf War illnesses as
a result of the letters the White House has been receiving, as
well as the concerns directly raised with you by citizens. Many
Gulf War veterans, it seems, have been left with the terrible
impression that their country has forgotten them. I wanted to
let you know what I have learned in the last several weeks, as I
have been consulting with key government officials, Gulf War
veterans and their families, and outside advocates. What I have
found is that this remains a complex and elusive problem,
frustrating both to those who suffer from debilitating illnesses
and to the government officials working to address their
problems.
Background Information:
There were 697,000 U.S. troops that served in the Persian
Gulf War in 1990-91. Many had flu-like symptoms when they were
there and after they came home, but it wasn't until more than a
year later that concerns were raised about chronic illnesses by
hundreds, and then thousands of PGW veterans, some of whom are
still on active duty. Of particular concern are a variety of
unexplained symptoms that do not fit any neat diagnosis.
Symptoms of the undiagnosed or "mystery illnesses" are
varied, including chronic fatigue, memory loss, rashes,
difficulty with sleeping, gastrointestinal disorders, allergies,
respiratory problems, recurrent infections, headaches, joint
pain, nasal discharge, tumors, and unusual bleeding.
Nobody knows what has caused these symptoms and it is likely
that there are several causes, some of which may interact with
each other. For example, if exposure to a chemical agent lowered
a soldier's immune response, he or she would be more susceptible
to infectious agents. The list of possible causes includes
exposures to: toxic by-products from oil fires or tent heaters;
depleted uranium; unapproved vaccinations and anti-nerve gas
compound (pyridostigmine) ; ; infectious agents (leishmaniasis,
malaria, brucellosis, giardiasis) ; chemical and biological
warfare; pesticides; microwaves; and special paints and solvents.
2
An alternative explanation is post-traumatic stress disorder or
stress.
What is particularly unusual is the growing number of
reports of spouses and children who also appear to be ill with
similar symptoms, as well as reported miscarriages and birth
defects. Thus far, no well designed studies have been conducted
to determine whether Gulf War veterans are more likely to have
family members with these problems than other veterans. However,
the VA and CDC have examined this issue with the limited data
that are currently available, and they believe that there is no
evidence to support these complaints.
VA and DOD Registries
PL 102-585 directed VA to establish a Persian Gulf War
Veterans' Health Registry that could easily be cross-referenced
with a Department of Defense (DoD) registry that had been
previously established under the National Defense Authorization
Act for FY 1992-1993. The purpose of the Registries was to
gather information about individuals that would be useful in
determining whether certain exposures or experiences (especially
oil fires) resulted in certain illnesses.
Unfortunately, according to a report issued on September 30,
1993 by the Office of Technology Assessment (OTA), the VA and DoD
registries are not well coordinated. Additionally, OTA indicated
that the registries cannot be used to determine cause-and-effect
relationships between illnesses and exposures. Because the
registries were constructed with emphasis on oil fire exposure,
the registries are much less useful for examining other potential
exposures. Similarly, the medical testing performed through the
VA Registry were not relevant to the diagnosis of disorders that
have now been associated with the mystery illnesses (i.e., immune
dysfunction, neurologic disease, chemical sensitivities). .
Of the 697,000 U.S. troops serving in the Persian Gulf war,
more than 337,500 are now veterans. Approximately 40,000
veterans are currently enrolled in the VA Registry, and 85% of
them are sick. Of those studied thus far, 17% complain of
fatigue, 17% have rashes, 14% have unusual headaches, 14% have
muscle or joint pain, and 11% have loss of memory, and 8% have
shortness of breath. It is unknown how many of these have
undiagnosed illnesses.
NIH Workshop on Persian Gulf War Illnesses
In April 1994, several Federal agencies co-sponsored a
workshop at NIH, where a panel of experts listened to testimony
from Government experts, veterans, and scientists.
3
They issued a report that concluded that Gulf War veterans
were suffering from undiagnosed illnesses of unknown origins, but
that there was no single entity that could be reasonably called
"Gulf War Syndrome." They recommended that more research be
done.
Recent Reports
In June 1994, the Task Force on Persian Gulf War Health
Effects of the Defense Science Board, chaired by Dr. Joshua
Lederberg, issued its report on the possible exposure of US
troops to chemical or biological weapons or other hazardous
agents. The report concluded that there was no evidence that US
troops were exposed to chemical or biological weapons, and that
"the overall health experience of US troops in Operation Desert
Storm was favorable beyond previous military precedent. " The
report also recommended "substantial improvements" in medical
assessments of US troops before and after deployment, to enable
DOD and VA to better assess the health effects of military
service.
Although some of its findings received wide support, the
report was criticized by veterans and Congress because some of
its information was based on DoD reports that were not considered
credible. For example the report stated that less than one tenth
of one percent of the Gulf War troops have reported undiagnosed
illnesses. Although the exact number is unknown, this number is
considered by many to be unrealistically low and contributed to
the perception of the report as a "DOD cover-up." Dr. Lederberg
is a very well respected Nobel Laureate, but his selection was
criticized because he has financial ties to DOD.
PL 102-585 also required VA and DoD to contract with the
Institute of Medicine's Medical Follow-up Agency (MFUA) to review
existing scientific, medical, and other information on the health
consequences of military service in the Persian Gulf theater of
operations.
The Institute of Medicine issued an interim report in
January 1995. They concluded that research was needed to
determine the prevalence and likely causes of Gulf War illnesses.
They criticized the VA and DOD research that was underway as not
adequately peer reviewed and concluded that the quality of the
data was questionable.
The Senate Veterans Affairs Committee, chaired by Sen. Jay
Rockefeller, issued a staff report in December 1994 that
concluded that investigational drugs and vaccines were
inappropriately distributed to US troops during the Persian Gulf
War. Prior to the war, DOD obtained permission from FDA to use
pills (pyridostigmine) in a way that was not proven safe or
effective and a botulism vaccine that was not proven safe or
4
effective. The report concluded that U.S. troops were not
adequately informed of the possible risks of the drugs or
vaccines (as required by law), and that the vaccines and drugs
were used in such a way that they probably would not have
provided adequate protection against biological or chemical
weapons.
The Senate report expressed strong concern that the
pyridostigmine, which was intended to protect against chemical
weapons, may have caused adverse reactions in some individuals,
or may have enhanced the toxic effects of insecticides or other
chemicals that were widely used in the Gulf.
Sen. Donald Riegle, Jr. issued two reports claiming that
allied troops were exposed to chemical warfare, resulting from
scud missile attacks or U.S. military bombing of Iraq's chemical
warfare plants at a time when down-winds were unfavorable.
My meetings with DOD, VA and HHS
In January, I met with key officials from the DoD, VA, and
HHS to discuss how best the Administration can respond to the
concerns that have been raised. The agencies have been very
engaged in addressing this issue. They are trying to improve
medical evaluations and services for Gulf War veterans, conduct
research that will enable them to better understand the causes of
the illnesses, and provide compensation to veterans who are
disabled. I received assurances that the departments are moving
quickly to implement legislative provisions that you signed into
law in October and November.
However, in the course of these meetings, I also learned
that some of the research that the law requires to be conducted
by independent researchers (such as university scientists) under
grants from DoD was mistakenly being conducted by DoD. Deputy
Secretary John Deutch assured me that this could be corrected,
and suggested that he might ask NIH to assist DoD with a peer
review system for these grants. I raised this issue with Dr.
Phil Lee, the Assistant Secretary of Health at HHS, who agreed
that PHS has much more expertise with peer review of grants than
DOD.
Agency officials report that they are doing their best under
difficult circumstances and feel besieged by Congress and the
media. They claim that anecdotes, while compelling, do not
constitute scientific evidence, and that Congress and the media
are taking these anecdotes too seriously. In contrast, well
respected scientists have testified before Congress that these
"anecdotes" should be considered case studies, and point out that
they may well be the first sign of significant health problems
that will become obvious when research is finally conducted.
5
Meeting with Veterans' Service Organization Representatives
I also have had meetings with officials from the American
Legion and the Veterans of Foreign Wars. Both of these meetings
have been extremely helpful in helping me understand how the
veterans view our Administration's role in helping Gulf War
veterans. For example, I met with Steve Robertson, who is
Legislative Director of the American Legion, and is himself a
Gulf War veteran with multiple undiagnosed illnesses. One of his
concerns was the DoD and VA view that stress was the main cause
of these symptoms. He made it clear that he had experienced
extreme stress in previous deployments (he gave the example of
the possibility that he would have to "push the button" to launch
nuclear weapons at the Soviet Union) and made it clear that his
Persian Gulf experience was not at all stressful in comparison.
He recited a long list of potential toxic exposures that were
common in the Gulf; for example, pesticides that were sprayed
everywhere, including on cooking utensils. He is very concerned
that the combination of these exposures could have been much more
toxic than any would have been individually. The Executive
Director of the Legion, John Sommer, was clearly supportive of
Steve's views.
In talking to the Commander of the Veterans of Foreign Wars
(Gunner Kent) and their staff, I was assured that the VFW
appreciates the legislative efforts that you and the VA have made
to provide medical care and compensation to Gulf War veterans.
He praised this Administration's quick response, especially
compared to the "15 years it took to get anything for Agent
Orange." However, the VFW has conducted a survey of more than
2,000 Gulf War veterans, which found that most have undiagnosed
illnesses that are not being successfully treated. (This is not
a random sample, but it is worrisome nevertheless.) The VFW does
not blame the VA, but they do believe that the DOD is not
providing VA with the information it needs to help determine the
causes of these illnesses.
Veterans and Their Family Members
I have received many letters from Gulf War veterans and
their spouses, and have had the opportunity to speak to some of
these individuals on the telephone as well. They express great
frustration with VA and DOD, and they clearly feel that the
government has not done enough to address this health problem and
that the government has not taken their concerns seriously
enough. The specter of the government cover-up of the dangers of
Agent Orange for Vietnam veterans is frequently mentioned.
One recurring theme is that doctors at the individual VA
facilities minimize the seriousness of the patients' symptoms,
are not particularly well informed about Gulf War illnesses, and
sometimes even ignore the law that requires VA to provide free
6
medical care to these veterans. For example, the President of
the Gulf War Veterans of Massachusetts wrote on February 9, 1995:
"Veterans are bitter, and many of the ones I speak to have
concluded that they are never going to get any help from the VA
system. Why? First, despite the laws which have been passed,
and despite Secretary Brown's convictions, Gulf veterans are
still frequently refused service in VA hospitals. The VA claims
system is a disaster
(my own claim was lost for over a year,
and 30 months have passed since I initially filed it.) One of
the biggest problems which I have been trying to work with on a
local basis is simple ignorance of the situation by many of the
VA physicians who are treating us. During my Persian Gulf
Registry exam in January 1994, the doctor who examined me had
never heard of depleted uranium and did not believe me when I
told him of the exposure."
I have also heard from veterans who have cancer or who
report that an usually high number of young Gulf War veterans
have died of cancers or heart conditions. There is great fear
that these fatal diseases were caused by service in the Gulf.
Many veterans believe that the VA and DOD have not provided full
and accurate information about deaths and diagnoses, and some
staff from the agencies concur (off the record) with that
assessment. I don't think that anyone knows whether there is
statistical evidence of an abnormally high number of cancers or
heart disease among Gulf War veterans, but it seems to me the
thing to do is make sure that kind of information is available to
the public, and properly analyzed by CDC. According to reports I
have heard, several FOIA requests for such information have gone
unanswered, or have been answered with information that is
perceived to be inaccurate.
Lack of Effective Treatment
One of the major problems is that many of the undiagnosed
illnesses do not respond to treatment. For example, some
veterans complain of having diarrhea for 3 years, rashes that
come and go but do not respond to treatment, or sensitivities to
chemicals that make it impossible to go to gas stations or sit in
hospital waiting rooms. Women who are married to Gulf War
veterans report constant vaginal infections and pain related to
sexual intercourse; neither the cause nor an effective treatment
has been determined. VA does not provide medical care to
spouses, so many of these women do not have access to medical
tests or treatment. This is especially true if the veteran is
too ill to work. This lack of health care makes it especially
difficult to determine whether these illnesses are unusual or
whether the major problem is lack of appropriate medical care.
In cases where VA and DOD medical facilities have been
unable to effectively treat Gulf War veterans, many veterans have
sought care in the private sector. Some Gulf War veterans have
7
complained that the VA and DOD facilities are too conservative in
their treatments. The countervailing point of view is that
private sector doctors are taking advantage of the desperation of
Gulf War veterans, by selling useless or even dangerous
diagnostic tests or treatment.
My staff has called scientists from across the country to
learn more about the controversial treatments that Gulf War
veterans are receiving in the private sector. Thus far, the
experts suggest that there are no good diagnostic tools for
determining chemical exposures to the brain, and that such
diagnostic tools as SPECT scan and brain mapping have limited
usefulness. One of the veterans who is very ill is currently
going to a private facility for plasma pharesis at a cost of
$15,000/month. Several experts have claimed that such a painful,
dangerous, and expensive treatment would be difficult to justify
except on an experimental basis. So, thus far the academic
experts have made statements that are consistent with VA
decisions not to use those tests and treatment. However, the
usefulness of treatments that have been devised for multiple
chemical sensitivity and other controversial diagnoses are more
debatable.
Compensation
Veterans who have disabilities that are associated with
military service are entitled to monthly benefits from the VA.
The maximum benefit is approximately $23,000/year for a veteran
who is considered 100% disabled.
As of
1994 there were approximately
claims filed
by PGW veterans or their survivors for general VA benefits.
Approximately 10% were from veterans claiming disabilities from
exposure to environmental hazards, but very few of those claims
were granted. This is partly a function of the lack of diagnosis
for these symptoms, and partly because it is more difficult to
prove that an illness is service-connected if it is not reported
until after a person leaves the military (battle wounds are
obviously much easier to prove when filing a claim)
Thanks to the law that you signed in November (PL 103- ),
veterans whose illnesses are not diagnosed will, for the first
time, be eligible to receive compensation if they can prove that
they are disabled as a result of military service. The first
compensation checks resulting from this law should be distributed
in March. However, proving disability may still be difficult,
and it will be essential to monitor this program to make sure
that veterans receive the compensation that they deserve.
8
Working as a Team With VA, DOD and HHS
Among the VA, DOD, and HHS officials and the Gulf War
veterans there is wide agreement that more targeted and
coordinated research is needed. The Defense Reauthorization and
the Veterans' Persian Gulf War Benefits Act that you signed in
October and November include some important new research efforts,
including research on the possibility that the veterans's health
problems are transmissible to spouses and offspring. It is
important that these efforts go forward expeditiously.
The agency officials expressed their desire to work together
to ensure that the needs of Gulf War veterans are met. We agreed
that we must convey to the American people that the
Administration recognizes that there are serious questions that
need to be resolved, and we are committed to working to address
them. For example, Dr. Kizer, the VA Under Secretary for Health,
admitted that some VA facilities are doing a better job than
others, and indicated his strong commitment to improving that
situation, so that all veterans receive the care they deserve.
He also is planning a major new effort to examine whether birth
defects and reproductive problems are unusually prevalent among
Gulf War veterans.
As you said when you asked me to follow up on this issue, we
must do our very best to guarantee that the concerns of our
veterans who served our nation so nobly in the Gulf are addressed
properly and honestly, with the compassion their cases merit.
This must be our collective guiding principle.
I suggested to Secretary Perry and Secretary Brown that
together we visit appropriate sites, such as hospitals or
research centers, to demonstrate the concern of this
Administration and our commitment to working together to get
answers and provide assistance to those who are suffering health
problems from their service during the Gulf War. My first such
visit, at the VA Medical Center in Washington, DC, is scheduled
for February 14.
I believe that the agencies involved are making great
efforts to improve the research and services for Gulf War
veterans, but that the statements made by Department officials
are often perceived as defensive and less than candid. This may
be partly because many of the career employees who are providing
information to Department officials are themselves responsible
for previous decisions. It is human nature to be reluctant to
admit that mistakes might have been made; however, these mistakes
were made during the previous Administrations, and we should be
willing to admit that they occurred and that we must and will do
better in the future. Given the enormous publicity and the
increased concerns that the veterans are expressing about the
9
adequacy of the Administration response, I believe it is
essential to be more open and let veterans and the American
people know that we are not satisfied with the status quo.
I believe we can move ahead to immediately reassure the
veterans and the public by moving quickly on some new
initiatives, and making those initiatives public. We need to let
the American people know that we are just as concerned as they
are about the veterans whose illnesses are not responding to
treatment. And of course, we need to move as quickly as possible
to make progress on these issues.
I suggest that we consider two very public announcements in
the coming weeks:
A. DoD Press Conference:
1. The message needs to be that DoD is concerned that the
safety of the long-term use of pyridostigmine, alone and in
combination with stress, pesticides, and other toxic chemicals,
was not adequately studied under the Reagan/Bush Administration
prior to the Persian Gulf War. That is why new research is now
underway. DoD can announce that research is underway, and that
most of it will be peer reviewed, independent research. This
will have implications for future soldiers, in addition to Gulf
War veterans who are ill. Of course, any future use of these
agents will be reviewed in light of the results. Dr. Steven
Joseph could be in charge of this effort.
2. Announce that DoD has developed new policies to make
sure that all service members are adequately warned about any
potential side effects from any vaccines, drugs, pesticides,
decontamination agents, and other toxic chemicals that they will
come in contact with. Dr. Susan Bailey is the person in charge
of this effort.
3. I believe that DOD should announce that they have
withdrawn a request for a permanent waiver of informed consent
for the use of experimental drugs. [They may still request such
waivers on a case by case basis]. This could be done by
Executive Order, or Secretary Perry could make the decision.
B. President (and Secretary Brown) Announces:
1. You and/or Secretary Brown could request that the VA
Inspector General investigate allegations that some VA facilities
are not providing appropriate free medical care to Gulf War
veterans as required by law. VA does not have enough
investigative staff to do this, and anyway, the IG is preferable
because it is independent of VA.
10
2. The VA PGW Hot Line will compile information about any
reported problems regarding access to medical care or
compensation, and Secretary Brown will ensure that information
will be used by VA to improve those efforts.
3. The lack of mortality statistics has angered some
veterans groups. The VA could announce that, in response to
requests from veterans groups, the VA will analyze data from PGW
veterans who have died, and CDC will work with them to evaluate
whether the number of deaths or diagnoses are unusual.
4. The VA will include information about ill spouses and
children, including miscarriages and stillbirths, on the PGW
Health Registry starting [insert date]. VA is already including
information about birth defects. This will help provide
information about whether an unusually large number of these
problems are occurring. Dr. Ken Kizer has also proposed an even
more ambitious surveillance system for reproductive problems
among veterans, which he should announce.
5. Announce that the first compensation checks for
undiagnosed illnesses will be sent in March.
Blue Ribbon Panel
I also believe that we should consider a new "blue ribbon"
panel to examine these issues. This panel should have a broader
mandate than the Lederberg panel, and should not include members
who have contracts or consulting relationships with DOD or VA, or
the chemical industry. In order to have credibility with
veterans and the public, we need to make sure that the panel
includes scientific experts who have reputations as being
consumer-oriented or absolutely objective. The panel should have
an adequate staff that enables them to monitor the many
activities of these three agencies for at least one year.
We may want to consider "reinventing" the concept of a blue
ribbon panel to make it less reliant on the expertise of a large
number of extremely busy scientists. Unfortunately, such experts
are often perceived as relying too heavily on the information
provided by the agencies. Perhaps the focus should be on a small
top-notch, independent investigative staff that is advised by a
small number of well-respected experts, such as Admiral Zumwaldt,
a medical ethicist, and a small number of scientists.
CC: Leon Panetta
Defense Issues: Volume 12, Number 1-- Report to the President on Gulf War Illnesses
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I know that there are numbers who are here of the commission, and I'd
Notice
like them, if they would, to stand so that we could see all -- they're all
standing. We appreciate very much the time and effort that went into this
service. And I know firsthand how important and difficult your task has
been.
Over the last four years, the president and I have received many heart-
wrenching letters from Gulf War veterans and family members. Many
veterans and their family members said they felt that their country had
forgotten them. So in the fall of 1994, the president asked me to explore
the issues surrounding the health needs of Gulf War veterans and to look
into the federal government's efforts to address their concerns.
I met with officials from the Department of Defense, the Veterans
Administration and the Department of Health and Human Services to
determine if we were doing the very best we could to respond to our
veterans' needs and to facilitate research into their illnesses.
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I met with representatives of the American Legion and the Veterans of
Foreign Wars, who shared their own observations and told me of their
efforts to bring more serious national attention to these illnesses, and I
visited with individual veterans, active duty soldiers and their families. At
Walter Reed Hospital [Army Medical Center] and the Veterans Hospital
here in Washington. I listened to veterans as they tried to describe to me
what it was like to live day after day, year after year, not knowing why
they had become sick.
I heard stories of hard-working men and women who could no longer
keep steady jobs and support their families because of their illnesses. One
veteran officer who had been diagnosed as 100 percent disabled told me
about the healthy and active life he had led before his tour in the Persian
Gulf and about his frustration in seeking effective treatments for his
systems.
In February 1995, I reported to the president and the chief of staff on
these findings and recommended some steps the administration could take
in the future, including the creation of a blue ribbon panel to investigate
these issues further. And I had the privilege of testifying at the first
meeting of this committee in August 1995, and I've been following the
work that has been done closely ever since.
So I'm particularly gratified to be here today, and I'm also gratified that
our government is making progress and being responsive in taking
affirmative steps to do all that can be done on behalf of our veterans and
on behalf of future members of our forces who might be put in harm's
way in the future.
I want to thank all who served for their persistent efforts on this
committee and for considering thoroughly the diverse and strongly held
opinions, theories, explanations and evidence about these illnesses. But I
particularly want to thank Gulf War veterans and their families for taking
the time to share their experiences with this committee. We could not
have had a better chairperson of this presidential committee than the one
who was persuaded to undertake this significant responsibility, and it's
my pleasure now to introduce Dr. Joyce Lashof, who will tell us more
about the committee's findings.
Lashof. Thank you very much, Mrs. Clinton, especially for your
compassion and your interest in this important issue. And thank you, Mr.
President, for your very courageous leadership for wanting to get to the
bottom of this issue and the effort you've made to bring this committee
about.
Mr. President, Secretary [of Health and Human Services Donna E.]
Shalala, Secretary [of Veterans Affairs Jesse] Brown, Deputy Secretary
[of Defense John P.] White and Deputy [CIA] Director [George J.] Tenet,
on behalf of the advisory committee it is a pleasure for me to transmit to
you this, our final report.
Over the past 16 months, we have conducted a broad analysis of issues
related to health consequences of Gulf War service. Our efforts to address
the complexities of Gulf War veterans' illnesses would not have been
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possible without the contributions of hundreds of Gulf War veterans and
their families. They have served with distinction, and we thank them.
Our interim and final reports make several recommendations which we
believe can improve the government's approach to addressing the health
concerns of veterans who served in the gulf. In all areas save one, these
suggestions are to fine-tune the government's programs on gulf health
matters. Overall, the government has responded with a comprehensive
series of measures to resolve questions about Gulf War veterans' illnesses.
Unfortunately, the positive nature of these efforts has been diminished by
how the Department of Defense approached the possibility that U.S
troops had been exposed to chemical weapons. It is essential now to move
swiftly to resolving Gulf War veterans' principal remaining concern --
how many U.S troops were exposed to chemical warfare agents and to
what degree.
The committee is pained by the atmosphere of government mistrust that
now surrounds every aspect of Gulf War veterans' illnesses because of
these concerns. It is regrettable, but also understandable.
Our investigation of DoD's efforts related to chemical and biological
weapons led us to conclude the department's early efforts were superficial
and lacked credibility. DoD's failure to seriously investigate these issues
also adversely affected decisions related to funding research on health
effects of low-level exposure to chemical warfare agents. DoD was
intransigent originally in refusing to fund such research until late this
year. This has done a disservice to the veterans and the public.
But the committee recognizes that in November 1996, DoD announced it
was expanding its investigation and research related to low-level chemical
warfare agent exposure. We hope these initiatives can begin to restore
confidence in DoD's investigation on chemical agent incidents.
But moving beyond the specific, albeit important, topic, it is important to
reiterate that many veterans clearly are experiencing health difficulties
connected to their service in the gulf.
First and foremost, it is vital that the government continue to provide the
excellent clinical care for these veterans. Next, we must try to find why
they are sick. Based on existing scientific data, none of the individual
environmental Gulf War risk factors commonly suspected appears to be
the cause. And while the government finds that stress is while the
committee finds that stress is likely to be an important contributing factor
to Gulf War veterans' illnesses, the story is by no means complete.
Veterans, their physicians and policy makers clearly stand to benefit
greatly from the comprehensive range of ongoing research. We believe a
continued commitment to long-term studies is important. Some health
effects such as cancer would not be expected to appear until a decade or
more after the end of the Gulf War.
Additionally, the committee recommends new research in three areas: the
long-term health effects of low-level exposure to chemical warfare agents;
the synergistic effect of pyridostigmine bromide with other Gulf War risk
factors; and the most physical response to stress.
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However, veterans and their families will realize maximum benefits from
such research only through a thoughtful, inclusive dialogue between
veterans and the departments. In light of current public skepticism, the
committee strongly believes that a sustained risk communication effort is
the only way to repair public trust.
The volunteers who served in defense of our national interest deserve
complete and accurate information about the risks they faced, and I am
sure that we will be able to provide it to them.
The committee also felt there were lessons to be learned about health
matters based on Gulf War experience. We believe the government can
avoid many future postconflict health concerns through better
communication, better data and better services, and we make
recommendations in all these areas.
In closing, I would like to re-emphasize that in many important and, in
some places, unprecedented ways, the nation has begun to pay its debt to
the 697,000 men and women who served in Operation Desert Shield-
Desert Storm. We were impressed with the research the government had
already initiated to understand the nature and causes of the illnesses so
many veterans suffer from. The committee hopes the same degree of
commitment will be applied to the issues still outstanding.
Finally, the committee gratefully acknowledges the significant time and
effort that individuals within and outside government devoted to our
effort. We also have been fortunate to have a talented and dedicated staff.
On their behalf and on behalf of my fellow committee members, I thank
you for your leadership in addressing Gulf War veterans' health concerns
and for providing us with the unique opportunity to contribute to this
vitally important issue.
President Clinton. Thank you very much to Dr. Lashof and the members
of the Presidential Advisory Committee on Gulf War Illnesses: Secretary
White, Secretary Brown, Secretary Shalala, Deputy Director Tenet. I'd
like to say a special word of thanks to Dr. Jack Gibbons [assostant to the
president for science and director of the Office of Science and
Technology Policy] for the work that he did on this. I thank Sen. [John
D.] Rockefeller [IV], Sen. [Arlen] Specter, Congressman Lane Evans for
their interest and their pursuit of this issue, and all the representatives
from the military and veterans organizations who are here.
I am pleased to accept this report. I thank Dr. Lashof and the committee
for their extremely thorough and dedicated work for 18 months now. I
pledge to you and to all the veterans of this country, we will now match
your efforts with our action.
Six years ago, hundreds of thousands of Americans defended our vital
interest in the Persian Gulf. They faced a dangerous enemy, harsh
conditions, lengthy isolation from their families. And they went to victory
for our country with lightening speed. When they came home, for reasons
that we still don't fully understand, thousands of them became ill. They
served their country with courage and skill and strength, and they must
now know that they can rely upon us. And we must not, and will not, let
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them down.
Three years ago, I asked the secretaries of defense, health and human
services and veterans affairs to form the Persian Gulf Veterans
Coordinating Board to strengthen our efforts to care for our veterans and
find the causes of their illnesses. I signed landmark legislation that pays
disability benefits to Gulf War veterans with undiagnosed illnesses. DoD
and VA established toll-free lines and medical evaluation programs.
I am especially grateful to the first lady, who took this matter to heart and
first brought it to my attention quite a long while ago now. I thank her for
reaching out to the veterans and for making sure that their voices would
be heard.
To date, we have provided Gulf War veterans with more than 80,000 free
medical exams. We've approved more than 26,000 disability claims.
HHS, DoD and the Veterans Department have sponsored more than 70
research projects to identify the possible causes of the illnesses. But early
on, it became clear that answers were not emerging fast enough.
Hillary and I shared the frustration and concerns of many veterans and
their families. We realized the issues were so complex they demanded a
more comprehensive effort. That is why, in May of 1995, I asked some of
our nation's best doctors and scientists, as well as Gulf War veterans
themselves, to form a presidential advisory committee that could provide
an open and thorough and independent review of the government's
response to veterans' health concerns and the causes of their ailments.
Since that time, we have made some real progress. The Department of
Defense with the CIA launched a review of more than 5 million pages of
Gulf War documents, declassifying some 23,000 pages of materials and
putting them on the Internet. Through this effort, we discovered important
information concerning the possible exposure of our troops to chemical
agents in the wake of our destruction of an arms depot in southern Iraq.
The committee made clear, and the Defense Department agrees, that this
new information demands a new approach, focusing on what happened
not only during, but after, the war and what it could mean for our troops.
Based on the committee's guidance, the Department of Defense has
restructured and intensified its efforts, increasing tenfold its investigating
teams, tracking down and talking to veterans who may have been exposed
to chemical agents and devoting millions of dollars to research on the
possible effects of low-level chemical exposure.
I'm determined that this investigation will be comprehensive and credible.
We haven't ended the suffering; we don't have all the answers; and I won't
be satisfied until we have done everything humanly possible to find them.
That's why I welcome this committee's report and its suggestions on how
to make our commitment even stronger. I also take seriously the concern
regarding DoD's investigation of possible chemical exposure. I'm
determined to act swiftly on these findings not only to help the veterans
who are sick, but to apply the lessons of this experience to the future.
I've asked the secretaries of defense, health and human service, and
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veterans affairs to report to me in 60 days with concrete, specific action
plans for implementing these recommendations. And I am directing
Secretary [of Defense]-designate [William S.] Cohen, when confirmed by
the Senate [confirmed, Jan. 22], to make this a top priority of the Defense
Department.
I'm also announcing two other immediate initiatives First, I've asked this
committee to stay in business for nine more months to provide
independent, expert oversight of DoD's efforts to investigate chemical
exposure and also to monitor the governmentwide response to the broader
recommendations.
The committee's persistent public effort has helped to bring much new
information to light, and I have instructed them to fulfill their oversight
role with the same intensity, resolve and vigór they have brought to their
work so far. Dr. Lashof has agreed to continue, and I trust the other
committee members will as well.
Second, I'm accepting Secretary Brown's proposal to reconsider the
regulation that Gulf War veterans with undiagnosed illnesses must prove
their disabilities emerged within two years of their return in order to be
eligible for benefits. Experience has shown that many disabled veterans
have their claims denied because they fall outside the two-year time
frame. I've asked Secretary Brown to report back to me in 60 days with a
view toward extending that limit.
And we will do whatever we can and whatever it takes to research Gulf
War illnesses as thoroughly as possible. Every credible possibility must
be fully explored, including low-level chemical exposure and combat
stress.
I know that Congress shares our deep concern, and let me again thank
Sen. Specter, Sen. Rockefeller and Congressman Evans for being here.
Caring for our veterans is not a partisan issue, it is a national obligation,
and I thank them for the approach that they have taken.
As we continue to investigate Gulf War illnesses, let me again take this
opportunity to urge the Congress to ratify the Chemical Weapons
Convention, which would make it harder for rogue states to acquire
chemical weapons in the future and protect the soldiers of the United
States and our allies in the future.
This report is not the end of the road, anymore than it is the beginning.
We have a lot of hard work that's been done and we have made some
progress, but the task is far from over. The committee's assessment gives
me confidence that we are on the right track, but we have much yet to
learn and much to do.
As we do make progress, we will make our findings public. We will be
open in how we view Gulf War illnesses and all their possible causes --
open to the veterans whose care is in our hands; open to the public
looking to us for answers. I pledge to our veterans and to every American,
we will not stop until we have done all we can to care for our Gulf War
veterans to find out why they are sick and to help to make them healthy
again.
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Thank you very much.
Q. Mr. President, this has been studied to death. Do you believe that there
is a Gulf War illness?
A. I believe that there are a lot of veterans who got sick as a result of their
service in the gulf. And I believe it took experts to determine whether
there is one or a deliberation of them in exactly what the cause and
connection is. That has been apparent for some time. That's why the
Congress agreed to support our efforts that for the first time paid
disability payments for people with undiagnosed conditions.
I think that this committee has done a good job. I think I want to
compliment the work that has been done in the last few months by John
White of the Defense Department in facing up to the things which were
not done before. No one has ever suggested that anybody intentionally
imposed -- exposed American soldiers to these dangers, and there is
nothing -- there is no reason that anyone in this government should ever
do anything but just try to get to the truth and get it out and do what is
right for the veterans.
And there are also I think we need to be a little humble about this.
There are a lot of things that we still don't know. That's what Dr. Lashof
said. And that's why these research projects are so very important.
And the final thing I'd like to say is we don't know all the answers here.
You heard Dr. Lashof say that sometimes when people were exposed to
substances that can cause cancer it may not be manifested for 10 years,
which is why I want to thank Secretary Brown for urging that we stress
the two-year rule. We have to -- we have to be vigilant about this. And
my successor will be working on it. We will be monitoring this for a long
time to come.
But we've got a process now the American people and the veterans and
their families can have confidence in. We've got the appropriate
commitment of personnel and money. And more important, we've got the
appropriate commitment of the heart and mind. And I'm convinced now
that we will do justice to this issue and to the people that have been
affected by it.
Thank you, Mr. President.
Press Conference
Q. Dr. Lashof, just a few minutes ago, Sen. Specter said that they are
going to be holding hearings on Thursday on the Hill, and he was talking
about the possibility of a cover-up by the Pentagon. Do you agree with
that assessment? Do you think that that's
?
A. We found no evidence of a cover-up in our work.
Q. Could we use another word? I mean, was the information adequately
conveyed to the public about what they had found?
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A. Let me put it this way: They were very slow, and the actual
investigation for the possibility of exposure was, we say in the report,
superficial and inadequate initially. I think now.
Q. Was it intentional or ?
A. We have no way of judging what their intentions were. We were
critical of the lack of effort, and they now have made a commitment. But
they can answer that, and I would turn that question to Paul Busick.
Q. Dr. Lashof, in the context of the Defense Science Board investigation
of '94, which was presented as a thorough, exhaustive study of exposures,
how do you rate that study compared to what you've found out?
A. Well, we obviously uncovered, and it was brought to light, the incident
at Khamisiyah [Iraq] that apparently was not known at that time.
Q. Adm. Busick, would you be able to answer the first question?
A. Sure. I think that the Defense Department has acknowledged that it
needs to do more and has moved very quickly recently to do more. I think
that the secretary of defense has taken the allegations of a cover-up very
seriously, and the deputy secretary of defense has instructed the secretary
of the Army to launch an Army inspector general investigation into the
incident at Khamisiyah.
Q. Admiral, why was the department so slow, though?
A. When we get the inspector general's investigation, then we will have
more information about what to do, and we look forward to having that.
Q. Why was the initial investigation so slow? You obviously had had the
experience of Agent Orange in Vietnam. There was a precedent for this.
Why wasn't there a better effort made initially?
A. I think that the PAC report has stated that the Defense Department had
two triggering events that they viewed as critical. One was whether the
Iraqis presented or used offensive chemical weapons, and the second was
whether there were acute symptoms.
Q. And what did they find?
A. Neither of those have been found to be the case, and that's in large part
why there was no belief that there was a chemical event.
Q. Dr. Lashof, did your inquiry find any evidence of widespread exposure
of American troops to chemical weapons, one? And two, do you have any
chemical evidence to suggest that low-level exposure causes any of the
symptoms that Gulf War veterans are now reporting?
A. The only evidence of exposure that we were able to find was the
event at Khamisiyah. There are reports of other site-specific reading on
M-254s and Fox vehicles that need to be further investigated. And that's
why we've asked for further investigation of possible exposures. There
are other reports of detections, but an actual source has only been
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identified in Khamisiyah.
To your second question of low-level exposure and is this the cause of the
illness, we have no clinical evidence now of long-term health effects from
high-level exposures from times when people are ill. The research on
long-term effects from low-level is not really available at this point.
In my view, it would be unlikely to see results from low level when we
don't see long-term effects from high-level exposure. But we believe that
research needs to be done around this, and there are, and we suggest in the
committee report, that there are two populations that could be looked at.
One is the Japanese in the subway who were exposed, and the other are
the pesticide applicators who often are exposed for long times to very low
levels. And we think these could be investigated and that question put to
rest.
Q. Just to follow up that, if I might, given the uncertainty about whether
any more than one chemical alarm went off at Khamisiyah, do you regard
the exposure at Khamisiyah as a case of potential exposure or actual
exposure?
A. I think we feel that we know that there were weapons that contained
chemical agents at Khamisiyah that were exploded. Therefore, we have to
assume that there was exposure to the troops from that release from those
weapons that were destroyed at Khamisiyah.
Q. Even if chemical alarms didn't go off?
A. I was going to say, I thought there was a chemical alarm that went off
there and one positive detection. We'll get back -- I can get this. They
have to research that, and they can get back to you with further detail.
Q. You've termed so far today the Pentagon's response to this problem as
being inadequate, superficial, incredible, intransigent, various other
adjectives. Yet your conclusion is that they will be able to do the follow-
up with a tenfold investigative staff. Isn't there a dichotomy there?
A. I do not believe there is a dichotomy. In fact, I'm glad you asked the
question about that. We feel it's very essential that the follow-up be done
and that it be done under very strong oversight with a public view of it.
The committee's work, actually, on this issue I think has been
misrepresented. I have held back from reporting on the
mischaracterizations until our work was finally completed, but let me
point out that I think it's unfortunate that our deliberations have been cast
in the light that suggests that we have backed off from any suggestion of
an independent investigation.
At the committee's September meeting, the staff briefed us on its
investigations on the exposure half of the chemical and biological
weapons issue. In the transcript of that meeting, the staff reported -- and I
will quote from that transcript because I'd like this to be on the record
correctly because it has been misrepresented: "The Department of
Defense has assets that cannot be replaced in pursuing those
investigations. DoD has to play a critical role in investigating possible
exposures. And credible review cannot be accomplished internally by the
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Department of Defense, however. To be credible amongst veterans and
the American public in general, there is a need for outside, independent
oversight review and involvement." Now, that was the quote from our
September meeting.
At the November meeting, the committee met to review and complete the
recommendation process. For the recommendation in question, our
discussion at the November meeting centered around adding language to
provide greater context and depth to the recommendation adding
language to the report, that is. And I'm aware that many people portrayed
this discussion as a re-evaluation of staff's recommendation. As the record
clearly shows, however, this is just not true. Our position has been clear
from the outset, and our final recommendation reflects that position. The
investigation must be done by DoD, but it must be done under very
vigorous and extensive oversight. And I think that the president's action
today to extend the committee fully meets the intent and the spirit of that
recommendation, and we intend to be vigorous in our oversight of this.
Q. Adm. Busick, the veterans groups have been on record as saying that
in the case of the missing logs and missing records, that there is an issue,
potentially criminal issue, of chain of custody, whether they are missing
or whether they do exist but have been misplaced. What's the current
situation with that?
A. I think the Department of Defense has started the investigation to
reconstruct what's occurred. I know that the Department of Defense has
launched an inspector general investigation into the events surrounding
Khamisiyah, and that will include the look at logs.
Q. Doctor, this study seems to focus mostly on stress, and in the three that
you all list early on about what you've found you can't find any casual
link between the illnesses and these types of pesticides and chemicals and
the like. What caused the stress?
A. Going to war is a stressful situation and having alarms going off
around you, the oil well fires, the general conditions under which people
were living and working. All of these add stress, and different people are
going to react to stress differently, and different degrees of stress have
different effects on individuals.
Q. Could you see this as any different than any other type of wartime
scenario?
A. Well, we see effects of stress in any war; that is correct. Whether it's
more or less, we have no data on that, one way or the other.
Q. You seemed careful in the previous session to say that you found no
causal link between any individual factor and the veterans illnesses.
A. That's correct.
Q. Does that leave the door open to synergistic effects, particularly
between stress and, for instance, various chemical agents or even the PB
[pyridostigmine bromide] pills?
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A. I think it does leave that door open. We do recommend further
research specifically on the synergistic effects between pyridostigmine
bromide and pesticides. You are correct that we say stress is a
contributing factor and we don't know what other factors it could relate
with. We really have a lot of epidemiologic research ongoing, and until
that research is completed, we're not going to be able to answer some of
the questions you're now -- you and the vets, appropriately, and we are
asking.
Q. Doctor, do you come away from this study thinking that the U.S
military force structure should somehow be altered so that the Guard and
Reserves aren't relied upon so heavily in wartime performance?
A. That's not an issue that was in the realm of our committee to consider.
Q. Doctor, much was made a few months ago of a claim by two former
CIA analysts that documents that they had examined demonstrated
beyond doubt Iraqi use of chemical weapons and a CIA cover-up. Are
you satisfied you got those documents from the CIA, and did they show
any evidence of Iraqi chemical use during the war?
A. We reviewed those documents and do not see that they present any
evidence that the Iraqis used [chemical] weapons during the war.
Q. Did we use any?
Lashof. No.
Busick. Can I follow up on that? Again, the director of central
intelligence found that the accusation, the allegations that there was a
cover-up on CIA, were important, and they have also launched an
inspector general investigation into that issue.
Q. Dr. Lashof, can you address the issue of why Dr. Jonathan Tucker was
dismissed, I guess over a year ago -- a member, a researcher on the
committee?
A. I'm aware of the circumstances concerning his departure, and I will not
discuss personnel matters. I know that the staff acted appropriately in that.
Q. Do you think that has damaged your credibility at all, dismissing one
of your top researchers? He's now saying that there was disagreements
among himself and some of the members I think on the research
A. I think our report on that stands as a good record. We've obviously
dealt very heavily into this area. We have an excellent investigator who
has taken on that area and done an excellent job, and I think -- look at the
report.
Q. Just a very basic kind of technical question, but are you, at this point,
aware -- do you feel that you are aware -- of every single chemical that
people in that region may have been exposed to, as opposed to how these
chemicals may have worked together? In other words, is there any factor,
any chemical factor, that you feel you do not know existed there that
might have been used?
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A. Well, it's always hard to know something that you don't know. I
believe we know everything that's been issued to them. We know
everything that you could logically think about. If there's something that's
illogical, unknown out there, I don't know how anyone knows what they
don't know. But there's obviously no evidence that anyone has
information that they're keeping from us. We certainly know everything
that's been issued. We know what oil well fires burned. We know what
diesel fuel was used. We went into this extensively.
Q. Do you have fixed in your mind a population that shares these multiple
symptoms? How many active duty, how many veterans?
A. No, the only data -- we do in the report review briefly the data from the
comprehensive clinical evaluation protocol of the Department of Defense,
and then the VA has a registry, and we give a table that shows what
percentage had symptoms of ill-defined conditions and PTSD
[posttraumatic stress disorder] and so forth.
Q. What do you have fixed in your mind as the population who are
complaining or have some illness as a result of this? What is it?
A. You mean, how many, numbers? The only numbers we have are the
numbers who have gone in for examinations. And until we have the
epidemiologic studies, we don't know what percentage that represents,
whether it represents who has been ill or not. We've got to await those
studies.
Q. Dr. Lashof, do you think that nine more months of operations by your
committee will produce a definitive conclusion as to what's behind these
illnesses?
A. I think we'll be able to elucidate a great deal more. I don't think a
definitive solution will be known in nine months. It depends really on
what the results of the major studies that are ongoing now show as to how
far we can go in nine months. They may open up avenues that are new
that will need further exploration. They may give us answers. I really
couldn't speculate.
A. I think the objective on the part of the administration here is to get to
credibility in terms of process. One of the major factors that we wanted
the PAC to stay on for was to address the issue of the process that the
Department of Defense is using to get to the answers that we need, in
terms of investigations into low-level chemicals and those kinds of issues.
If we can get to a credible process that has been independently verified,
then we'll be a long way down the road toward the answers that we need
to get at. That's the objective.
Published for internal information use by the American Forces
Information Service, a field activity of the Office of the Assistant
Secretary of Defense (Public Affairs), Washington, D.C Parenthetical
entries are speaker/author notes; bracketed entries are editorial notes
This material is in the public domain and may be reprinted without
permission Defense Issues is available on the Internet via the World Wide
Web at http://www.defenselink.mil/speeches/index.html.
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Copyright 1997 Bergen Record Corp.
The Record
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January 21, 1997; TUESDAY
SECTION: NEWS; 5 Star, ALSO IN, 4 Star, 3 Star, 2 Star; Pg. A08
LENGTH: 775 words
HEADLINE: FOR 2ND TERM, FIRST LADY HINTS HER ACTIVISM WILL BE DISCREET
SOURCE: Wire services
BYLINE: LISA ANDERSON, Special from the Chicago Tribune
DATELINE: WASHINGTON
BODY:
While her husband builds a bridge to the next millennium, first lady
Hillary Rodham Clinton has been quietly planning her own role over the
next four years.
She has revealed few details of that role, but in recent weeks she
has dropped some hints of the essential approach she plans to take:
high-octane in content, but low-key in style.
While she has mentioned her concern about the impact of new welfare
regulations on women and children, and her interest in helping states
and municipalities to handle them humanely, she has framed that
involvement more in terms of a subdued advocate, rather than an
aggressive activist.
During her trip to Asia in November, the first lady said she was
considering a"formal role"in her husband's second term, a phrase that
set off shock waves among Republicans and other critics and a flurry of
denials from the White House.
But what she said, in context, signaled she may have concluded that
discretion is the better part of successful policy implementation.
Clinton said she was contemplating"a formal role that would make
sense in terms of reporting to the president, kind of like what I did on
the gulf war disease, go out, listen to people, maybe write him some
memoranda."
She said her office quietly had become a point of contact for people
concerned about the so-called gulf war syndrome.
Having emerged as one of the most controversial first ladies in
history during her husband's first term, failing in her effort to
spearhead his health-care reform program, Clinton adopted a low profile
during the second campaign. And, she steadfastly adhered to it during
this inauguration.
Compared with her strong inaugural presence four years ago, the
first lady's appearances and public utterances have been relatively few
and discreet this time around. She gave only two interviews during the
inaugural weekend, to C-SPAN and"CBS Sunday Morning."
Filling in for her husband, who was preparing his inaugural address
and conserving his voice, she stopped by at a party for Arkansas
supporters, dropped in at a women's inaugural ball, and made a brief
appearance at the MTV-Conde Nast party.
Perhaps her most substantial speech of the weekend was the 10-minute
address she made to a luncheon for newly elected congressional women
hosted by Emily's List, the fund-raising organization for female
Democratic candidates.
Greeted by a cheering audience of some 2,500, she was introduced by
Emily's List President Ellen Malcolm as"our role model."
"Who better to celebrate the power of women than the woman who has
used her power to help so many," Malcolm said of Clinton.
Given a second term to define herself for Americans and history,
Clinton clearly seems to have power on her mind, but is shifting the way
in which she wields that power and even talks about it.
"It is important that there be a balance of power between men and
women"in political and private life, she told the luncheon group,
repeating a somewhat conciliatory theme she introduced during her Asian
trip.
"Women do not seek power over men, "she said. "They seek power over
themselves."
And, in the C-SPAN interview she said,"I want to bring the
discussion about women and power out of the dark recesses and put it
into the bright light and let women begin to talk about what they want
out of life."
Clinton may have concluded that the hard-charging, upfront manner
she used in the first term was a tactical error, according to Betty Boyd
Caroli, author of two books on first ladies.
"First ladies have a great deal of power. As Nancy Reagan said, I'm
sleeping with the president and, if that doesn't give you power, I don't
know what does. The difference is that Hillary Clinton admitted she had
power"i her own right, said Caroli.
There is no question that bothered many people, driving the first
lady's popularity down to 57 percent, according to a recent poll by the
Pew Research Center for the People and the Press.
But others admired her courage and competence.
Shivering along the inaugural parade route Monday, Sandy
Butterfield, a health-care consultant, said,"I believe that the first
lady should do whatever her education and background allow and,
certainly, Hillary Clinton is well-qualified."
Butterfield, 52, said she hoped Clinton would not downplay her role
in the next term.
"I know it's controversial, but I think she needs to take an active
role, not just in terms of issues involving women and children, but in
any issues in which she's qualified."
GRAPHIC: ASSOCIATED PRESS PHOTO - The Clintons taking their turn on the dance
floor at the New England Ball. For Hillary Rodham Clinton, it was a day
blissfully free of the controversies that dogged her during her husband's first
four years in office.
LANGUAGE: English
LOAD-DATE: January 21, 1997
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01/07/97: TALKING IT
OVER COLUMN
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07:30 PM
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TALKING IT OVER
BY HILLARY RODHAM CLINTON
FOR IMMEDIATE RELEASE
For most Americans, the Persian Gulf War, fought nearly six years ago, is
a distant memory. But for thousands of brave men and women who served our
country in Operation Desert Storm, the experience lingers in a variety of
undiagnosed illnesses - from rashes to respiratory problems to headaches to
gastrointestinal disorders -- that befell them when they came home.
Over the last four years, Bill and I have received many heart-wrenching
and haunting letters from Gulf War veterans and their families. Many veterans
told us they felt that their country had forgotten them, that America was not doing
enough to help them become healthy again. So in the fall of 1994, the President
asked me to explore issues surrounding the health needs of our Gulf War
veterans and to look into ways to improve the federal government's efforts to
address their concerns.
I spoke with many veterans on the phone, in my office and at military and
veterans' hospitals. I listened as they tried to describe what it was like to live day
after day, year after year, not knowing why they had become sick. I heard stories
of hard-working men and women who could no longer keep steady jobs and
support their families because of their illnesses. One veteran officer who had
been diagnosed as 100 percent disabled told me about the healthy and active
life he had led before his tour in the Persian Gulf and about his frustration in
seeking effective treatments for his symptoms.
I also met with officials from the Departments of Defense, Veterans Affairs
and Health and Human Services to determine if we were doing the very best we
could to respond to our veterans and to facilitate research into their illnesses.
Representatives of the American Legion and the Veterans of Foreign Wars
shared their own observations and told me of their efforts to bring attention to
these illnesses. Almost two years ago, I reported to the President on these
findings.
Bill then asked some of our nation's best doctors and scientists, as well
as Gulf War veterans themselves, to form a Presidential Advisory Committee
that could provide an open, thorough and independent review of the
government's response to veterans' health concerns. I had the privilege of
Creators Syndicate
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01/7/97
07:30 PM
3/3
TALKING IT OVER 1/7/97
Page 2
testifying at the first meeting of this committee in August 1995. And earlier this
week, I watched as the committee presented its final report to the President.
The committee found that, overall, the government had acted responsibly
and comprehensively. In 1994, the President signed legislation that pays
disability benefits to eligible Gulf War veterans with undiagnosed illnesses. The
Departments of Defense and Veterans Affairs established toll-free lines and
medical evaluation programs. Gulf War veterans have received more than
80,000 free medical exams. The government has approved more than 26,000
disability claims and sponsored more than 70 research projects to identify the
possible causes of the illnesses.
But the committee also noted areas for improvement, especially in the
realm of building trust and strengthening the lines of communication between
veterans and the government agencies that serve them. It expressed concern
that the Defense Department had not investigated possible chemical weapons
exposure thoroughly enough in the past.
As a result, the Defense Department has intensified its investigation into
this issue, tracking down veterans who may have been exposed to chemical
agents and devoting millions of dollars to researching the possible effects of
low-level chemical exposure. The Defense Department and the CIA have
declassified 23,000 pages of documents and placed them on the Internet. And a
review of more than 5 million pages of Gulf War documents has already yielded
some evidence that our troops may have been exposed to chemical agents.
In the years since the Gulf War, there has been no shortage of opinions,
theories and explanations about the health problems of veterans who served
our country. But at least we can agree that we need to do whatever it takes to
bring good health and peace of mind to the men and women who fought on our
behalf thousands of miles from home.
As the President said this week at the White House, "They served their
country with courage and skill and strength, and they must now know that they
can rely upon us. And we must not, and will not, let them down."
COPYRIGHT 1997 CREATORS SYNDICATE, INC.
ALL RIGHTS RESERVED
January 7, 1997
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SUPPLEMENTAL TEXT
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THE WHITE HOUSE
Office of the Press Secretary
For Immediate Release
January 30, 1997
EXECUTIVE ORDER 13034
EXTENSION OF PRESIDENTIAL ADVISORY COMMITTEE
ON GULF WAR VETERANS' ILLNESSES
By the authority vested in me as President by the Constitution
and the laws of the United States of America, it is hereby ordered as
follows:
Section 1. Extension. The Presidential Advisory Committee
on Gulf War Veterans' Illnesses (the "Committee"), established
pursuant to Executive Order 12961 of May 26, 1995, is hereby
extended for the purposes set forth herein. All provisions
of that order relating to membership and administration shall
remain in effect. All Committee appointments, as well as
the President's designation of a Chairperson, shall remain
in effect. The limitations set forth in section 2(c)-(e)
and section 4 (a) of Executive Order 12961 shall also remain
in effect. The Committee shall remain subject to the Federal
Advisory Committee Act, as amended, 5 U.S.C. App. 2.
Sec. 2. Functions. (a) The Committee shall report to
the President through the Secretary of Defense, the Secretary
of Veterans Affairs, and the Secretary of Health and Human
Services.
(b) The Committee shall have two principal roles:
(1) Oversight of the ongoing investigation being
conducted by the Department of Defense with the assistance,
as appropriate, of other executive departments and agencies
into possible chemical or biological warfare agent
exposures during the Gulf War; and
(2) Evaluation of the Federal Government's plan for
and progress towards the implementation of the Committee's
recommendations contained in its Final Report submitted on
December 31, 1996.
(c) The Committee shall provide advice and recommendations
related to its oversight and evaluation responsibilities.
(d) The Committee may also provide additional advice and
recommendations prompted by any new developments related to its
original functions as set forth in section 2 (b) of Executive
Order 12961.
(e) The Committee shall submit by letter a status
report by April 30, 1997, and a final supplemental report by
October 31, 1997, unless otherwise directed by the President.
Sec. 3. General Provisions. (a) The Committee shall
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terminate 30 days after submitting its final supplemental
report.
(b) This order is intended only to improve the internal
management of the executive branch and it is not intended to
create any right, benefit or trust responsibility, substantive
or procedural, enforceable at law or equity by a party against
the United States, its agencies, its officers, or any person.
WILLIAM J. CLINTON
THE WHITE HOUSE,
January 30, 1997.
# # #
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Persian Gulf War Veterans Health and Services Enhancement Act (Introduced in the House)
HR 4542 IH
103d CONGRESS
2d Session
H. R. 4542
To provide an improved system of health-related information for Persian Gulf War veterans and to
extend the availability of certain health care for Persian Gulf War Veterans.
IN THE HOUSE OF REPRESENTATIVES
June 8, 1994
Mr. KENNEDY (for himself, Mr. EVANS, Mr. GUTIERREZ, Mr. HOCHBRUECKNER, Mr.
MONTGOMERY, and Mr. SANDERS) introduced the following bill; which was referred to the
Committee on Veterans' Affairs
A BILL
To provide an improved system of health-related information for Persian Gulf War veterans and to
extend the availability of certain health care for Persian Gulf War Veterans.
Be it enacted by the Senate and House of Representatives of the United States of America in
Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the `Persian Gulf War Veterans Health and Services Enhancement
Act'.
SEC. 2. TOLL-FREE HOTLINE FOR PERSIAN GULF WAR VETERAN
HEALTH INFORMATION.
(a) IN GENERAL- The Secretary of Veterans Affairs shall maintain an information system
involving the use of a toll-free telephone number to provide veterans of the Persian Gulf War
and their family members (and other members of the public at the Secretary's discretion) with
information regarding the following:
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(1) The Persian Gulf War Veterans Health Registry established by the Persian Gulf War
Veterans' Health Status Act (38 U.S.C. 527 note).
(2) Access to health services and health-related benefits provided by or under the
auspices of the Department of Veterans Affairs, including--
(A) marriage and family counseling available under section 121 of the Veterans'
Medical Programs Amendments of 1992 (38 U.S.C. 1712A note);
(B) health care available under section 1710(e)(1)(C) of title 38, United States
Code; and
(C) health examinations, consultation, and counseling available under section 703
of the Persian Gulf War Veterans' Health Status Act (38 U.S.C. 527 note).
(3) Compensation and benefits related to disabilities resulting from service in the Persian
Gulf War, including disabilities resulting from illness that resulted from such service.
(4) Significant developments in research relating to the health consequences of service in
the Persian Gulf War.
(5) Any other information that the Secretary determines to be appropriate.
(b) DATE OF ESTABLISHMENT OF INFORMATION SYSTEM- The Secretary of Veterans
Affairs shall establish the information system required by subsection (a) not later than 90 days
after the date of the enactment of this Act.
SEC. 3. OUTREACH TO VETERANS OF PERSIAN GULF WAR.
Section 702(f) of the Persian Gulf War Veterans' Health Status Act (38 U.S.C. 527 note) is
amended to read as follows:
'(f) ONGOING OUTREACH TO INDIVIDUALS LISTED IN REGISTRY-
'(1) IN GENERAL- The Secretary of Veterans Affairs shall notify each individual listed
in the Registry, or, in the case of such an individual who is deceased, the surviving
spouse, children, or parents of such individual, at least quarterly, by newsletter or by
other means that the Secretary determines to be appropriate, of--
'(A) the status and findings of federally sponsored research relating to the illnesses
of individuals who served as members of the Armed Forces in the Persian Gulf
theater of operations during the Persian Gulf War or to the illnesses of the family
members of such individuals;
`(B) compensation and benefits, including health care and other health-related
benefits, that may be provided by the Department of Veterans Affairs or the
Department of Defense to an individual who served as a member of the Armed
Forces in the Persian Gulf theater of operations during the Persian Gulf War or, in
the case of such an individual who is deceased, to the surviving spouse, children,
or parents of such an individual; and
'(C) any other information that the Secretary determines to be appropriate.
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'(2) CONSULTATION WITH VETERANS SERVICE ORGANIZATIONS- In
preparing the newsletter or other means used to conduct the notification required by
paragraph (1), the Secretary of Veterans Affairs shall consult with veterans' service
organizations.
'(3) DATE THAT QUARTERLY NOTIFICATIONS BEGIN- The Secretary of
Veterans Affairs shall make the first of the periodic notifications required by paragraph
(1) not later than 90 days after the date of the enactment of the Persian Gulf War
Veterans Health and Services Enhancement Act.'.
SEC. 4. EXTENSION OF AUTHORITY TO PROVIDE PRIORITY HEALTH
CARE TO VETERANS OF THE PERSIAN GULF WAR.
(a) HOSPITAL AND NURSING HOME CARE- Section 1710(e)(3) of title 38, United States
Code, is amended by striking `December 31, 1994' and inserting `December 31, 1998'.
(b) OUTPATIENT CARE- Section 1712(a)(1)(D) of title 38, United States Code, is amended
by striking `December 31, 1994' and inserting `December 31, 1998'.
SEC. 5. EXTENSION OF MARRIAGE AND FAMILY COUNSELING
AVAILABILITY FOR PERSIAN GULF WAR VETERANS.
(a) IN GENERAL- Section 121(a) of the Veterans' Medical Programs Amendments of 1992
(38 U.S.C. 1712A note) is amended by striking `September 30, 1994' and inserting `December
31, 1998'.
(b) AUTHORIZATION OF APPROPRIATIONS- Section 121(g) of the Veterans' Medical
Programs Amendments of 1992 (38 U.S.C. 1712A note) is amended by striking `and 1994' and
inserting `through 1999'.
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H.R.5193
Veterans Health Care Act of 1992 (Enrolled Bill (Sent to President))
TITLE VII-PERSIAN GULF WAR VETERANS' HEALTH STATUS
SEC. 701. SHORT TITLE.
This title may be cited as the `Persian Gulf War Veterans' Health Status Act'.
SEC. 702. PERSIAN GULF WAR VETERANS HEALTH REGISTRY.
(a) ESTABLISHMENT OF REGISTRY- The Secretary of Veterans Affairs shall establish and
maintain a special record to be known as the 'Persian Gulf War Veterans Health Registry' (in
this section referred to as the `Registry').
(b) CONTENTS OF REGISTRY- Except as provided in subsection (c), the Registry shall
include the following information:
(1) A list containing the name of each individual who served as a member of the Armed
Forces in the Persian Gulf theater of operations during the Persian Gulf War and who--
(A) applies for care or services from the Department of Veterans Affairs under
chapter 17 of title 38, United States Code;
(B) files a claim for compensation under chapter 11 of such title on the basis of
any disability which may be associated with such service;
(C) dies and is survived by a spouse, child, or parent who files a claim for
dependency and indemnity compensation under chapter 13 of such title on the
basis of such service;
(D) requests from the Department a health examination under section 703; or
(E) receives from the Department of Defense a health examination similar to the
health examination referred to in subparagraph (D) and requests inclusion in the
Registry.
(2) Relevant medical data relating to the health status of, and other information that the
Secretary considers relevant and appropriate with respect to, each individual described in
paragraph (1) who--
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(A) grants to the Secretary permission to include such information in the Registry;
or
(B) at the time the individual is listed in the Registry, is deceased.
(c) INDIVIDUALS SUBMITTING CLAIMS OR MAKING REQUESTS BEFORE DATE OF
ENACTMENT- If in the case of an individual described in subsection (b)(1) the application,
claim, or request referred to in such subsection was submitted, filed, or made, before the date
of the enactment of this Act, the Secretary shall, to the extent feasible, include in the Registry
such individual's name and the data and information, if any, described in subsection (b)(2)
relating to the individual.
(d) DEPARTMENT OF DEFENSE INFORMATION- The Secretary of Defense shall furnish
to the Secretary of Veterans Affairs such information maintained by the Department of Defense
as the Secretary of Veterans Affairs considers necessary to establish and maintain the Registry.
(e) RELATION TO DEPARTMENT OF DEFENSE REGISTRY- The Secretary of Veterans
Affairs, in consultation with the Secretary of Defense, shall ensure that information is collected
and maintained in the Registry in a manner that permits effective and efficient cross-reference
between the Registry and the registry established under section 734 of the National Defense
Authorization Act for Fiscal Years 1992 and 1993 (Public Law 102-190; 105 Stat. 1411; 10
U.S.C. 1074 note), as amended by section 704.
(f) ONGOING OUTREACH TO INDIVIDUALS LISTED IN REGISTRY- The Secretary of
Veterans Affairs shall, from time to time, notify individuals listed in the Registry of significant
developments in research on the health consequences of military service in the Persian Gulf
theater of operations during the Persian Gulf War.
SEC. 703. HEALTH EXAMINATIONS AND COUNSELING FOR VETERANS ELIGIBLE
FOR INCLUSION IN CERTAIN HEALTH-RELATED REGISTRIES.
(a) IN GENERAL- (1) The Secretary of Veterans Affairs--
(A) shall, upon the request of a veteran described in subsection (b)(1), provide the
veteran with a health examination and consultation and counseling with respect to the
results of the examination; and
(B) may, upon the request of a veteran described in subsection (b)(2), provide the veteran
with such an examination and such consultation and counseling.
(2) The Secretary shall carry out appropriate outreach activities with respect to the provision of
any health examinations and consultation and counseling services under paragraph (1).
(b) COVERED VETERANS- (1) In accordance with subsection (a)(1)(A), the Secretary shall
provide an examination, consultation, and counseling under that subsection to any veteran who
is eligible for listing or inclusion in the Persian Gulf War Veterans Health Registry established
by section 702.
(2) In accordance with subsection (a)(1)(B), the Secretary may provide an examination,
consultation, and counseling under that subsection to any veteran who is eligible for listing or
inclusion in any other similar health-related registry administered by the Secretary.
SEC. 704. EXPANSION OF COVERAGE OF PERSIAN GULF REGISTRY.
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(a) IN GENERAL- Subsections (a) and (b) of section 734 of the National Defense
Authorization Act for Fiscal Years 1992 and 1993 (Public Law 102-190; 105 Stat. 1411; 10
U.S.C. 1074 note) are amended to read as follows:
'(a) ESTABLISHMENT OF REGISTRY- The Secretary of Defense shall establish and
maintain a special record (in this section referred to as the 'Registry') relating to the following
members of the Armed Forces:
'(1) Members who, as determined by the Secretary, were exposed to the fumes of
burning oil in the Operation Desert Storm theater of operations during the Persian Gulf
conflict.
'(2) Any other members who served in the Operation Desert Storm theater of operations
during the Persian Gulf conflict.
`(b) CONTENTS OF REGISTRY- (1) The Registry shall include--
'(A) with respect to each class of members referred to in each of paragraphs (1) and (2)
of subsection (a)--
`(i) a list containing each such member's name and other relevant identifying
information with respect to the member; and
`(ii) to the extent that data are available and inclusion of the data is feasible, a
description of the circumstances of the member's service during the Persian Gulf
conflict, including the locations in the Operation Desert Storm theater of
operations in which such service occurred and the atmospheric and other
environmental circumstances in such locations at the time of such service; and
'(B) with respect to the members referred to in subsection (a)(1), a description of the
circumstances of each exposure of each such member to the fumes of burning oil as
described in such subsection (a)(1), including the length of time of the exposure.
'(2) The Secretary shall establish the Registry with the advice of an independent scientific
organization.'.
(b) CONFORMING AMENDMENTS- (1) Subsection (c)(1) of such section is amended by
striking out `subsection (a)' and inserting in lieu thereof subsection (a)(1)'.
(2) Subsection (d) of such section is amended by inserting `pursuant to subsection (a)(1)' after
'Registry'.
SEC. 705. STUDY BY OFFICE OF TECHNOLOGY ASSESSMENT OF PERSIAN GULF
REGISTRY AND PERSIAN GULF WAR VETERANS HEALTH REGISTRY.
(a) STUDY- The Director of the Office of Technology Assessment shall, in a manner
consistent with the Technology Assessment Act of 1972 (2 U.S.C. 472(d)), assess--
(1) the potential utility of each of the Persian Gulf Registry and the Persian Gulf War
Veterans Health Registry for scientific study and assessment of the intermediate and
long-term health consequences of military service in the Persian Gulf theater of
operations during the Persian Gulf War;
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(2) the extent to which each registry meets the requirements of the provisions of law
under which the registry is established;
(3) the extent to which data contained in each registry--
(A) are maintained in a manner that ensures permanent preservation and facilitates
the effective, efficient retrieval of information that is potentially relevant to the
scientific study of the intermediate and long-term health consequences of military
service in the Persian Gulf theater of operations during the Persian Gulf War; and
(B) would be useful for scientific study regarding such health consequences;
(4) the adequacy of any plans to update each of the registries;
(5) the extent to which the Department of Defense or the Department of Veterans
Affairs, as the case may be, is assembling and maintaining information on the Persian
Gulf theater of operations (including information on troop locations and atmospheric and
weather conditions) in a manner that facilitates the usefulness of, maintenance of, and
retrieval of information from, the applicable registry; and
(6) the adequacy and compatibility of protocols for the health examinations and
counseling provided under section 703 and health examinations provided by the
Department of Defense to members of the Armed Forces for the purpose of assessing the
health status of members of the Armed Forces who served in the Persian Gulf theater of
operations during the Persian Gulf War.
(b) ACCESS TO INFORMATION- The Secretary of Veterans Affairs and the Secretary of
Defense shall provide the Director with access to such records and information under the
jurisdiction of each such secretary as the Director determines necessary to permit the Director
to carry out the study required under this section.
(c) REPORTS- The Director shall--
(1) not later than 270 days after the date of the enactment of this Act, submit to Congress
a report on the results of the assessment carried out under this section of the Persian Gulf
Registry and health-examination protocols; and
(2) not later than 15 months after such date, submit to Congress a report on the results of
the assessment carried out under this section of the Persian Gulf War Veterans Health
Registry.
(d) DEFINITIONS- For the purposes of this section:
(1) The term `Persian Gulf Registry' means the registry established under section 734 of
the National Defense Authorization Act for Fiscal Years 1992 and 1993 (Public Law
102-190; 105 Stat. 1411; 10 U.S.C. 1074 note), as amended by section 704.
(2) The term `Persian Gulf War Veterans Health Registry' means the Persian Gulf War
Veterans Health Registry established under section 702.
SEC. 706. AGREEMENT WITH NATIONAL ACADEMY OF SCIENCES FOR REVIEW OF
HEALTH CONSEQUENCES OF SERVICE DURING THE PERSIAN GULF WAR.
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(a) AGREEMENT- (1) The Secretary of Veterans Affairs and Secretary of Defense jointly
shall seek to enter into an agreement with the National Academy of Sciences for the Medical
Follow-Up Agency (MFUA) of the Institute of Medicine of the Academy to review existing
scientific, medical, and other information on the health consequences of military service in the
Persian Gulf theater of operations during the Persian Gulf War.
(2) The agreement shall require MFUA to provide members of veterans organizations and
members of the scientific community (including the Director of the Office of Technology
Assessment) with the opportunity to comment on the method or methods MFUA proposes to
use in conducting the review.
(3) The agreement shall permit MFUA, in conducting the review, to examine and evaluate
medical records of individuals who are included in the registries referred to in section 705(d)
for purposes that MFUA considers appropriate, including the purpose of identifying illnesses
of those individuals.
(4) The Secretary of Veterans Affairs and the Secretary of Defense shall seek to enter into the
agreement under this section not later than 180 days after the date of the enactment of this Act.
(b) REPORT- (1) The agreement under this section shall require the National Academy of
Sciences to submit to the committees and secretaries referred to in paragraph (2) a report on the
results of the review carried out under the agreement. Such report shall contain the following:
(A) An assessment of the effectiveness of actions taken by the Secretary of Veterans
Affairs and the Secretary of Defense to collect and maintain information that is
potentially useful for assessing the health consequences of the military service referred to
in subsection (a).
(B) Recommendations on means of improving the collection and maintenance of such
information.
(C) Recommendations on whether there is sound scientific basis for an epidemiological
study or studies on the health consequences of such service, and if the recommendation
is that there is sound scientific basis for such a study or studies, the nature of the study or
studies.
(2) The committees and secretaries referred to in paragraph (1) are the following:
(A) The Committees on Veterans' Affairs of the Senate and House of Representatives.
(B) The Committees on Armed Services of the Senate and House of Representatives.
(C) The Secretary of Veterans Affairs.
(D) The Secretary of Defense.
(c) FUNDING- (1) The Secretary of Veterans Affairs and the Secretary of Defense shall make
available up to a total of $500,000 in fiscal year 1993, from funds available to the Department
of Veterans Affairs and the Department of Defense in that fiscal year, to carry out the review.
Any amounts provided by the two departments shall be provided in equal amounts.
(2) If the Secretary of Veterans Affairs and the Secretary of Defense enter into an agreement
under subsection (a) with the National Academy of Sciences--
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(A) the Secretary of Veterans Affairs shall make available $250,000 in each of fiscal
years 1994 through 2003, from amounts available to the Department of Veterans Affairs
in each such fiscal year, to the National Academy of Sciences for the general purposes of
conducting epidemiological research with respect to military and veterans populations;
and
(B) the Secretary of Defense shall make available $250,000 in each of fiscal years 1994
through 2003, from amounts available to the Department of Defense in each such fiscal
year, to the National Academy of Sciences for the purposes of carrying out the research
referred to in subparagraph (A).
SEC. 707. COORDINATION OF GOVERNMENT ACTIVITIES ON HEALTH-RELATED
RESEARCH ON THE PERSIAN GULF WAR.
(a) DESIGNATION OF COORDINATING ORGANIZATION- The President shall designate,
and may redesignate from time to time, the head of an appropriate department or agency of the
Federal Government to coordinate all research activities undertaken or funded by the Executive
Branch of the Federal Government on the health consequences of military service in the
Persian Gulf theater of operations during the Persian Gulf War.
(b) REPORT- Not later than March 1 of each year, the head of the department or agency
designated under subsection (a) shall submit to the Committees on Veterans' Affairs of the
Senate and House of Representatives a report on the status and results of all such research
activities undertaken or by the Executive Branch of the Federal Government during the
previous year.
SEC. 708. DEFINITION.
For the purposes of this title, the term `Persian Gulf War' has the meaning given such term in
section 101(33) of title 38, United States Code.
TITLE VIII-COURT OF VETERANS APPEALS
SEC. 801. DISCIPLINARY PROCEDURES FOR JUDGES OF COURT OF VETERANS
APPEALS.
Section 7253(g) is amended--
(1) by inserting '(1)' after '(g)'; and
(2) by adding at the end the following:
'(2) The provisions of paragraphs (7) through (15) of section 372(c) of title 28, regarding
referral or certification to, and petition for review in, the Judicial Conference of the United
States and action thereon, shall apply to the exercise by the Court of the powers of a judicial
council under paragraph (1) of this subsection. The grounds for removal from office specified
in subsection (f)(1) shall provide a basis for a determination pursuant to paragraph (7) or (8) of
section 372(c) of title 28, and certification and transmittal by the Conference shall be made to
the President for consideration under subsection (f).
'(3)(A) In conducting hearings pursuant to paragraph (1), the Court may exercise the authority
provided under section 1821 of title 28 to pay the fees and allowances described in that section.
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`(B) The Court shall have the power provided under section 372(c)(16) of title 28 to award
reimbursement for the reasonable expenses described in that section. Reimbursements under
this subparagraph shall be made from funds appropriated to the Court.'.
Speaker of the House of Representatives.
Vice President of the United States and
President of the Senate.
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H.R.4386
Veterans' Persian Gulf War Benefits Act (Reported in the House)
AUGUST 4, 1994
Reported with an amendment, committed to the Committee of the Whole House on the State of the
Union, and ordered to be printed
[Strike out all after the enacting clause and insert the part printed in italic]
[For text of introduced bill, see copy of bill as introduced on May 11, 1994]
A BILL
To amend title 38, United States Code, authorizing the Secretary of Veterans Affairs to provide
compensation to veterans suffering from disabilities resulting from illnesses attributed to service in
the Persian Gulf theater of operations during the Persian Gulf War, to provide for increased research
into illnesses reported by Persian Gulf War veterans, and for other purposes.
Be it enacted by the Senate and House of Representatives of the United States of America in
Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the 'Veterans' Persian Gulf War Benefits Act'.
SEC. 2. CONGRESSIONAL FINDINGS.
The Congress makes the following findings:
(1) During the Persian Gulf War, members of the Armed Forces were exposed to
numerous potentially toxic substances, including fumes and smoke from military
operations, oil well fires, diesel exhaust, paints, pesticides, depleted uranium, infectious
agents, chemoprophylactic agents, and indigenous diseases, and were also given
multiple immunizations. It is not known whether these servicemembers were exposed to
chemical or biological warfare agents. However, threats of enemy use of chemical and
biological warfare heightened the psychological stress associated with the military
operation.
(2) Significant numbers of veterans of the Persian Gulf War are suffering from illnesses,
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or are exhibiting symptoms of illness, that cannot now be diagnosed or clearly defined.
As a result, many of these conditions or illnesses are not considered to be service
connected under current law for purposes of benefits administered by the Department of
Veterans Affairs.
(3) The Technology Assessment Workshop on the Persian Gulf Experience and Health
conducted by the National Institutes of Health concluded that the complex biological,
chemical, physical, and psychological environment of the Southwest Asia theater of
operations produced complex adverse health effects in Persian Gulf War veterans and
that it appears that no single disease entity or syndrome exists. Rather, it appears that
the illnesses suffered by those veterans result from multiple illnesses with overlapping
symptoms and causes that have yet to be defined.
(4) That workshop concluded that the data concerning the range and intensity of
exposure to toxic substances by military personnel in the Southwest Asia theater of
operations are very limited and that such data were collected only after a considerable
delay.
(5) In response to concerns regarding the health-care needs of Persian Gulf War
veterans, particularly those who suffer from illnesses or conditions for which no
diagnosis has been made, the Congress, in Public Law 102-585, directed the
establishment of a Persian Gulf War Veterans Health Registry, authorized health
examinations for veterans of the Persian Gulf War, and provided for the National
Academy of Sciences to conduct a comprehensive review and assessment of information
regarding the health consequences of military service in the Persian Gulf theater of
operations and to develop recommendations on avenues for research regarding such
health consequences. In Public Law 103-210, the Congress authorized the Department
of Veterans Affairs to provide health care services on a priority basis to Persian Gulf
War veterans. The Congress also provided in Public Law 103-160 (the National Defense
Authorization Act for Fiscal Year 1994) for the establishment of a specialized
environmental medical facility for the conduct of research into the possible health effects
of exposure to low levels of hazardous chemicals, especially among Persian Gulf
veterans, and for research into the possible health effects of battlefield exposure in such
veterans to depleted uranium.
(6) Further research and studies must be undertaken to determine the underlying causes
of the illnesses suffered by Persian Gulf War veterans and, pending the outcome of such
research, veterans who are seriously ill as the result of such illnesses should be given the
benefit of the doubt and be provided compensation benefits to offset the impairment in
earnings capacities they may be experiencing.
SEC. 3. PURPOSES.
The purposes of this Act are--
(1) to provide compensation to Persian Gulf War veterans who suffer disabilities
resulting from illnesses that cannot now be diagnosed or defined, and for which other
causes cannot be identified,
(2) to require the Secretary of Veterans Affairs to develop at the earliest possible date
case assessment strategies and definitions or diagnoses of such illnesses,
(3) to promote greater outreach to Persian Gulf War veterans and their families to
inform them of ongoing research activities, as well as the services and benefits to which
they are currently entitled, and
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(4) to ensure that research activities and accompanying surveys of Persian Gulf War
veterans are appropriately funded and undertaken by the Department of Veterans
Affairs.
SEC. 4. DEVELOPMENT OF CASE ASSESSMENT PROTOCOL AND CASE
DEFINITIONS.
(a) IN GENERAL- The Secretary of Veterans Affairs shall--
(1) develop and implement at the earliest possible date a uniform case assessment
protocol that will ensure thorough assessment, diagnosis, and treatment of all Persian
Gulf War veterans suffering from illness attributed to service in the Southwest Asia
theater of operations during the Persian Gulf War; and
(2) develop at the earliest possible date case definitions or diagnoses for illnesses
associated with such service.
(b) CONSULTATION- Development of a uniform case assessment protocol under subsection
(a)(1) and development of case definitions or diagnoses under subsection (a)(2) shall be
carried out by the Secretary of Veterans Affairs in consultation with the Secretary of Defense
and the Secretary of Health and Human Services.
(c) REPORTS- The Secretary shall submit to the Committees on Veterans' Affairs of the Senate
and House of Representatives an annual report on the status of the activities required by this
section. The first such report shall be submitted not later than six months after the date of the
enactment of this Act.
SEC. 5. PROVISION OF INFORMATION TO VETERANS OF THE PERSIAN
GULF WAR.
(a) OUTREACH PROGRAM- The Secretary of Veterans Affairs shall develop and implement a
comprehensive outreach program and information system to provide Persian Gulf War
veterans and their families with information regarding the following:
(1) The Persian Gulf War Veterans Health Registry established by the Persian Gulf War
Veterans' Health Status Act (38 U.S.C. 527 note).
(2) Access to health services and health-related benefits provided by or under the
auspices of the Department of Veterans Affairs, including--
(A) marriage and family counseling available under section 121 of the Veterans'
Medical Programs Amendments of 1992 (38 U.S.C. 1712A note);
(B) health care available under section 1710(e)(1)(C) of title 38, United States
Code; and
(C) health examinations, consultation, and counseling available under section 703
of the Persian Gulf War Veterans' Health Status Act (38 U.S.C. 527 note).
(3) Compensation and benefits related to disabilities resulting from service in the
Persian Gulf War, including disabilities resulting from illness that resulted from such
service.
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(4) Significant developments in research relating to the health consequences of service in
the Persian Gulf War.
(5) Any other information that the Secretary determines to be appropriate.
(b) TOLL-FREE TELEPHONE NUMBER- The information system required by subsection (a)
shall include the establishment and staffing of a toll-free telephone number for the use of such
veterans and their families.
(c) FURTHER INFORMATION- Section 702(f) of the Persian Gulf War Veterans' Health
Status Act (38 U.S.C. 527 note) is amended to read as follows:
`(f) ONGOING OUTREACH TO INDIVIDUALS LISTED IN REGISTRY- (1) The Secretary of
Veterans Affairs shall notify each individual listed in the Registry or, in the case of such an
individual who is deceased, the surviving spouse, children, or parents of such individual, at
least quarterly, by newsletter or by other means that the Secretary determines to be
appropriate, of--
`(A) the status and findings of federally sponsored research relating to the illnesses of
individuals who served as members of the Armed Forces in the Persian Gulf theater of
operations during the Persian Gulf War or to the illnesses of the family members of such
individuals;
`(B) compensation and benefits, including health care and other health-related benefits,
that may be provided by the Department of Veterans Affairs or the Department of
Defense to an individual who served as a member of the Armed Forces in the Persian
Gulf theater of operations during the Persian Gulf War or, in the case of such an
individual who is deceased, to the surviving spouse, children, or parents of such an
individual; and
'(C) any other information that the Secretary determines to be appropriate.
'(2) In preparing the newsletter or other means used to provide information as required by
paragraph (1), the Secretary shall consult with veterans' service organizations.
'(3) The requirement of paragraph (1) shall not apply regarding notification of any individual
if that individual makes a written request to the Secretary of Veterans Affairs that the
notification not be provided.'.
SEC. 6. COMPENSATION BENEFITS FOR DISABILITY RESULTING FROM
ILLNESS ATTRIBUTED TO SERVICE DURING THE PERSIAN GULF WAR.
(a) IN GENERAL- (1) Chapter 11 of title 38, United States Code, is amended by adding at the
end of subchapter II the following new section:
`Sec. 1117. Compensation for disabilities associated with Persian Gulf War
`(a) The Secretary shall pay compensation under this subchapter to a Persian Gulf veteran
suffering from a chronic disability resulting from an undiagnosed illness (or combination of
undiagnosed illnesses) that became manifest to a degree of 10 percent or more before the later
of (1) October 1, 1996, or (2) the end of the two-year period beginning on the last date on
which the veteran performed active military, naval, or air service in the Southwest Asia theater
of operations while on active duty.
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`(b) A disability for which compensation under this subchapter is payable shall be considered
to be service connected for purposes of all other laws of the United States.
`(c) Compensation may not be paid under this section with respect to a disability occurring in
a veteran--
'(1) where there is affirmative evidence that the disability was not incurred by the
veteran during service in the Persian Gulf theater of operations during the Persian Gulf
War; or
'(2) where there is affirmative evidence to establish that an intercurrent injury or illness
which is a recognized cause of the disability was suffered by the veteran between the
date of the veteran's most recent departure from that theater of operations while on
active duty and the onset of the disability.
'(d) The Secretary may not make payments under this section with respect to a disability for
which compensation is paid under this section for any month after the month during which the
Secretary determines that such disability was not incurred as the result of service in the
Southwest Asia theater of operations during the Persian Gulf War.
'(e) For purposes of this section, the term `Persian Gulf veteran' means a veteran who served
on active duty in the Armed Forces in the Southwest Asia theater of operations during the
Persian Gulf War.
`(f)(1) No payment may be made under this section for any month that begins after the end of
the three-year period beginning on the date of the enactment of this section.
'(2) If, before the end of such three-year period, the Secretary submits to the Committees on
Veterans' Affairs of the Senate and House of Representatives a report stating that, as of the
date of the report, no diagnoses for the illnesses referred to in subsection (a) can be made
based on current medical knowledge, such three-year period shall continue for an additional
three years.
'(3) The Secretary shall submit to those committees a report addressing the issue of diagnoses
of such illnesses not later than April 1, 1997.'.
(2) The table of sections at the beginning of such chapter is amended by inserting after the item
relating to section 1116 the following new item:
`1117. Compensation for disabilities associated with Persian Gulf War.'.
(b) EFFECTIVE DATE- Section 1117 of title 38, United States Code, as added by subsection
(a), shall take effect on October 1, 1994.
SEC. 7. AUTHORIZATION OF APPROPRIATIONS FOR PERSIAN GULF
ILLNESS RESEARCH.
There is authorized to be appropriated to the Department of Veterans Affairs $5,000,000 for
each of fiscal years 1995 through 1997 for the conduct of research, which the Secretary of
Veterans Affairs, in consultation with the Secretary of Defense and the Secretary of Health and
Human Services, determines would advance understanding of health risks and effects of
service during the Persian Gulf War and effective means of treating such health effects.
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SEC. 8. SURVEY OF PERSIAN GULF VETERANS.
(a) IN GENERAL- There is authorized to be appropriated to the Department of Veterans
Affairs such sums as are needed for fiscal year 1995 for the conduct of a survey of Persian
Gulf veterans to gather information on the incidence and nature of health problems occurring
in Persian Gulf veterans and their families.
(b) COORDINATION WITH DEPARTMENT OF DEFENSE- The survey under subsection (a)
shall be carried out in coordination with the Secretary of Defense.
(c) PERSIAN GULF VETERAN- For purposes of this section, a Persian Gulf veteran is an
individual who served on active duty in the Armed Forces in the Southwest Asia theater of
operations during the Persian Gulf War as defined in section 101(33) of title 38, United States
Code.
SEC. 9. AUTHORIZATION FOR EPIDEMIOLOGICAL STUDIES.
(a) STUDY OF HEALTH CONSEQUENCES OF PERSIAN GULF SERVICE- If the National
Academy of Sciences includes in the report required by section 706(b) of the Veterans Health
Care Act of 1992 (Public Law 102-585) a finding that there is a sound basis for an
epidemiological study or studies on the health consequences of service in the Persian Gulf
theater of operations during the Persian Gulf War and recommends the conduct of such a
study or studies, the Secretary of Veterans Affairs is authorized to carry out such study.
(b) OVERSIGHT- (1) The Secretary shall seek to enter into an agreement with the Medical
Follow-Up Agency (MFUA) of the Institute of Medicine of the National Academy of Sciences
for (A) the review of proposals to conduct the research referred to in subsection (a), (B)
oversight of such research, and (C) review of the research findings.
(2) If the Secretary is unable to enter into an agreement under paragraph (1) with the entity
specified in that paragraph, the Secretary shall enter into an agreement described in that
paragraph with another appropriate scientific organization which does not have a connection
to the Department of Veterans Affairs. In such a case, the Secretary shall submit to the
Committees on Veterans' Affairs of the Senate and House of Representatives, at least 90 days
before the date on which the agreement is entered into, notice in writing identifying the
organization with which the Secretary intends to enter into the agreement.
(c) ACCESS TO DATA- The Secretary shall enter into agreements with the Secretary of
Defense and the Secretary of Health and Human Services to make available for the purposes of
any study described in subsection (a) all data that the Secretary, in consultation with the
National Academy of Sciences and the contractor, considers relevant to the study.
(d) AUTHORIZATION- There are authorized to be appropriated to the Department such sums
as are necessary for the conduct of studies described in subsection (a).
SEC. 10. EXTENSION OF MARRIAGE AND FAMILY COUNSELING
AVAILABILITY FOR PERSIAN GULF WAR VETERANS.
(a) IN GENERAL- Section 121(a) of the Veterans' Medical Programs Amendments of 1992 (38
U.S.C. 1712A note) is amended by striking out `September 30, 1994' and inserting in lieu
thereof 'December 31, 1998'.
(b) AUTHORIZATION OF APPROPRIATIONS- Section 121(g) of the Veterans' Medical
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Programs Amendments of 1992 (38 U.S.C. 1712A note) is amended by striking out `and 1994'
and inserting in lieu thereof `through 1999'.
SEC. 11. COST-SAVINGS PROVISIONS.
(a) ELECTION OF DEATH PENSION BY SURVIVING SPOUSE- Section 1317 of title 38,
United States Code, is amended--
(1) by striking out 'No person' and inserting in lieu thereof '(a) Except as provided in
subsection (b), no person'; and
(2) by adding at the end the following:
`(b) A surviving spouse who is eligible for dependency and indemnity compensation by reason
of any death occurring after December 31, 1956, may elect to receive death pension instead of
such compensation.'.
(b) POLICY REGARDING COST-OF-LIVING ADJUSTMENT IN COMPENSATION RATES
FOR FISCAL YEAR 1995- The fiscal year 1995 cost-of-living adjustments in the rates of and
limitations for compensation payable under chapter 11 of title 38, United States Code, and of
dependency and indemnity compensation payable under chapter 13 of such title will be no
more than a percentage equal to the percentage by which benefit amounts payable under title
II of the Social Security Act (42 U.S.C. 401 et seq.) are increased effective December 1, 1994,
as a result of a determination under section 215(i) of such Act (42 U.S.C. 415(i)), with all
increased monthly rates and limitations (other than increased rates or limitations equal to a
whole dollar amount) rounded down to the next lower dollar.
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TROOP HEALTH Presidential Review Directive
http://www.whitehouse.gov/WH/EOP/OSTP/Science/html/troophealth.html
TROOP HEALTH Presidential Review Directive
Background:
President Clinton established the Presidential Advisory Committee on Gulf War
Veterans' Illnesses on May 26, 1995, to ensure an independent, open and
comprehensive examination of health concerns related to Gulf War service. Working
with the First Lady's Office, Cabinet Affairs, and the National Security Council, OSTP
played the central role in establishing this Committee. The Committee issued its Final
Report on December 31, 1996, documenting its review of the government's outreach,
medical care, research, efforts to protect against and to assess exposure to chemical
and biological weapons, and coordination activities pertinent to Gulf War veterans'
illnesses. The Committee was asked by the President to continue its oversight of
government efforts and they issued another report in October 1997. During the course
of the Committee's deliberations, government efforts to address and to resolve veterans'
concerns continued, consistent with respective agencies' missions to provide for the
health and welfare of active, reserve, and retired service personnel and their
dependents.
This extensive review and analysis of Gulf War veterans' illnesses and risk factors have
identified a number of opportunities for government action aimed at minimizing or
preventing future post-conflict health concerns. Ameliorating, avoiding or, ideally,
preventing such health effects can be approached through a variety of means. These
include improving service personnel's understanding of health risk information;
enhancing government collection of health and exposure data; coordinating agency
research programs; and improving the delivery of health care services to veterans and
their families, as could be accomplished by establishing effective linkages between
health information systems.
In its December 1996 report, the Advisory Committee recommended that the National
Science and Technology Council (NSTC) develop an interagency plan to address health
preparedness for and readjustment of veterans and families after future conflicts and
peacekeeping missions.
Status:
In accordance with the Advisory Committee's recommendation, the NSTC develop this
plan and released it on November 11, 1998. Acting on its primary recommendation, the
President ordered the formation of the Military and Veterans Health Coordinating Board
to improve health protection for our armed forces, veterans and families. The Military and
Veterans Health Coordinating Board will coordinate the functions of DoD, VA, and HHS
in matters concerning: research, deployment health, health care, and risk
communication. This Board will oversee the implementation of the NSTC interagency
plan.
A National Obligation: Planning for Health Preparedness for and Readjustment of the
Military, Veterans, and their Families after Future Deployments, November 1998. This
report is responsive to PRD/NSTC-5. It lays out a comprehensive interagency plan for
improving the health of our military, veterans and their families.
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EXECUTIVE SUMMARY
The Persian Gulf Veterans Coordinating Board Action Plan
with Respect to the Findings and Recommendations of the Presidential Advisory
Committee on Gulf War Veterans' Illnesses Final Report
The Persian Gulf Veterans Coordinating Board comprised of the Secretaries of Defense (DoD),
Health and Human Services (DHHS), and Veterans Affairs (VA) greatly appreciates the effort,
thought and constructive recommendations provided by the Presidential Advisory Committee
on Gulf War Veterans' Illnesses in its final report.
Like the Presidential Advisory Committee, the three Departments recognize that the issues
surrounding Gulf War veterans' illnesses are complex. Since the end of the Gulf War, concerns
have been raised as to whether there is a relationship between the illnesses (diagnosed and
undiagnosed) being experienced by some Gulf War veterans and their family members and a
variety of possible hazardous exposures during service, including chemical warfare agents. We
share these concerns and are taking concrete steps to determine the causes of these illnesses and
to provide care for veterans who are ill.
The Presidential Advisory Committee's "Final Report" provides a number of important findings
and valuable recommendations. This plan outlines the Departments' actions, including those
already partially or fully implemented, taken in response to the findings and recommendations
of the Presidential Advisory Committee in their "Final Report." This Action Plan is a dynamic
document which will need to be revisited and adjusted as information becomes available and
we learn more. Furthermore, in the upcoming weeks, the three Departments and the Persian
Gulf Veterans Coordinating Board will develop specific timelines for the actions proposed.
The plan addresses actions to be taken in the areas of outreach, medical and clinical issues,
research, coordination, investigations, and chemical and biological weapons. These actions
include:
Initiation of a Presidential Review Directive pursuant to which the National Science and
Technology Council will create an interagency plan to address health preparedness for, and
readjustment of, veterans and their families after future conflicts and peacekeeping
missions.
The Persian Gulf Veterans Coordinating Board's Clinical Working Group will develop a
comprehensive risk communication plan. Government and non-government risk
communication experts will be engaged to assist in development and implementation of the
plan.
VA Transition Assistance Program briefings for service members separating from active duty
will emphasize the VA programs and services available to Gulf War veterans and their
families.
VA will ensure that its outreach to the Latino populations provides information on Gulf War-
related programs. A Spanish language information pamphlet and federal veterans benefits
guide are being produced.
Re-evaluation and enhancement of the Persian Gulf Veterans Coordinating Board will include
the addition of new members to the existing Clinical, Research, and Compensation
Working Groups. Further, a Deployment Planning Working Group will be established to
make recommendations for interagency activities, and to monitor pre-deployment,
deployment, and post-deployment medical surveillance programs.
The Food and Drug Administration is preparing regulations that will solicit public and expert
comment on any rule that permits waiver of informed consent for use of investigational
products in military exigencies.
Deployment health surveillance programs will be carried out involving pre-deployment health
screening and education, deployment operational, environmental, and medical surveillance,
and post-deployment health surveillance and risk communication.
DoD is developing enhanced orientation and training procedures to inform service personnel
about the health risks, benefits and proper use of military medical countermeasures to
chemical and biological warfare agents.
Military medical record keeping will be given particular priority by DoD officials at the highest
levels. Computerized medical records, meditags, and compatible information systems are
under development.
Continuing medical education programs for health care providers in VA and DoD will be
enhanced to ensure up-to-date patient education and delivery of high quality health care.
DoD is developing a Directive on Combat Stress that will set forth policy, improve stress
reduction and management programs, and involve military leadership in stress management
and unit cohesion programs.
DHHS will engage in a special effort designed specifically to impact the stigmatization of
stress-associated and other mental health conditions.
DoD has established the Office of the Special Assistant for Gulf War Illnesses, which is
responsible for investigation of reported Gulf War-related incidents that may have health
consequences. This effort involves case management and release of investigation
narratives, and outreach to veterans and Military Coalition organizations. Recent activities
include initiation of a Khamisiyah survey to collect information from veterans who were
there and to encourage them to participate in the health registries.
Service members who may have been exposed at Khamisiyah and other sites will be notified
and any needed evaluation and care provided; moreover, appropriate research will be
conducted.
Research activities are a key component of the government's response. Related initiatives
include:
The Persian Gulf Veterans Coordinating Board has encouraged Public Advisory
Committees be established for all large epidemiologic studies;
Federal research requests for proposals include:
the possible long-term health effects of chemical and other hazards (including
subclinical exposure to chemical warfare nerve agents);
studies of combined exposures to pyridostigmine bromide, pesticides and other agents;
epidemiologic feasibility studies on Khamisiyah veterans and other groups possibly
exposed to low-level chemical agents; and
research on stress-related disorders.
Development of a strategic plan for research into the potential health consequences of exposure
to chemical and other hazards, including low-levels of chemical warfare agents; and
Support for long-term mortality studies and cancer registries.
The Persian Gulf Veterans Coordinating Board has engaged in a comprehensive, coordinated
effort to respond to the health concerns of Gulf War veterans. DoD, DHHS and VA are
committed to finding answers to Gulf War illnesses and look forward to working with the
Presidential Advisory Committee on Gulf War Veterans' Illnesses to achieve this goal. Our
veterans and their families deserve no less.
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Office of Public Affairs
Washington, D.C. 20420
News Service
(202) 273-5700
www.va.gov
Department of
Veterans Affairs
VA Fact Sheet
VA PROGRAMS FOR GULF WAR VETERANS
April 1998
The Department of Veterans Affairs (VA) offers Gulf War veterans physical examinations and
special eligibility for follow-on care, and it operates a toll-free hotline at 800-749-8387 to inform
these veterans of the program and their benefits. VA also is compensating veterans under
unprecedented regulations addressing undiagnosed conditions. Most Gulf veterans are diagnosed and
treated; but for some, such symptoms as joint pain or fatigue have been chronic. Some respond to
treatment of symptoms even though their doctors have not yet identified an underlying illness or
pathogenic agent.
UNEXPLAINED ILLNESS: The prevalence of unexplained illnesses among Gulf War veterans is
uncertain. Answers about illness prevalence are expected through epidemiologic research involving
representative samples of the Gulf veteran population (see National Health Survey, page 3). Data
reviewed from about 10,000 of the most recent exams in the special Gulf War Registry health
examination program showed physicians had determined that the veteran had unexplained illness in
about 12 percent of the cases.
GULF WAR "SYNDROME" UNDEFINED: Several panels of government physicians and
private-sector scientific experts have been unable to discern any new illness or unique symptom
complex such as that popularly called "Gulf War Syndrome." "No single disease or syndrome is
apparent, but rather multiple illnesses with overlapping symptoms and causes," wrote an outside
panel led by professors from Harvard and Johns Hopkins University that convened for an April 1994
National Institutes of Health (NIH) workshop. Similarly, neither the independent Institute of
Medicine nor the Presidential Advisory Committee on Gulf War Veterans' Illnesses was able to
identify any unique symptom complex or new illness. VA has neither confirmed nor ruled out the
possibility of a singular Gulf syndrome.
RESEARCH AND RISK FACTORS: With variation in exposures and veterans' concerns ranging
from oil well fire smoke to possible contamination from Iraqi chemical/biological agents, VA has
initiated wide-ranging research projects evaluating illnesses as well as environmental risk factors.
The activation of four research centers has enabled VA to broaden its activity from largely
descriptive evaluations to greater emphasis on hypothesis-driven research. In the last five fiscal years,
the federal government committed approximately $115 million for 121 research projects related to
Gulf War illnesses (see Research, page 3).
Statistics
More than one million servicemembers served in the Gulf from August 1990 through the end of
1997, nearly 697,000 of them serving in the first year. About 786,000 have become potentially
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eligible for VA care as veterans, having separated from the military or having become deactivated
reservists or Guard members. More than 67,000 veterans have responded to VA's outreach
encouraging any Gulf veteran to get a free physical exam under VA's Gulf War Program. Not all are
ill:
12 percent of the veterans who had the registry health exam had no health complaint (among
the first 52,000 computerized records).
26 percent of the same group rated their health as poor or very poor, while 73 percent reported
their health as all right to very good (the remaining 1 percent did not have an opinion).
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VA Health Programs for Gulf Veterans
SPECIAL HEALTH EXAMINATION: A free, complete physical examination with basic lab
studies is offered to every Gulf War veteran, whether or not the veteran is ill. A centralized registry of
participants, begun in August 1992, is maintained to enable VA to update veterans on research
findings or new compensation policies through periodic newsletters. This clinical database could
suggest areas to be explored in future scientific research. The 67,000 Gulf War veterans who have
taken advantage of the physical examination program become part of a larger Gulf War Registry. As
defined by 102-585, this includes about 242,000 Gulf veterans (generally including those counted
in the special examination program) who have been seen for routine VA hospital or clinic care, or
who have filed compensation claims or whose survivor registers a claim. If the veteran's illness
defies diagnosis, the veteran may be referred to one of four Gulf War Referral Centers. Created in
1992, the first centers were located at VA medical centers in Washington, D.C.; Houston; and Los
Angeles, with an additional center designated at Birmingham, Ala., in June 1995.
GULF WAR VETERANS INFORMATION CENTER: VA offers a toll-free information line at
800-PGW-VETS (800-749-8387) where operators are trained to help veterans with general questions
about medical care and other benefits. It also provides recorded messages that enable callers to obtain
information 24 hours a day.
SPECIAL ACCESS TO FOLLOW-ON CARE: VA has designated a physician at every VA
medical center to coordinate the special examination program and to receive updated educational
materials and information as experience is gained nationally. Where an illness possibly related to
military service in the Southwest Asia theater of operations during the Gulf War is detected during
the examination, followup care is provided on a higher-eligibility basis than most non-service-
connected care. As with the health examination registry, VA requested and received special statutory
authority to bypass eligibility rules governing access to the VA health system.
STANDARDIZED EXAM PROTOCOLS: VA has expanded its special examination protocol as
more experience has been gained with the health of Gulf veterans. The protocol elicits information
about symptoms and exposures, calls the clinician's attention to diseases endemic to the Gulf region,
and directs baseline laboratory studies including chest X-ray (if one has not been done recently),
blood count, urinalysis, and a set of blood chemistry and enzyme analyses that detect the
"biochemical fingerprints" of certain diseases. In addition to this core laboratory work for every
veteran undergoing the Gulf War program exam, physicians order additional tests and specialty
consults as they would normally in following a diagnostic trail -- as symptoms dictate. If a diagnosis
is not apparent, facilities follow the "comprehensive clinical evaluation protocol" originally
developed for VA's referral centers and now used in VA and military medical centers nationwide.
The protocol suggests 22 additional baseline tests and additional specialty consultations, outlining
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dozens of further diagnostic procedures to be considered, depending on symptoms.
Risk Factors of Concern to Veterans
Veterans have reported a wide range of factors observed in the Gulf environment or speculative risks
about which they have voiced concerns. Some are the subject of research investigations and none
have been ruled out. There appears to be no unifying exposure that would account for all unexplained
illnesses. Individual veterans' exposures and experiences range from ships to desert encampments,
and differences in military occupational specialty frequently dictate the kinds of elements to which
servicemembers are exposed.
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Gulf War Veterans Page 3
Veteran concerns include exposure to the rubble and dust from exploded shells made from depleted
uranium; the possibility of exposure to the nerve agent sarin or some yet-unconfirmed Iraqi chemical-
biological agent; and use of a nerve agent pre-treatment drug, pyridostigmine bromide. Many other
risk factors also have been raised. In 1991, VA initially began to develop tracking mechanisms that
matured into the Gulf War Registry as a direct consequence of early concerns about the
environmental influence of oil well fires and their smoke and particulate.
Medical Research
Most of the 121 federally supported research projects are being conducted by non-federal
investigators. Thirty-nine have been completed, 78 are ongoing and four have been awarded funds
that are pending startup. Ongoing VA initiatives include:
Environmental Hazards Research Centers. Through a vigorous scientific competition, VA
developed major focal points for Gulf veteran health studies at three medical centers: Boston; East
Orange, N.J.; and Portland, Ore. With 14 protocols among them, the centers are conducting a variety
of interdisciplinary projects, including some aimed at developing a working case definition for an
unexplained illness and clarification of risk factors. Some protocols involve areas of emerging
scientific understanding, such as chronic fatigue syndrome or multiple chemical sensitivity, while
others are evaluating or comparing factors in immunity, psychiatry, pulmonary response,
neuroendocrinology and other body systems, some at the molecular level. A fourth research center,
the Center for the Study of Environmental Hazards to Reproductive Health, funded in late 1996, is a
joint venture of the Louisville VA Medical Center and the University of Louisville's Kentucky
Institute for the Environment and Sustainable Development. One project will be addressing
reproductive outcomes in Gulf War veterans.
National Health Survey of Gulf War Veterans. VA's National Health Survey of Gulf War Veterans
is designed to determine the prevalence of symptoms and illnesses among a random sampling of Gulf
War veterans. The survey is being conducted in three phases: a mail survey of the health of 30,000
veterans of the Gulf War era, half of whom served in the theater of operations; telephone interviews
of samples to determine if there are any response differences between those who responded and those
who did not, and to validate responses from the mail survey; and a comprehensive physical
examination for a sample of 2,000 veterans participating in the first two phases, as well as a physical
examination for their families. Data from the questionnaire phase is being analyzed and the telephone
interview phase is nearing completion. Completion of data collection from the physical examination
phase is anticipated in mid-1999.
VA Mortality Study. VA is pursuing a continuing mortality study, analyzing death certificates to
determine any patterns of difference in causes of death between deceased Gulf veterans and matched
controls. In their initial report covering the first two years after the war, as has been observed after
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other wars, veterans of the Gulf War have experienced a higher incidence of death due to accidents.
When this contributing factor is excluded, Gulf War veterans have not experienced a higher mortality
rate due to disease-related causes. Both the Gulf War and non-deployed control group veterans had a
lower death rate than Americans
their age in general. A report was published Nov. 14, 1996, in the New England Journal of Medicine.
An update of data through December 1995 revealed results similar to the published study.
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Gulf War Veterans Page 4
Exposure-Oriented Clinical Surveillance Programs. Some ongoing VA clinical evaluations respond
to hypotheses of specific potential risk factors:
A Baltimore clinical evaluation is providing periodic examinations of individuals
thought exposed to depleted uranium (DU), a heavy metal used in armaments,
including some who retained tiny embedded fragments when in the vicinity of
exploding shells. Among 29 (from an initial 33) being followed, at the most recent
examination no clinically significant abnormalities were found. The Department of
Defense (DoD) estimates that at least 300 veterans may have been exposed to DU
by inhalation in the Gulf War during incidents where U.S. troops accidentally fired
on U.S. vehicles. DoD is calling these veterans to invite them to come to VA or
DoD for evaluation under a protocol developed by the two departments.
Another Gulf War health surveillance program is ongoing at the VA medical
center in Birmingham. A pilot project there offers an extensive battery of
neurological tests aimed at detecting dysfunction that would be expected after
exposure to certain chemical weapons.
Treatment Trial for Chronic Fatigue Syndrome and Fibromyalgia. VA and DoD are investing $10
million in a joint VA/DoD multi-center treatment trial for chronic fatigue syndrome and fibromyalgia
in Gulf veterans as an outgrowth of efforts to seek candidate treatments of clearly defined medical
syndromes or illnesses among groups of Gulf veterans.
Outside Reviews. In addition to the work of the Presidential Advisory Committee on Gulf War
Veterans' Illnesses, VA and DoD contracted with the National Academy of Sciences' Institute of
Medicine (IOM) to review existing scientific and other information on the health consequences of
Gulf operations. Another IOM contract calls for an assessment of health outcomes and treatment
efficacy of VA efforts on behalf of Gulf veterans.
VA Disability Compensation
Since early 1995, VA has been providing compensation payments to chronically disabled Gulf War
veterans with undiagnosed illnesses. This benefit was expanded under an April 29, 1997, regulation
that essentially eliminated the date of initial manifestation of latent symptoms as a consideration in
adjudication through the end of the year 2001. A disability is considered chronic if it has existed for
at least six months.
Outside of the new regulation, VA has long based monthly compensation for veterans on finding
evidence a condition arose during or was aggravated by service. VA has approved more than 141,700
compensation claims of Gulf veterans for service injuries or illnesses of all kinds, with nearly 95,000
disabled at a compensable level who are receiving monthly benefits. The 141,700 approved claims
include 1,500 approved under the new undiagnosed illnesses regulation.
Interagency Coordination and White House Response
The federal response to the health consequences of Gulf War service is being led by the Persian Gulf
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Veterans Coordinating Board composed of VA, DoD, and the Department of Health and Human
Services. Working groups are collaborating in the areas of research, clinical issues and disability
compensation. The Board and its subgroups are a valuable vehicle for communication between top
managers and scientists, including a staff office for the Board that follows up on critical issues and
promotes continuity in agency activities. President Clinton designated VA as the Coordinating
Board's lead agency.
The Presidential Advisory Committee on Gulf War Veterans' Illnesses, formed by President Clinton
in March 1995, met from August 1995 to October 1997 and made recommendations on Coordinating
Board activities; research, medical examination and treatment programs; federal outreach; and other
issues ranging from risk factors to chemical exposure reports. It published reports Feb. 15, 1996; Dec.
31, 1996; and Oct. 31, 1997.
###
VA
Compliments, Questions,
Table of Contents
Home Page
Complaints, and Concerns
i
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DoD FACT SHEET
Department of Defense Gulf War Illnesses Initiatives
Coordination efforts:
Nov 1996. DoD requested the Institute for Defense Analyses (IDA) convene an independent panel
of experts in meteorology, physics, chemistry and related disciplines to review the modeling analysis
done for the CIA using the U.S. Army's Chemical and Biological Defense Command's NUSSE4
transport and diffusion model. IDA's final report is expected some time in 1997.
Nov 1996. Establishment of the Office of the Special Assistant for Gulf War Illnesses under Dr.
Bernard Rostker's direction.
Nov 1996. DoD expands the size of the Persian Gulf Illnesses Investigation Team from 12 to 110
people. This expanded organization added significant resources to efforts to determine the causes of
Gulf War illnesses.
Nov 1996. Reconstitution of the Senior Level Oversight Panel. The Panel membership consists of
the Chairman of the Joint Chiefs of Staff, the Secretaries of the Military Departments, the Under
Secretaries of Defense and the Assistant Secretaries of Defense for Public Affairs and Health Affairs.
Oct 1996. Five million dollars designated for new research into low-level chemical exposure.
Oct 1996. DoD requests a review by the National Academy of Sciences on issues surrounding the
causes of Persian Gulf veteran's illnesses and future force protection efforts.
Oct 1996. DoD requested the Institute of Medicine re-evaluate the CCEP clinical protocols in light
of Khamisiyah and the possible low-level exposures.
Oct 1996. In concert with VA initiated joint health professional education programs, which
included video teleconferences with health care providers.
Jan 1996. In concert with DHHS began developing a "risk communication" plan on Gulf War
veterans' illnesses to ensure that all communications with Gulf War veterans are effective in
conveying health information.
External Review Efforts:
Oct 1996. The Department of Defense requested that the IOM provide recommendations for
possible modification to the CCEP with respect to possible low-level exposure to chemical agents.
May 1994. DoD contracted with Harrison C. Spencer, Jr., MD, Dean, Tulane University School of
Public Health and Tropical Medicine, to review all aspects of unexplained illnesses among Gulf War
veterans and to facilitate discussions on epidemiology and tropical medicine.
Medical Care Efforts:
June 1994. DoD and VA launch an effort to provide standardized health examinations and care to
Gulf War veterans with health concerns. (Comprehensive Clinical Evaluation Program (CCEP)) Toll-
free telephone hotlines established. Jan 1997 Update: 37,845 total participants, 28,590 participants
have or will soon complete medical evaluations and 9,255 have declined medical evaluations.
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June 1993. Interagency agreement developed between DoD and VA to contract with the Medical
Follow-up Agency (MFUA) of the National Academy of Sciences for epidemiological assessments
and studies.
Aug 1992. A medical reporting system for Gulf War veterans is established.
Outreach Efforts:
Dec 1996. Initiated call backs to all new 800 calls received.
Oct 1996. The Defense Department announced a series of actions to reach out and seek the help of
20,000 Gulf War veterans that may have been near Khamisiyah during the period March 4-15, 1991.
These actions include telephone interviews, letters and surveys as well as encouragement to
participate in medical evaluation programs.
Oct 1996. DoD alerts health providers of the incident at Khamisiyah.
Oct 1996. Review of process for declassifying documents placed on GulfLINK.
June 1996. DoD announced that some persons who served in the Gulf War may have been exposed
to chemical warfare agents as a result of munitions demolition at Khamisiyah ammunition storage
area.
Sep 1996. DoD announced notifications of some 5,000 service members who were in the possible
dispersal area of chemical agent from munitions demolition at Khamisiyah.
Sep 1996. Deputy Secretary of Defense White broadened Defense Department investigative
actions on Persian Gulf Veterans illnesses.
Oct 1995. DoD prints a message on leave and earnings statements for active duty personnel
regarding availability of the CCEP and the incident reporting 800 lines.
Jul 1995. GulfLINK established. GulfLINK is a worldwide web site on DefenseLINK, which
contains information specific to Gulf War issues: hotline numbers, reports issued by the Department
regarding the CCEP, information gleaned from declassified documents, list of DoD medical facilities
offering CCEP examinations, among others.
May 1995. Toll-free Gulf War Incident Reporting Line established.
May 1994. Letter mailed to all Gulf War veterans who separated from service following Gulf
deployment. The letter explained the formation of the CCEP.
Benefits and Compensation Efforts:
Sep 1993. Instituted a policy to define Gulf War Veterans' Illnesses for Physical Evaluation Boards
(PEB) ratings.
Investigation:
Oct 1996. Directed Army Inspector General to conduct inquiry into Khamisiyah.
Mar 1995. Established the Persian Gulf Investigation Team (PGIT) to analyze classified and
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declassified material related to the illnesses of Gulf War veterans. The team was created to integrate
information from operational, intelligence, medical and research data bases and coordinate with other
DoD agencies, the DVA, the CIA and other non-governmental organizations.
Mar 1995. DoD establishes the Senior Level Oversight Panel chaired by the Deputy Secretary of
Defense and consisting of the Director of the Defense Intelligence Agency, the Principal Deputy
Assistant to the Secretary of Defense for Atomic Energy, the Assistant Secretary of Defense for
Health Affairs, the Under Secretary of the Army, the Deputy Assistant Secretary of Defense for
Intelligence and Security, and the Deputy Director for Current Operations of the Joint Staff.
Declassification Efforts:
Oct 1996. Conducting a review of previously classified documents to determine whether any relate
to chemical exposure or environmental agents relevant to Gulf War veterans' illnesses and should be
declassified.
Oct 1996. Status report: DoD Declassification Project has reviewed over 5.4 million pages of
operational and intelligence information. Seven-hundred sixty-four thousand pages have been
provided to the Persian Gulf Investigation Team for further review and 34,600 pages of information
have been posted onto GulfLINK.
Mar 1995. Establishes a declassification effort encompassing all DoD records in the research,
medical, operational and intelligence communities that could relate to possible causes of the gulf War
veterans' illnesses. The Army is the Executive Agent.
Force Protection Efforts:
Jan 1996. Based on "lessons learned" in the Gulf War, DoD refines guidelines for medical
surveillance during deployments. Changes include improvements to the collection of data on health
and environmental issues and potential exposures and strengthening the training to deploying troops
regarding health risks and potential exposures.
1996. Developing the Joint Service Warning and Reporting Network (JWARN), an integrated,
nuclear, biological and chemical (NBC) agent detection, warning and reporting system capable of
interfacing with all NBC sensors and detectors.
1996. Modified the Navy's Improved Point Detection System (IPDS) to reliably detect chemical
warfare agents at 90 parts per billion within 30 seconds. The IPDS has also been modified to reduce
the false alarm rate caused by non-toxic agents typically found in a 'dirty' environment.
1996. Initiated procurement of over 10,000 Automatic Chemical Agent Detectors (ACADA).
ACADA registers significantly fewer false alarms.
1996. Developing the Joint Service Lightweight Stand-off Chemical Agent Detector (JSLSCAD)
to scan a wide field of view and automatically detect nerve or blister agents at a distance of up to 5
kilometers.
1994. Developing the Joint Service Lightweight Integrated Technology (JSLIST is a next-
generation form of individual protective equipment). The JSLIST is as effective as earlier protective
equipment, but is more lightweight, durable and cooler than its predecessor. Jan 1997 Update:
Currently in testing stage; fielding expected in Mar 1997.
1994. Emphasized "joint service" approaches to chemical detection research, development and
acquisition. The Joint Service Chemical Miniature Agent Detector is a two-year old cooperative
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effort underway to develop a family of miniature chemical agent detectors for all Services that will
provide near real-time information of the presence of chemical agents.
1991. Acquired and fielded a prototype of the improved Chemical Agent Monitor (ICAM). ICAM
will reduce required maintenance without lessening the monitor's performance.
Research Efforts:
Peer Reviewed Research Announcements
Dec 1996. Requesting proposals for independent research studies from non-federal agencies and
academic institutions on possible causes and treatment of Gulf War veterans' illnesses. Two million
dollars has been set aside for these proposals which will address the feasibility of epidemiological
studies in human subjects, including those thought to be near Kamisayah, and conduct animal studies
designed to assess the possible long-term or delayed clinical effects of low-level or subclinical
exposures to chemical agents which are insufficient to cause acute sighs or symptoms.
May 1996. Requested proposals for independent research studies from non-federal agencies and
academic institutions on possible causes and treatment of Gulf War veterans' illnesses. The U.S.
Army Medical Research and Materiel Command (USAMRC) released the request of research
proposals on behalf of the DoD, VA and HHS. June 1996 Update: $7.3 million was awarded for 12
research studies on epidemiological studies; health effects of PB alone and in combination with other
chemicals; and clinical studies and other research on the causes, modes of transmission and
appropriate treatments for Gulf War-related illnesses.
Combat Stress
Due 1999. A study on Combat Stress Pharmacotherapy. The study objective is on developing
countermeasures to casualties of stress.
Due 1999. Dysregulation of the Stress Response in the Persian Gulf Syndrome. The purpose of this
study is to demonstrate that objective neurohormonal abnormalities in the human 'stress response' are
present in Gulf War veterans with unexplained multiple symptons similar to fibromyalgia, chronic
fatigue syndrome, somatoform disorder, multiple chemical sensitivity and that these neurohormonal
abnormalities are at least partly responsible for these symptons.
Due 1998. Combat Stress Diagnosis, PTSD Prevention. The study's objective is to develop
diagnostic instruments for far-forward, early diagnosis of soldiers at risk for combat stress reaction
(CSR) and posttraumatic stress disorder (PYSD) to allow early intervention to prevent chronic PTSD.
Cancer
Due 1999. Gulf War and Vietnam Veterans Cancer Incidence Surveillance. Purpose: To examine
the pattern of cancer diagnosed in Massachusetts Vietnam veterans as compared with Vietnam-era
veterans for the time period 1988-1993. Another objective is to establish a database linkage for New
England area Persian Gulf War veterans so as to be able to examine cancer incidence in this cohort at
a later point in time.
Pyridostigmine Bromide (PB) Studies
Due 1999. Neurobehavioral and Immunological Toxicity of Pyridostigmine, Permethrin, and
DEET in Male and Female Rats. This study's objectives is to determine the effects of small doses,
alone of in combination, in males and females.
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Due February 1997. A study on Male/Female Differential Tolerances to Pyridostigmine Bromide.
March 1995. Initiated a Pyridostigmine Synergistic Study to determine potential toxic interactions
when pyridostigmine bromide, permethrin and DEET are given concurrently to male rats by gastric
lavage. In addition, DoD analyzed concerns about possible synergism of PB taken by service
members during the Gulf War. Report published May 31, 1995. The principle finding is that there is
significant increase on the lethal effect in rats given PB, permethrin and DEET simultaneously by
gavage when compared to expected additive lethal effect of the individual compounds.
May 1992. Launched retrospective studies involving military use of Pyridostigmine (PB) as a
pretreatment for nerve agent poisoning initiated with the FDA to help perform retrospective
evaluation of effects of PB use in the Persian Gulf. Completed May 1992. Results indicated that
pyridsotigmine continues to be safe. Side effects reported were primarily gastrointestinal in nature.
Headaches were also reported by the respondents.
Infectious Diseases
Sep 2001. Forward Deployable Diagnostics for Infectious Diseases. Ongoing.
Jan 2000. Development of a Leishmania Skin Test Antigen (LSYA). The study objective is to
develop a reliable skin test for Leishmania infection.
Jul 1998. Identification of the Genetic Factors Which Control Tropism in Leishmania. Ongoing.
1997. Serologic Diagnosis of Viscerotropic Leishmaniasis (VTL) The goal of the study is to
identify an antibody-based serologic assay to detect active infection with Leishmania parasites
causing the clinical syndrome of VTL using a standard format such as enzyme-linked immunosorbent
assay. To date, none of these peptides reliably discriminates infected from noninfected samples.
Low-Level Chemical Exposure Studies
Due 1998. A DoD study on Chronic Organophophorus Exposure and Cognition. This study will
evaluate the effects of low-level sub-chronic exposure to an organophosphorus cholinesterase
inhibitor on normal cognitive function in animal models. The long term goals are to identify the
underlying mechanisms of organic brain damage related to environmental toxins to develop novel
treatment strategies to improve memory/cognitive performance in affected patients.
Oil Well Fire Studies
May 1993. Kuwait Oil Fires Troop Exposure Assessment Model (TEAM). This aim of the model
is to address the risks to DoD troops located at the eight fixed air/soil sampling sites where actual
environmental data were collected and analyzed. This project is ongoing. A majority of the data hae
been entered into the system. Both satellite plume and modeled plume boundaries have been
digitized. Over 2,000,000 records have been entered into the TEAM database.
May 1991. Kuwait Oil Fire Health Risk Assessment. This environmental monitoring study
attempted to characterize the concentration of pollutants that DoD personnel were exposed to during
their deployment in the Gulf region. Completed Feb 1994. The results indicate the potential for
significant long-term adverse health effects for the exposed DoD troop or civilian employee
populations is minimal.
Other fuels
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Due 1998. Characterization of Emissions from Heaters Burning Leaded Diesel Fuel in Unvented
Tents. The objective is to conduct a study that simulates human exposure to aerosols in invented tents
heated by leaded diesel fuel, with the tent and fuel composition similiar to those used in the Persian
Gulf, so that the contribution of exposure to this in-tent pollutant can be estimated.
Depleted Uranium Studies
Due 1998. Carcinogenicity of Depleted Uranium Fragments. Study began Jan 1995. The objectives
of this study is to assess the carcinogenic risks associated with long-term exposure to DU-containing
shrapnel in wounds.
Due 1998. Health Risk Assessment of Embedded Depleted Uranium: Behavior, Physiology,
Histology and Biokinetic Modeling. The objectives of this study is to evaluate health risks associated
with tissue-embedded depleted uranium (DU) fragments by studying the behavioral, physiological,
and histological consequences of implanted DU in a rodent model.
1994. Kuwait Oil Fire Health Risk Assessment. Completed.
1993. Report to Congress: Health Consequences of the exposure of PG Force members to the
Fumes of Burning Oil. Completed.
Birth Outcome Studies
Due 1997. DoD, VA and CDC are conducting three epidemiological studies that addresses the
issue of adverse reproductive outcomes among a number of health related topics.
-Study 1: A comparative study of pregnancy outcomes among Gulf War veterans and other active-
duty personnel. Current status: data collected, manuscripts being prepared.
-Study 2: Infertility and Miscarriage in Gulf War veterans. Current status: Data collection stage.
-Study 3: Prevalence of Congenital Anomalies Among Children of Gulf War veterans. Current status:
Data collection stage.
June 1994. U.S. Air Force epidemiologists reviewed pregnancy outcomes among families of Gulf
War veterans assigned to Robins AFB, Georgia. Congenital malformations and miscarriages in
USAF personnel assigned to Robins AFB were at or below those of the U.S. general population.
Jan 1994. Conducted an investigation on 6,392 pregnancies occurring at six selected Army
hospitals comparing miscarriage rates for Pre-Desert Storm (1990) and Post-Desert Storm (1991).
Results showed that there was no difference among the populations (8% for both time periods -
which is almost half that experienced in the general population (15%)).
Sep 1993. The Army conducted a study at William Beaumont Army Medical Center examined the
postulation that emotional stress and exposure to chemicals were risk factors for spontaneous
abortion or miscarriage. Miscarriage rates before and after the Gulf War deployment were evaluated.
The results showed no difference in the rates.
Health Risk Assessment Studies
Due 1998. Study on Acute and Long-Term Impact of Deployment to Southwest Asia on the
Physical and Mental Health of Soldiers and their families.
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Due 1997. Epidemiologic studies of Morbidity among Gulf War veterans: A search for Etiologic
Agents as Risk Factors (this is one of the seven epidemiologic studies, of which the three birth
outcome studies are included).
January 1995. Released a Comparative Mortality Study among U.S. Military Personnel Worldwide
during Operation Desert Shield and Desert Storm. Results: Except for hostile action deaths, the
overall mortality experience among U.S. military personnel who deployed to the Gulf War did not
significantly differ from that observed among U.S. military who did not deploy to the Gulf.
Nov 1994. The Pennsylvania State Health Department, VA and DoD requested that CDC conduct
an independent evaluation of a group of Air National Guard Gulf War veterans for any pattern of
unusual illnesses. Phase 1 and 2 completed. Results: Phase 1 found no consistent abnormalities
identified on physical examination. Phase 2 established that in all units, symptom rates (symptoms
being fatigue, mood and cognition
disorders and musculoskeletal complaints) were higher in veterans who had been deployed to the
Gulf than in those not deployed.
Nov 1992. Released a report on the Navy Seabee outbreak investigation.
Sep 1992. Reported that the Army has directed a standing operating procedure for evaluating
afflicted Persian Gulf veterans.
Aug 1992. Released a memo from Area Medical Clinic Director, Dhahran, Saudi Arabia, reporting
no mystery illness in the local population of Saudi and American citizens.
Mar 1992. Released a study on the Indiana outbreak investigation done by Walter Reed Army
Institute of Research (WRAIR).
Jan 1992. Published a summary of Health Risk Assessment of the 11th Armored Cavalry
Regiment.
This fact sheet is not intended to be all inclusive, but instead present a representative sample of
past, present and future DoD efforts.
As of Jan 7, 1997
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Testimony
Testimony on Gulf War Veterans' Illnesses by Drue H. Barrett,
Ph.D.
Division of Environmental Hazards and Health Effects
National Center for Environmental Health
Centers for Disease Control and Prevention
U.S. Public Health Service
U.S. Department of Health and Human Services
Before the House Committee on Government Reform, Subcommittee on
National Security, Veterans' Affairs and International Relations
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February, 2000
CONTACT US
Mr. Chairman, thank you for the opportunity to update the Subcommittee on the
Centers for Disease Control and Prevention's (CDC) research programs pertaining to
Gulf War veterans' illnesses and to discuss the General Accounting Office's (GAO)
report, "Gulf War Illnesses: Management Actions Needed to Answer Basic Research
Questions." I am Dr. Drue Barrett, Chief of the Veterans' Health Activity Working
Group in the Division of Environmental Hazards and Health Effects of the National
Center for Environmental Health (NCEH). I serve as CDC's liaison to the Department
of Health and Human Services (HHS) on Gulf War issues and I am a member of the
Research Working Group of the Persian Gulf Veterans Coordinating Board. NCEH
has been designated as the lead Center at CDC for addressing Gulf War veterans'
health concerns, however other Centers within CDC have also been involved in this
effort, most notably, the National Center for Infectious Diseases.
The purpose of my testimony is to update the Committee on the extent of CDC's Gulf
War research activities, the productivity of our research efforts, and how our research
has been coordinated with the research being conducted by other Federal agencies.
Completed CDC-funded Gulf War Studies:
Before describing our current studies, I would like to review the results from two
completed CDC-funded studies because these studies are pertinent to questions raised
by the GAO regarding the success of the federal government in documenting the
symptoms of Gulf War veterans. The Iowa study, conducted in collaboration with the
Iowa Department of Public Health and the University of Iowa, was one of the first
population-based epidemiologic studies to document that Gulf War veterans are
reporting more medical and psychiatric conditions than their non-deployed military
peers. In fact, this study was recently described by the Institute of Medicine as "perhaps
the strongest study on Gulf War veterans' experience of symptoms related to
deployment in the Gulf." The 3,695 subjects who completed this study were selected
from a larger population of almost 29,000 military personnel who listed Iowa as their
home of record. Furthermore, the subjects in this study were specifically selected to
represent individuals from all four branches of the military, and include both regular
military personnel and National Guard and reservists. Seventy-six percent of the
eligible study subjects completed the detailed telephone interviews. This study is also
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one of the first controlled epidemiological studies to evaluate the health consequences
of the Gulf War. The study included a carefully selected comparison group of military
personnel who were not deployed to the Persian Gulf but who served during the time
of the Gulf War. The Iowa study found that the Gulf War military personnel were
more likely than those who did not serve in the Gulf War to report symptoms
suggestive of cognitive dysfunction, depression, chronic fatigue, post-traumatic stress
disorder, and respiratory illness (asthma and bronchitis). The conditions identified in
this study appear to have had a measurable impact on the functional activity and daily
lives of these Gulf War veterans. Among Gulf War veterans, minimal differences
were observed between the National Guard or reserve troops and the regular military
personnel.
The results of the Iowa study were published in the Journal of the American Medical
Association in 1997. In addition, a number of other manuscripts from the Iowa study
have been published, are in press, or are currently in the process of peer review. These
include an article on quality of life and health service utilization among military
personnel reporting multiple chemical sensitivities, published in 1999 in the Journal of
Occupational and Environmental Medicine, and an article on symptom prevalence and
risk factors of multiple chemical sensitivities, in press in the Archives of Internal
Medicine. Manuscripts are currently being considered at peer-reviewed journals on the
topics of defining a Gulf War syndrome, the relationship between post-traumatic stress
disorder and physical health status, and self-reported injuries among Gulf War
veterans.
Likewise, the CDC Air Force study has significantly contributed to our understanding
of the health consequences of the Gulf War. This study organized symptoms reported
by Air Force Gulf War veterans into a case definition, characterized clinical features,
and evaluated risk factors. The cross-sectional questionnaire was sent to 3723 currently
active volunteers from four Air Force populations. Clinical evaluations were performed
on 158 Gulf War veterans from one unit, irrespective of health status. A case was
defined based on reporting one or more chronic symptoms from at least 2 of 3
categories (fatigue, mood-cognition and musculoskeletal) and was further characterized
as mild-to-moderate or severe depending on the severity of the reported symptoms. The
prevalence of mild-to-moderate and severe cases were 39% and 6%, respectively,
among 1155 Gulf War veterans versus 14% and 0.7% among 2520 non-deployed
veterans. Fifty-nine (37%) clinically evaluated Gulf War veterans were non-cases, 86
(54%) were mild-to-moderate cases and 13 (8%) were severe cases. The key
observation of the study was that Air Force Gulf War veterans were significantly
more likely to meet criteria for severe and mild-to-moderate illness than were non-
deployed personnel. There was no association between the chronic multisymptom
illness and risk factors specific to combat in the Gulf War (month of season of
deployment, duration of deployment, duties in the Gulf War, direct participation in
combat, or locality of Gulf War service). The finding that 15% of non-deployed
veterans also met illness criteria was equally important and suggests that the
multisymptom illness observed in this population is not unique to Gulf War service.
The clinical evaluation component of the study found that neither mild-to-moderate nor
severe cases were associated with clinically significant abnormalities on physical
examination or routine laboratory tests. However, Gulf War veterans classified as
having mild-to-moderate and severe illness had a significant decrease in functioning
and well-being compared with non-cases.
The results from this study were published in CDC's Morbidity and Mortality Weekly
Report in 1995 and in the Journal of the American Medical Association in 1998. In
addition, an article from the Air Force study examining the relationship between
deployment stressors and chronic multisymptom illness is currently in press in the
Journal of Nervous and Mental Disorders.
Current CDC-funded Gulf War Studies:
CDC is currently funding a follow-up to the Iowa study focusing on evaluating self-
reported symptoms of asthma. This study involves a detailed clinical evaluation of a
sample of subjects who completed the initial telephone survey. This evaluation includes
a physical examination; tests of lung functioning; questions regarding medical,
occupational, and exposure history; assessment of functional status and quality of life;
and assessment of psychiatric history and personality functioning. The examinations
are being conducted at the University of Iowa Hospitals and Clinics in Iowa City, Iowa.
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This study is in its final phases of data collection and we anticipate that results should
be available later this year.
The University of Iowa has also been funded by the Department of Defense (DoD) to
conduct validation studies of additional health outcomes among participants of the
telephone survey. These include validation of depression, cognitive dysfunction, and
fibromyalgia. CDC is providing technical assistance to DoD and the University of Iowa
for this study.
We are also funding the Boston University School of Public Health to conduct a study
examining the relationship between cognitive function and symptom patterns among
Gulf War veterans. In one component of this study, functional magnetic resonance
imaging (fMRI) is being used to examine possible differences in brain activation
patterns between Gulf War veterans and era controls with different levels of
symptoms. A second component of the study is using a new data-driven mathematical
technique, Logical Analysis of Data, to examine how Gulf War veterans' symptoms
cluster together. This may provide useful information for determining etiology or for
developing a case definition. Finally, this study also includes a component examining
the neuropsychological functioning of a sample of Danish Gulf War troops.
Investigators are currently in the data collection phase for the fMRI component of this
study and in the data analysis phase for the other two components. We anticipate that
this study will be complete by the end of this year.
Finally, CDC is funding the University of Medicine and Dentistry of New Jersey-
Robert Wood Johnson Medical School to conduct a study examining case definition
issues. The study will assess the persistence and stability of Gulf War veterans
symptoms over time, compare the performance of data-driven case definitions to
existing definitions for medically unexplained symptoms, and examine the role of
psychiatric conditions in Gulf War veterans' unexplained illnesses. We originally
expected that this study would be completed in late 2000, however the process of
protocol development and clearance took somewhat longer than we anticipated. Thus,
we expect that this study will require an additional year to complete.
Research Collaborations:
CDC is collaborating with DoD and the Department of Veterans Affairs (VA) on a
number of projects including a study of health outcomes among Saudi Arabia National
Guard members and a study of Amyotrophic Lateral Sclerosis (ALS) among Gulf War
veterans. This collaboration has included providing input on study protocols,
reviewing human subjects issues, and assisting in laboratory assessments.
Future Gulf War Research Planning:
In addition to these current research projects, CDC, in collaboration with other HHS
agencies, recently sponsored a conference to develop future Gulf War research
recommendations. On February 28 through March 2, 1999, CDC brought together
scientists, clinicians, veterans, veterans' service organizations, Congressional staff,
and other interested parties to discuss and make recommendations regarding the
direction of future research on undiagnosed illnesses among Gulf War veterans and
their links with multiple chemical and environmental exposures.
Concurrent workgroups were convened in order to develop research recommendations
in four areas: pathophysiology, etiology, and mechanisms of action; assessment and
diagnosis of illnesses; treatment; and prevention of illnesses in future deployments.
This conference highlighted the importance of including veterans in the process of
planning and implementing research. Veterans and scientists alike expressed that they
found the process useful and that future similar efforts should be encouraged. A report
is soon to be released that summarizes the outcome of each of the four workgroup
sessions. It is anticipated that this report will be of interest to a broad range of
individuals and organizations and may provide the basis for development of new
research collaborations and exchanges. Recommendations for new research will need
to be considered in light of the existing research portfolio of the Research Working
Group in order to avoid unnecessary duplication of efforts.
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Coordination of Federal Research Efforts:
Finally, I would like to address the issue of coordination of federal research efforts.
There has been HHS representation on the Persian Gulf Veterans Coordinating Board
Research Working Group since its inception. In addition to CDC, the Office of the
Secretary, the National Institutes of Health, and the Agency for Toxic Substances and
Disease Registry are represented. Through its membership, HHS has been involved in
providing guidance and coordination for DoD, VA, and HHS research activities
relating to Gulf War veterans. Specifically, this has included assessing the state and
direction of research, review of government research concepts as they are developed,
identification of gaps in factual knowledge and conceptual understanding, and
providing recommendations regarding research direction.
The Research Working Group also serves as a forum for research data exchange among
the three departments and among federally funded investigators. CDC's role in this area
has included providing information on the status of projects for a research database of
all VA, DoD, and HHS research activities, input on the Annual Report to Congress on
federally sponsored Gulf War Veterans' Illnesses research, and participation on the
planning committee for the federal investigators meeting where new research results
are shared.
Conclusions:
An intensive research effort to address Gulf War veterans' health concerns has been
mounted by federal agencies and non-governmental scientists. As of 1999, there have
been 145 federally-funded research projects on Gulf War veterans' illnesses with a
cumulative expenditure of $133.5 million for research from FY94 through FY99.
These projects represent a broad spectrum of research efforts, ranging from small pilot
studies to large-scale epidemiology studies addressing mechanistic, clinical, and
epidemiological issues. Similar efforts have been initiated in other coalition countries,
most notably in the United Kingdom and Canada. In addition, numerous review panels
and expert committees have evaluated the available data on Gulf War veterans'
illnesses. As noted in the GAO report, despite these extensive research and review
efforts, many questions remain regarding the health impact of the Gulf War. However,
these remaining questions do not reflect scientific indifference; instead they reflect the
complexity of assessing and predicting the health impact of military deployments.
Despite this complexity, the federal research effort continues in an effort to uncover the
causes of illnesses among Gulf War veterans so that effective treatment approaches
can be developed and similar illnesses in future deployments can be prevented.
Mr. Chairman, this concludes my testimony. I would be happy to answer any questions
the Subcommittee may have.
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THE PERSIAN GULF VETERANS
COORDINATING BOARD
ACTION PLAN
WITH RESPECT TO
THE FINAL REPORT OF
THE PRESIDENTIAL ADVISORY COMMITTEE ON
GULF WAR VETERANS' ILLNESSES (PAC)
CHAPTER 2: THE GOVERNMENT'S RESPONSE
Findings and Recommendations Regarding Outreach
Finding 2-1: In their geographic areas, Vet Center staffs have established working
relationships with the veterans community, veterans service organizations, local municipal
and state veterans liaison offices, in-region Guard and Reserve units, community social
services organizations, local Department of Veterans Affairs (VA) medical center personnel,
and military establishments. These relationships enable Vet Centers to provide education
and outreach to local communities about issues and clinical programs concerning Gulf War
veterans, and a significant number of Gulf War veterans use their services.
Finding 2-2: The outreach initiative of VA's Persian Gulf Family Support Program was an
effective method of communicating information about Gulf War veterans illnesses--in
particular the established government clinical programs--to veterans, Reservists, National
Guard members, and local communities. The outreach component used trained,
knowledgeable personnel in the field to establish a communication network with the
community and deliver specific information directly to Gulf War veterans.
Recommendation: Department of Defense (DoD) and VA should follow the model of
field-based outreach demonstrated in the Vet Centers and the Persian Gulf Family Support
Program when developing health education and risk communication campaigns for active
duty service members, Reserve and Guard personnel, and other veterans. General, less
specific outreach methods--e.g., hotlines and public service announcements--should be
viewed as an important supplement, but not as replacements.
Response: Concur. After the conclusion of the Persian Gulf War in 1991, Vet Center
services were made available to those who served in the Persian Gulf. These Vet
Centers had seen over 25,000 Persian Gulf veterans by the summer of 1992. This
prompt response by the Vet Centers to the acute Post-Traumatic Stress Disorder (PTSD)
and other post-war readjustment difficulties, such as family and employment problems,
illustrates VA's commitment to early intervention and outreach. As of September 30,
1996, Vet Centers had seen more than 74,000 Persian Gulf veterans.
VA can apply the same successful Vet Center strategy of targeting specific
veteran populations, developing intensive networks, and creating referral relationships
with other community agencies to formulate health education and risk communication
campaigns. These field-based risk communication and health education outreach
programs will be directed specifically at Persian Gulf veterans, and Reserve and Guard
personnel. Persian Gulf veterans and their families will be invited to participate, as
appropriate, in future VA outreach and focus sessions, so VA can provide them with
risk communication and health education information and learn more about their health
care needs.
VA's annual National Training Program conferences update VA medical center
Persian Gulf Registry physicians, health care professionals, and Vet Center service
providers on the latest information available from the clinical and scientific studies of
Persian Gulf veterans' illnesses. Risk communication and health education issues will
continue to be included in future National Training Program continuing medical
education conferences. VA health care providers attending these conferences will be
able to recognize the most common symptoms and diagnoses of Persian Gulf veterans
and communicate potential health risks of Gulf War service to their patients.
DOD agrees that a strengthened "field-based" outreach system is needed to
address post-deployment follow-up. Likewise, DOD has in place an extensive system
available for outreach to active duty service members and their families and to Reserve
and Guard personnel who are currently associated with DOD. DOD is committed to
better using that system, including the command structure, both for Gulf War veterans
and for future post-deployment follow-up. As one example, with respect to active duty
personnel and their families, DOD will use the Family Service Centers which can
achieve the effectiveness of the VA field-based model. Liaison between the Assistant
Secretary of Defense (ASD)/Health Affairs and the ASD(Force Management
Policy)/Personnel Support, Families and Education will result in a more effective
strategy to use existing organizational resources to ensure appropriate dissemination of
information. DOD will also make better use of its health personnel with respect to
health education and risk communication. These health personnel, including frontline
medics, are located throughout the world with our active duty personnel and are
supporting active duty personnel and their families on a daily basis.
The Office of the Special Assistant for Gulf War Illnesses has in place an
outreach office which aggressively performs call-backs to follow-up on hotline calls.
This is the first over-arching DOD effort to establish two-way communication in the
form of a true dialogue versus only receiving information. These call backs not only
provide an in-depth debrief, but also, a single point of contact between the Office of the
Special Assistant for Gulf War Illnesses and the reporting Gulf War veteran for the
future. The process involves the veteran in the incident investigation process in a
significant and meaningful way. DoD's medical-treatment facilities (MTFs) at military
installations nationwide offer medical outreach and treatment for Gulf War veterans. As
service members call the Comprehensive Clinical Evaluation Program (CCEP) Hotline,
their first callback is from the nearest MTF to schedule their evaluation.
DOD is in the process of developing a new more proactive GulfLINK website to
include adding a Frequently Asked Questions (FAQ) page to address some of the
common concerns of those who served in the Gulf, their family members, and the
general public. Two-way E-mail will also be added to GuItLINK to allow users to
quickly query experts from the Office of the Special Assistant and receive an expeditious
reply. The intent is to publish all available public information as well as periodic status
reports on investigations in progress in a timely manner.
DoD will employ nationally recognized experts in the field of risk
communications to develop a DoD strategic plan that is: (1) fully coordinated and
integrated with the Persian Gulf Veterans Coordinating Board (PGVCB) plan; (2)
provides for the conduct of risk communication training for all DoD personnel involved
with direct public interface; (3) seeks the advice of experts on specific events or issues
affecting our veterans; and, (4) allows for the review of all products to ensure the most
effective dissemination of information. Additionally, DoD recognizes that feedback is
an important aspect of risk communication and will ensure the measures are in place to
evaluate the effectiveness of this communication plan.
VA has a long-standing relationship and communication network with Veterans
Service Organizations (VSOs). Additionally DoD's Office of the Special Assistant for
Gulf War Illnesses is establishing relationships with member organizations of the
Military Coalition that are critical to providing information at the local level. The
objective is to share information with the Military Coalition Organizations (MCOs)
nationwide, and to invite their participation in information-sharing, investigations and a
search for solutions process. This includes encouraging publications of information in
Military Coalition organization newsletters and magazines, presentations and briefs, and
demonstrations of military equipment that pertains to the detection and identification of
chemical warfare agents.
The PGVCB will incorporate these activities into the comprehensive risk
communication plan.
Finding 2-3: Ninety percent of separating active duty service members attend Transition
Assistance Program (TAP) workshop briefings conducted jointly by DoD, VA, and DOL.
VA benefits briefings during the TAP workshop could be an effective method of outreach
about DoD and VA programs for evaluating Gulf War veterans illnesses, yet there is no
evidence their clinical programs receive mention.
Recommendation: VA should direct its Transition Assistance Program workshop benefits
counselors to specifically mention DoD and VA programs related to Gulf War veterans'
illnesses.
Response: Concur. The outcome outlined by the recommendation is a part of Veterans
Benefits Administration's (VBA) transition assistance briefings. We agree that VA
benefits briefings conducted in association with TAP workshops are an effective
method of outreach to Gulf War veterans. To ensure the effectiveness of these
briefings, the Veterans Services Program Staff (VSPS) (which is responsible for TAP
administration within VA) provides Military Services Coordinators (MSCs) with
materials and/or guidance related to briefing content.
The VSPS has previously directed MSCs to include Gulf War issues in their
benefit presentations. In addition, VSPS creates and distributes overheads,
photographic slides, fact sheets, and pamphlets for use in benefit presentations. The
latest version of the slides includes a series covering the following Persian Gulf War
issues: (1) disability compensation for undiagnosed illnesses; (2) the types of evidence
needed to support compensation claims for undiagnosed illnesses; (3) other VA
programs or services available to Gulf War veterans and their families; and, (4) toll-free
numbers that service members may call for more detailed information and assistance.
The VSPS has distributed a revised set of transparencies to MSCs which provide
more information about VA and DoD programs for Gulf War veterans. These
transparencies stress the importance of continued discussion of VA and DoD programs
for Gulf War veterans during benefit briefings.
DoD supports this approach and the DoD Director of Transition Support and
Services will coordinate with the VA and help ensure that information on DoD and VA
clinical Persian Gulf veterans health care and compensation programs is effectively
provided to separating active duty service members. The Compensation and Benefits
Working Group of the PGVCB will monitor this process and explore options for
improvement.
Finding 2-4: Through the initiatives of the Women Veterans Health Programs, VA has
implemented a range of efforts to inform women veterans about available health services.
Recommendation: VA should ensure that its initiatives under the Women Veterans
Health Programs specifically provide information about Gulf War-related programs.
Response: Concur. Operations Desert Shield and Desert Storm involved the largest
deployment of women to a war zone in our nation's history; women composed 7 percent
of the approximately 697,000 deployed troops. VA's Office of Public Health and
Environmental Hazards is the Veterans Health Administration (VHA) program office
for both the Women Veterans Health and Persian Gulf Veterans Programs. In the past,
the Office has coordinated VA program planning in these two areas. VHA is committed
to long term continuation of these efforts as they relate to medical care, research
outreach and education for Women who served in the Persian Gulf War. Information
will be included regarding Gulf War-related women veterans' programs in both Persian
Gulf and Women Veterans Health communications and education programs in May and
June 1997.
The Clinical Working Group (CWG) of the PGVCB will monitor these efforts
and explore options for improvement.
Finding 2-5: In regions with significant Latino populations, Veterans Centers and
VAMCs deliver bilingual, cross-cultural outreach services.
Recommendation: VA should ensure that its outreach to Latino
populations specifically provides information about Gulf War-related programs.
Response: Concur. In 1996, VA published and distributed copies of the first Spanish
language version of Federal Benefits for Veterans and Dependents entitled "Beneficios
Federales Para Veteranos y Sus Dependientes." The Spanish language benefits book
was distributed to all VA Regional Benefits Offices and VA Medical Centers with
significant Latino populations. This booklet provides information regarding
compensation benefits for chronically disabled veterans who suffer from undiagnosed
illness believed to be the result of their service in the Gulf. In addition, Gulf War
veterans are informed about the Persian Gulf War Registry Program and special
eligibility for any Persian Gulf War veteran who may have been exposed to a toxic
substance or environmental hazard during the Gulf War. The Spanish language version
of the benefits book also lists the Persian Gulf Veterans information phone number
(800-PGW-VETS). VA will redistribute a 1997 version of the Spanish language
benefits book later this year. VA will also conduct Spanish language print, radio and
television interviews designed to inform Gulf War veterans of their benefits as well as
update them on VA's research agenda. In addition, VA is developing a new information
pamphlet for Gulf War veterans that will be distributed in English and Spanish by
Summer 1997.
Finding 2-6: While newspaper articles and television and radio broadcasts disseminated by
DoD's American Forces Information Service provide adequate media coverage of Gulf War
illnesses-related issues, few of the media products perform the outreach functions of
publicizing government-sponsored Gulf War veterans clinical programs and methods of
referral into them.
Recommendation: As the Committee stated in its Interim Report, DoD and VA should
develop and utilize more refined performance measures to determine how well outreach
services are reaching concerned parties. DoD and VA officials (specifically those in the
Armed Forces Information Service and its broadcasting arm, the Armed Forces Radio and
Television Service) using media products for outreach initiatives should be aware of the
difficulty in enumerating the actual readership and viewership figures and be concerned
about how effectively their message saturates the targeted population.
Response: Concur. VA conducted a Gulf War Veterans Public Service Announcement
(PSA) campaign in 1995 consisting of video, radio and print announcements. The
Committee's Interim Report recommended that the content of the announcements be
more specific regarding services available to and illnesses suffered by Gulf War
veterans. VA revised the PSAs and conducted another outreach campaign in 1996. VA
hired a media marketing firm to distribute the print, radio and television PSAs and
provide follow-up reports to VA regarding market penetration. In addition, VA
purchased satellite time to conduct one-on-one interviews with television stations in the
country's top media markets. These interviews afforded VA prime time viewership and
provided substantial outreach to Gulf War veterans and their families. VA's Regional
Public Affairs Offices will continue to augment its outreach effort by placing news
articles in regional media outlets to inform veterans and their families of available
benefits. Since the Interim Report, the VA Persian Gulf Helpline has begun to collect
data on how veterans heard about that service. A summary will be provided to the
Committee.
In late FY 96, DoD conducted a survey that addressed the awareness of the
CCEP and the Gulf War Incident Hotline in a representative sample of 54,000 active
duty and retired active duty Gulf War veterans. This survey indicated that a relatively
low proportion of active duty and retired active duty Gulf War veterans are aware of the
CCEP and the Incident Hotline. The survey findings will be useful in designing more
effective communication strategies for future outreach efforts. DoD agrees that there is
a need to assess which communications mechanisms are most effective for reaching
Gulf War veterans and will continue to do so in cooperation with the PGVCB.
A critical element of DoD's new Office of the Special Assistant for Gulf War
Illnesses is a public affairs/public outreach arm that is focused on reaching the public
through the organizations of the Military Coalition command information programs and
media channels. One of the primary charters of public outreach is to develop an
effective dialogue and to solicit feedback from veterans. The Office of the Special
Assistant will develop an assessment of all means of reaching out and informing the
public to include Armed Forces Information System (AFIS) and the Armed Forces
Radio and Television Service (AFRTS). This will be a part of DoD's strategic public
affairs plan and risk communication strategy as previously discussed (response to 2-2).
AFIS is a primary channel for disseminating information to active duty and reserve
component service members and their families. The information provided by AFIS and
used in installation and activity newspapers is available to all uniformed and civilian
personnel departmentwide. In addition, AFRTS is available to service members and
DoD civilians at 156 overseas locations and aboard ships at sea. The CCEP toll-free
number has been publicized through the Armed Forces Radio and Television Service,
and has been reported in over 1,100 DoD publications around the world. AFIS is also
available via the Worldwide Web. The CCEP hotline number will continue to be
publicized in numerous AFIS print and broadcast products. We will continue to make
our target audiences aware of the toll-free number and other important information on
Gulf War Illnesses.
These efforts will be incorporated into the PGVCB's comprehensive risk
communication plan.
Finding 2-7: DoD's 1996 Internal Information Plan--Persian Gulf Illnesses describes its
Comprehensive Clinical Evaluation Program, yet fails to provide the most basic information
on how to register for it.
Recommendation: DoD should reissue its Internal Information Plan on Gulf War related
illnesses. It should make a special effort to note the revision provides the toll-free number
and that individuals are encouraged to register for its Comprehensive Clinical Investigation
Program (CCEP). It also should take the opportunity to provide updated information.
Response: Concur. The AFIS Internal Information Plan (IIP) is a management plan
which lists broad topic areas to be addressed by DoD internal information media during
the year. Topics for FY 96 included subjects such as recycling, the flag, child abuse and
financial management. One page was allocated to each topic. Gulf War illnesses will
be included as a major focus in next year's plan. Additional public affairs guidance on
encouraging service members to register in the CCEP, how to register and publication
of the toll-free number will be issued.
The PGVCB risk communication plan will incorporate information on
registration for clinical examinations.
Recommendation: In an attempt to increase veterans' and the public's awareness and
understanding of the full range of the government's commitment to addressing the nature of
Gulf War veterans' illnesses, DoD and VA should reevaluate the goals and objectives of their
risk communication efforts. DoD and VA should develop effective methods that provide the
affected community with comprehensive information concerning possible exposures to
environmental hazards, potential health effects from risk factors, and explanations of
ongoing and completed clinical and epidemiologic studies.
Response: Concur. VA, DoD and the Department of Health and Human Services
(DHHS) will collaborate, through the PGVCB, to refine goals and objectives and
develop more effective methods for risk communication regarding Gulf War veterans'
illnesses. Risk communication will address possible exposure to hazards (chemical,
biological, and environmental hazards), explain potential health effects from these risk
factors, and provide information on studies on potential health risks and how to respond
to those risks. In that effort, DoD and VA will involve DHHS and their risk
communication experts as well as using the expertise of nationally recognized experts in
the field of risk communications.
Since June 1996, when the Defense Department first learned of the
potential exposure of our troops to chemical agents during the destruction of
ammunition and equipment at Khamisiyah, DoD has conducted an extensive
multimedia campaign designed to inform soldiers and veterans of the events at
Khamisiyah. Our coordinated and expanded outreach program asking soldiers to
provide information of their experiences at or near Khamisiyah and encouraging them to
seek assistance for health problems they believe may be a result of their service in the
Persian Gulf has been well-received, providing much new information and involving
thousands more veterans in the process.
In order to accomplish these goals, the PGVCB CWG will conduct a day-long
conference with risk communication experts to design a Gulf War veteran risk
communication plan. The plan will take into account the size and location of the Gulf
War veteran population and the existing communications tools of the Departments
including direct mail, newsletters, radio, print and television media. The goal of the
CWG will be to develop a risk communications plan that will be effective
communicating with Gulf War veterans and their families regarding information on
possible exposures to environmental hazards, potential health effects, treatment options
and ongoing research. The plan will be submitted to the Committee by May 1, 1997.
Finding 2-8: Effective risk communication is essential to the government's credibility on
Gulf War veterans' illnesses, but DoD and VA have not seriously attempted to educate
veterans about health effects of service in the Gulf War or to establish a dialogue concerning
research programs relevant to veterans' concerns.
Finding 2-9: Several federal agencies have developed, tested, and validated
techniques for health risk communication that could be adopted by DoD and VA.
Recommendation: DoD and VA should immediately develop and implement a
comprehensive risk communication plan. This effort should move forward in close
cooperation with agencies that have a high degree of public trust and experience with risk
communication, such as the Agency for Toxic Substances and Disease Registry (ATSDR)
and the National Institute for Occupational Safety and Health.
Response: Concur. The PGVCB will develop and implement a comprehensive risk
communication plan within the next six months. The Board recognizes that substantial
expertise exists within DHHS at the ATSDR, and National Institute for Occupational
Safety and Health (NIOSH), and will be collaborating with these agencies as well as
using the expertise of nationally recognized experts in the field of risk communications.
Recommendation: Because health risk information and education applies to service
members who remain on active duty and veterans no longer in military service, DoD and VA
should closely coordinate the federal government's risk communication effort for Gulf War
veterans and other members of the affected community. Departmental commitments to any
plan should be viewed as continuous and long-term; a sustained effort is particularly critical
in light of veterans' and public skepticism arising from the recent revelations related to
chemical weapons.
Response: Concur. The PGVCB agrees that the risk communication must be
coordinated, forward-looking, and dynamic with a commitment to long-term and
sustained communication to our Gulf War veterans.
DHHS, DoD and VA will work closely in sharing information. For example,
the PGVCB's CWG will provide their plain language fact sheets for dissemination to
veterans, family members and other interested parties on Gulf War-related topics.
Copies of these materials will be sent to the Committee for review by May 1, 1997.
DoD will make available the narratives on investigative activities as they become
available.
Recommendation: In its coordinated risk communication plan, DoD and VA should
engage MCOs and veterans service organizations as intermediaries--and include personnel in
leadership positions, such as senior enlisted personnel (for active duty military) and state
veterans' service officials--in the effort to establish an efficient information exchange process
where veterans receive accurate information and the departments receive valuable feedback
on clinical programs, health concerns, and communication efforts.
Response: Concur. VA and DoD are working towards development and
implementation of a comprehensive risk communication plan within the next six months
and with advice and assistance from ATSDR and NIOSH.
VA and DoD will closely coordinate the federal government's comprehensive
plan for disseminating clinical and epidemiological information to members of the
affected community and other interested parties through the interagency PGVCB. The
PGVCB's CWG is currently developing fact sheets on Gulf War-related issues for this
purpose. The CWG and Research Working Group (RWG) will collect information from
clinical investigations, epidemiological studies and basic research findings for
dissemination to veterans, health-care providers, researchers, and the general public.
VA and DoD view these risk communication efforts as a continuous long-term process,
and will maintain the activities necessary for accomplishing these objectives as. long as
the need exists.
VA and DoD agree that their coordinated risk communication plan should
engage veterans service organizations and include personnel in leadership positions,
such as senior enlisted personnel (for active duty military) and state veterans service
organization officials in the effort to establish an efficient information exchange process
where veterans receive accurate information and the departments receive valuable
feedback on clinical programs, health concerns, and communication efforts. VA has
long recognized the importance of involving stakeholders in developing health-care
programs and, along with DoD, will utilize this process for designing a comprehensive
risk communication plan. VHA will continue to use its monthly liaison meeting with
veterans service organizations to seek their advice and guidance, and receive feedback
on clinical programs, health concerns, and communication efforts. VSO representatives
serving on VA's Persian Gulf Expert Scientific Committee also serve as intermediaries
in the information exchange process.
In the interests of both providing Gulf War veterans with health-related
information and receiving feedback on DoD health programs, DoD will engage active
duty personnel, including senior enlisted personnel and officers, MCOs and VSOs,
working with VA, in the process of information exchange within the next six months.
Also, in response to the PAC findings, DoD established a veterans outreach
program designed to communicate information about Gulf War veterans' illnesses to
veterans and local communities. The Office of the Special Assistant for Gulf War
Illnesses communicates with MCOs and VSOs and feedback is received. In this
manner, the MCOs and VSOs can participate in the dissemination of information
regarding Gulf War Illnesses and ongoing efforts in providing care incident
investigation, research and education. At the same time, the MCOs and VSOs are able
to communicate to the outreach section the interests and concerns of the veterans
making up their organizations.
One action taken by DoD was a demonstration and review of the type of
chemical alarm and detectors used in the Gulf War. This demonstration, conducted on
December 11, 1996, was well-received with representatives from nearly 20
organizations attending. Additionally, VSO workshops were conducted on January 30,
and February 26, 1997. DoD will continue to host VSO workshops to stimulate a
dialogue with veterans.
Findings and Recommendations Regarding Medical and Clinical Issues
Finding 2-10: DoD has not been responsive to the Committee's recommendation that prior
to any deployment, DoD should undertake a thorough health evaluation, including a core set
of diagnostics, of a large sample of troops to enable better postdeployment medical
epidemiology along with timely postdeployment followup.
Recommendation: The PGVCB and other appropriate Departments and Agencies should
be charged to develop a protocol to implement the following recommendation which was
made in the Committee's Interim Report: Prior to any deployment, DoD should undertake a
thorough health evaluation of a large sample of troops to enable better postdeployment
medical epidemiology. Medical surveillance should be standardized for a core set of tests
across all services, including timely postdeployment followup.
Response: DoD concurs with this recommendation. Deployment medical surveillance
programs are composed of three major components involving pre-deployment health
screening and education, deployment operational, environmental, and medical
surveillance, and post-deployment health surveillance and risk communication.
DoD strongly agrees with the importance of pre-deployment health assessment.
The Department is developing a medical surveillance policy for deployments which
specifies a uniform concept for health screening. Rather than targeting sample
populations for assessment, the Department's position is that all deploying service
members of specified deployments receive pre- and post-deployment screening to
include standardized health screening questionnaires with medical follow-up as
clinically indicated. This policy was partially implemented in Bosnia and is being fully
implemented for Southwest Asia. We expect the new medical surveillance policy to be
formally adopted during 1997.
VA and DoD have expertise relevant to this program area. Deployment medical
surveillance planning and programs are of key importance to the success of future
deployments and veterans health. The planning required overlaps the responsibilities of
the CWG and RWG of the PGVCB. For these reasons, a fourth, newly constituted
Deployment Planning Work Group will be formed by the PGVCB to make
recommendations for appropriate action, coordinate interagency activities, and monitor
these important programs.
Finding 2-11: FDA is moving toward soliciting public comment on alternatives to the
Interim Final Rule related to permitting a waiver of informed consent for use of unapproved
products during military exigencies. The Committee remains seriously concerned about the
amount of time--currently exceeding six years--FDA is taking to open the process to public
comment.
Recommendation: FDA should solicit timely public and expert comment on any rule that
permits waiver of informed consent for use of investigational products in military
exigencies. Among the areas that specifically should be revisited are: adequacy of disclosure
to service personnel; adequacy of recordkeeping; long-term followup of individuals who
receive investigational products; review by an institutional review board outside of DoD;
and additional procedures to enhance understanding, oversight, and accountability.
Response: Concur. Since receiving the Committee's Interim Report, the Food and
Drug Administration (FDA) has carefully evaluated the Committee's recommendations
as well as other information that has come to its attention. FDA has engaged in
discussions within the agency, with the DoD, and with others on this important topic.
The issues that have been raised are complex and require extensive coordination. As a
result of these discussions, the FDA is preparing regulations that will solicit public
comment in line with the Committee's report. This public comment will be directed
toward whether the FDA should finalize the Interim Final Rule, modify it, or eliminate
it completely. As part of that process, FDA is exploring the approval mechanisms that
should be applied to drug and biological products that may be used in military or
civilian exigencies.
DoD agrees with the need for FDA to solicit timely public and expert comment
on rules that permit waiver of informed consent for use of investigational products in
military exigencies. DoD intends to work with FDA on ways to more expeditiously
process such rules in order to ensure that we have effective countermeasures to deal
with existing and new chemical and biological warfare threats. DoD agrees that, to the
full extent feasible, there should be disclosure to service personnel, good record-
keeping, and other procedures which enhance understanding, oversight and
accountability. As one example, the long-term follow-up of individuals who receive
investigational products such as pyridostigmine bromide (PB) will be enhanced by
current research into the potential interaction of DEET, Permethrin and PB, which is
being carried out at DoD laboratories as well as at the University of North Carolina and
the University of Florida.
Finding 2-12: DoD has not been responsive to the Committee's recommendation that it
should routinely inform recruits and troops, through orientation and training procedures,
about the possible use of investigational drugs or vaccines for chemical and biological
warfare agent proposed. DoD's lack of response in this highly sensitive area contributes to
the perception of many that U.S. troops were inappropriately subjected to investigational
drugs or vaccines during the Gulf War.
Recommendation: Given that FDA Interim Final Rule permitting a waiver of
informed consent for use of unapproved products in a military exigency is still in
effect, DoD should develop enhanced orientation and training procedures to alert service
personnel they may be required to take drugs or vaccines not fully approved by FDA if a
conflict presents a serious threat of chemical and biological warfare.
Response: Concur. Although medical personnel who participated in Operation Desert
Storm were thoroughly briefed about the side effects of PB, this information did not, in most
cases, get down to the individual service member. Some of the service members' concerns
could have been alleviated had they known that the side effects they experienced were, in
fact, attributed to the known side effects of PB, and which in most cases would go away as
the service member became tolerant to those effects of PB. To address this issue, all new
procurements, as well as existing stockpiles of PB, will contain appropriate labeling to
inform the individual service member of potential side effects and provide warnings for use.
DoD already does some orientation and training for new troops on the chemical and
biological threat and on the countermeasures which may be needed. More needs to be and
will be done within the next twelve months. The goal of DoD is that every service member
is fully informed during orientation and training of the health risks, benefits, and proper use
of all medical countermeasures, and, that when used, such countermeasures are documented
and maintained as a part of the individual's health record. Given the potential for serious
chemical and biological threats for future conflicts, both using countermeasures and having
our service members fully informed are critical to effectively protecting them. Our troop
information program and the new DoD medical surveillance policy combine to enhance
soldier welfare.
Given that FDA's Interim Final Rule permitting a waiver of informed consent for use of
unapproved products in a military exigency is still in effect, DoD will develop enhanced
orientation and training procedures to alert service personnel they may be required to take
drugs or vaccines not fully approved by FDA if a conflict presents a serious threat of
chemical and biological warfare.
Finding 2-13: DoD has made progress in improving medical record keeping in-theater and
stateside, but increased and sustained commitment from DoD's Joint Chiefs of Staff and
Commanders in Chief will be necessary for current prototypes and plans to be fully and
successfully integrated and implemented.
Recommendation: DoD officials at the highest levels, including the Joint Chiefs of Staff
and the Commanders in Chief, should assign a high priority to dealing with the problem of
lost or missing medical records. A computerized central database is important. Specialized
databases must be compatible with the central database. Attention should be directed toward
developing a mechanism for computerizing medical data (including classified information, if
and when it is needed) in the field. DoD and VA should adopt standardized record keeping
to ensure continuity.
Response: Concur. DoD continues to actively develop an automated medical records
system that is used during deployments and when Service members are at their home
base health facilities. Major portions of that system are already being used in Bosnia.
Further refinements, including the addition of an automated patient record and
"meditag" record, are being made as quickly as is feasible. These new information
svstems will be compatible with the records systems being used worldwide.
As part of a reengineering effort under a joint agreement between DoD and VA,
the two agencies are working to ensure compatibility of DoD and VA systems and to
facilitate the appropriate exchange of health information. VA and DoD jointly pursue
resource sharing to promote continuity of health care between the two departments and
reduce costs of services by avoiding the duplication of facilities, staff and equipment.
To address automation sharing issues, the Chief Information Officer (CIO) of the
Veterans Health Administration (VHA) established a Directorate for VA/DoD IRM
(Information Resources Management) Sharing to provide a central point for the
management of interagency agreements and the implementation of hardware and
software to allow for non-VA workload in VHA's automation environment.
A variety of mechanisms are available to promote sharing between the agencies.
The Federal Information Resources Sharing Work Group (FIRSWG) meets quarterly to
discuss sharing issues concerning VA, DoD, and the Indian Health Service (IHS).
DoD's Technical Integration Work Group (TIWG) encourages VA's participation in
their monthly meetings to share technical policies, philosophies, and directions.
Additionally, the VA-maintained Federal Health Care Resources Sharing (FHCRS)
Database allows the VA/DoD Sharing Office to manage information about the more
than four thousand sharing agreements between VHA and DoD facilities.
The VA/DoD IRM Sharing Directorate recently initiated the VA/DoD Data
Exchange Project and is working with contractors to develop a national solution to the
problem of sharing data between the two departments. The project's specific emphasis
is on sharing laboratory data, and success in this area will significantly benefit VA and
DOD health care providers. Inputs to this project include documentation and findings
from related VA, DoD and commercial efforts. The I&I Laboratory will be used to
develop and test the VA/DoD Data Exchange prototype.
The Pacific Medical Network (PACMEDNET) Project (now known as the
Theater Medical Information Infrastructure (TMII) Project) demonstrated successful
data sharing between Composite Health Care System (CHCS) and Veterans Health
Information Systems Technology Architecture (VISTA) during the Cobra Gold
exercises in Thailand in May 1996. The focus of the project is the use of a
Transportable Computer-Based Patient Record (TCPR) to provide a comprehensive
view of a patient's care history gathered from all medical facilities, DoD and VA, where
a patient has received care. Following the success of the Cobra Gold demonstration, the
TMII Project was expanded to include facilities outside the Pacific geographical area.
The CWG of the PGVCB will actively encourage and monitor these interagency
medical information systems efforts.
Recommendation: The PGVCB and other appropriate Departments and Agencies should be
charged to develop a protocol to implement the following recommendation, which is made in
the Committee's Interim Report. Prior to any deployment, DoD should undertake a thorough
health evaluation of a large sample of troops to enable better post-deployment medical
epidemiology. Medical surveillance should be standardized for a core set of tests across all
services, including timely postdeployment follow-up.
Response: Concur. As stated previously, DoD strongly agrees with the importance of
pre- and post-deployment health assessment. The Department is developing a medical
surveillance policy for deployments which specifies a uniform concept for health
screening. Rather than targeting sample populations for assessment, the Department's
position is that all deploying service members of specified deployments receive pre- and
post-deployment screening to include standardized health screening questionnaires with
medical follow-up as clinically indicated. This policy was partially implemented in
Bosnia and is being fully implemented for Southwest Asia. Interim and final
recommendations regarding deployment surveillance have been taken seriously by the
PGVCB. DoD expects the new medical surveillance policy to be formally adopted
during 1997. The newly established Deployment Surveillance Work Group will foster
this activity.
Finding 2-14: Clinical staff not directly involved in VA's Registry and DoD's CCEP are not
well informed about the programs.
Recommendation: VA and DoD should, in their educational outreach programs,
specifically target staff members not directly involved in the care of Gulf War veterans.
Recommendation: DoD and VA should include timely updates on the CCEP or Persian
Gulf Health Registry, respectively, in their Continuing Medical Education programs.
Recommendation: VA and DoD should regularly brief their staffs on the Gulf War
research portfolio and on the results of research studies as they become available.
Response: Concur. VA and DoD recognize that Gulf War-related continuing medical
education (CME) is an important component of assuring quality health care for Persian
Gulf veterans and their families. Within the next twelve months, VA and DoD will
coordinate their departmental CME programs through the activities of the CWG.
VA has used a multifaceted approach to continuing medical education
combining quarterly mailings of up-to-date scientific and clinical information,
interactive conference calls, national satellite video-teleconferences, and on-site CME
annual conferences. Future programs will continue to incorporate updates of clinical
case series (Registry and CCEP) information, clinical findings in Coalition Forces,
research developments and VA program updates.
In order to better address the needs of non-Persian Gulf Registry health care
providers, VA has developed a print material CME self-study program which is
scheduled for publication in the Spring of 1997. Copies of these materials will be made
available to non-VA health care providers on request.
DoD has already begun to develop an information distribution plan concerning
Gulf War veterans' illnesses through the three Service Surgeons General for health care
providers within the Military Health Services System. DoD and VA will work together
to expand the distribution of clinical and research information regarding Persian Gulf
illnesses to all of their respective clinical staff through timely updates and CME
programs.
Recommendation: VA and DoD should regularly review staffing needs, particularly in
mental health, and increase recruitment and retention of adequate numbers of medical
professionals to satisfy patient needs. Staffing reviews should consider that, despite
increased medical surveillance and better preventive measures, future deployments also will
generate a significant number of veterans who will need care for illnesses that are difficult to
diagnose.
Response: Concur. DoD is reviewing the clinical staffing needs required to satisfy
Gulf War veterans' health needs, including mental health, and ensuring that those
staffing needs are met. With respect to future deployments, the Department has in place
its CCEP, including support to all military treatment facilities, to assist with the
evaluation and care of illnesses that may result from those deployments and are difficult
to diagnose.
VHA's Prescription for Change made quality care, customer satisfaction and
timely access to health-care services for eligible veterans a primary goal. Staffing
requirements will be adjusted to meet these goals and reach the minimum performance
measures set for primary care and consultations at VA Medical Centers. An established
annual reporting of these performance measures will accomplish the "regular review" of
staffing needs recommended by the Committee. VA and DoD have programs in place
to deal with the expected number of difficult-to-diagnose illnesses resulting from future
deployments.
The Departments are committed to provide quality health care and will take the
Committee's staffing recommendation seriously.
Finding 2-15: Follow-up treatment, particularly when mental health visits are involved, is
problematic within both VA and DoD. Staffing constraints occasion long delays in
scheduling appointments. Commanders are sometimes resistant to making sufficient time
off available for active duty veterans to maintain an adequate treatment program.
Recommendation: Since 1986, U.S. service members with certain chronic illnesses, e.g.,
asthma and diabetes, have been allowed to remain on active duty when regular medical
monitoring is necessary. Veterans of the Gulf War with chronic illnesses are no different.
Troop commanders should be reminded that adequate time off for follow-up medical
appointments is a necessity and a priority.
Response: Concur. DoD will, within the next three months, develop an information
distribution plan for Commanders concerning Gulf War veterans' illnesses. The
Department will ensure that troop commanders are knowledgeable about the health
needs of Gulf War veterans and are supportive when follow-up medical appointments
are needed for Gulf War veterans with chronic illnesses.
Finding 2-16: Reproductive health care benefits available to active duty service members
and their families through the Military Health Services System are comprehensive and the
standard of care.
Finding 2-17: Reproductive health concerns are addressed on a case-by-case basis within
DoD, and VA has extremely limited authority to treat such concerns at all. Neither DoD nor
VA have widespread or systematic policies in place to address the concerns and questions of
Gulf War veterans concerning reproductive health.
Recommendation: The government should conduct a thorough review of its policies
concerning reproductive health and continue to seek statutory authority to treat veterans and
their families for service-connected problems. When indicated, genetic counseling should be
provided--either via VA treatment facilities or referral--to assist veterans and their families
who have reproductive concerns stemming from military service.
Response: Concur. DoD provides reproductive health care for its service members and
their families, and has made reproductive health concerns a higher priority for all
beneficiaries in their reproductive years. Currently, the Department is putting into place
performance matrices to better assess reproductive health outcomes and the associated
health care and to assist in the overall management of that care. Special efforts are
being made for Gulf War veterans in the areas of evaluation and care and
epidemiological and other research.
VHA is conducting a review of reproductive health services offered to eligible
veterans as part of its Eligibility Reform activities. Reproductive health services for
Persian Gulf veterans will receive serious consideration as part of this program review.
Finding 2-18: DoD and VA have implemented innovative programs to help veterans
cope with combat-related stress.
Recommendation: The government should continue and intensify its efforts to develop
stress reduction programs for all troops, with special emphasis on deployed troops.
Response: Concur. DoD is currently writing a Directive which addresses the
recognition and management of combat stress. When this policy directive is published,
the Services will be expected to publish implementation instructions within 120 days.
These instructions will focus on stress reduction programs, particularly for deployed
troops. Meanwhile, special combat stress coping units have deployed to Bosnia and
conduct critical incident stress debriefings for catastrophic incidents that occur in the
Services.
VA, DoD and DHHS will work together through the PGVCB CWG to monitor and
enhance the Departmental programs.
Recommendation: Since leadership and unit cohesion are so important in managing stress,
DoD should specifically involve senior commanders and senior noncommissioned officers in
stress management programs.
Response: Concur. DoD, through the forthcoming Directive on Combat Stress
(discussed above), will set the policy to have senior commanders and noncommissioned
officers involved in stress management programs.
Findings and Recommendations Regarding Research
Finding 2-19: DoD and VA have not taken serious steps to encourage their principal
investigators to convene and use public advisory committees for its Gulf War veterans'
epidemiologic health research.
Recommendation: The RWG of the PGVCB should require that any proposals for new,
large-scale Gulf War veterans' epidemiologic health research describe a plan to incorporate a
public advisory committee into the study design, dissemination of results, or both. The
RWG should consider justifying a waiver of such a committee under rare circumstances.
Response: Concur. Principal Investigators (Pls) conducting large epidemiologic
studies have been encouraged to establish Public Advisory Committees. Future
Requests for Proposals will require Pls to incorporate Public Advisory Committees into
the study design and results dissemination phases of the research.
The RWG of the PGVCB agrees with the Committee recommendation that any
proposals for new, large-scale Gulf War veterans' epidemiological studies of Persian
Gulf veterans incorporate a Public Advisory Committee. In the December 19, 1996
teleconference of the RWG, the members unanimously agreed to make funding of future
large-scale epidemiological studies contingent on the appointment of a public advisory
committee. The RWG has also recommended that ongoing epidemiological studies
institute Public Advisory Committees. This recommendation has been transmitted to
the relevant PIs.
Finding 2-20: DoD's Persian Gulf Registry of Unit Locations lacks the precision and detail
necessary to be an effective tool for the investigation of exposure incidents. The effort has
been no more successful than the effort to compile similar information following the
Vietnam War to examine possible exposures to Agent Orange.
Recommendation: The government should develop more accurate methods of recording
troop locations to facilitate post-conflict health research in the future. DoD should make full
use of global positioning technologies.
Response: Concur. The PAC is correct in pointing out that the Persian Gulf Registry
of Unit Locations database lacks the precision to serve as the basis for determining
individual locations for investigation of exposure incidents. Individuals do not remain
with their units throughout a conflict but rather deploy in small groupings or as
individuals. Combat, Combat Service and Combat Service Support soldiers frequently
are called upon to cross march or work in small teams on a temporary basis to satisfy
mission requirements, e.g., fuel handlers regularly make 50 kilometer round trips to
refuel front line units.
Individual and team movements are too numerous to track in detail in unit level daily
journals. Although it cannot be considered to be a singularly authoritative source of
information, the Joint Services Environmental/Support Group database does provide
decision makers with a valuable tool for the investigation of unit movements in the Gulf
War. It should not and can not be used as the exclusive source for investigation of
exposure incidents. The recommendation that DoD make full use of global positioning
technologies is sound and this technology is being tested and incorporated throughout
the Services. The efficacy of global positioning technologies to track individual and
unit situational awareness will be demonstrated by the Army and other Services during
the March 1997 Task Force YXI Advanced Warfighting Exercise at the National
Training Center, Fort Irwin, California.
Finding 2-21: Overall, the government's current research portfolio on Gulf War veteran's
illnesses is appropriately weighted toward epidemiologic studies and studies on stress-
related disorders that are more likely to improve our understanding of Gulf War veterans'
illnesses. For the most part, the government prioritization process has worked.
Finding 2-22: Research on Gulf War veteran's illnesses is treated, appropriately, as a subset
of the government's broader research portfolio on the health consequences of military
service. Any new research should be directed toward the principal uncertainties, which are:
long-term health effects from stress; long-term health effects from low-level exposure to
chemical weapons; long-term health effects from exposure to known carcinogenic and
mutagenic compounds, such as mustard agent; and long-term health effects of interactions
between pyridostigmine bromide and other agents.
Finding 2-23: Stress is not well understood in terms of diagnoses, physiological sequelae,
and effective prevention and treatment strategies; yet it is likely to be an important
contributing factor to illnesses currently reported by Gulf War veterans. Additional attention
to basic and applied research of stress-related disorders across the entire federally funded
biomedical research portfolio would benefit DoD's and VA's capabilities to manage combat
stress and its effects.
Recommendation: The government should plan for further research on possible
long-term health effects of low-level exposure to organophosphorus agents such as sarin,
soman, or various pesticides, based on studies of groups with well-characterized exposures,
including: a) cases of U.S. workers exposed to organophosphorus pesticides; and b) civilians
exposed to the chemical warfare agent Sarin during the 1994 and 1995 terrorist attacks in
Japan. Additional work should include followup and evaluation of an appropriate subset of
any U.S. service personnel who are presumed to be exposed during the Gulf War.
The government should begin by consulting with appropriate experts, both governmental
and nongovernmental, on organophosphorus nerve agent effects. Studies of human
populations with well-characterized exposures will be much more revealing than studies
based on animal models, which should be given lower priority.
Response: Concur. The recommendation for more research on low-level exposure to
organophosphorus agents is fully supported by the PGVCB. In December 1996, the
RWG has released the 1996 revision of A Working Plan for Research on Persian Gulf
Veterans' Illnesses (Working Plan) first published in 1995. The RWG developed the
revision as a part of its ongoing commitment to continually reevaluate the research
needs for Persian Gulf veterans' illnesses. In the 1996 Working Plan, the RWG
developed focused research recommendations based on the current state of information
and understanding regarding the nature and potential causes of Persian Gulf veterans'
illnesses. Near-term recommendations for additional research include:
Follow-up of the mortality experience of Persian Gulf veterans, encompassing cause-
specific mortality, at appropriate future time-points;
More longitudinal follow-up studies of the health of Persian Gulf veterans, including
those with illnesses that are difficult to diagnose;
Critical peer-review of models used to predict exposure concentrations of environmental
pollution (such as the Kuwait oil well fires) and chemical warfare agents (such as
the demolition of weapons storage sites at Khamisiyah in March 1991 and aerial
bombing of chemical weapons facilities during the air war);
Assessment of the potential for clinical investigations of the health status of the service
members in the vicinity of Khamisiyah when weapons bunker 73 and the storage pit
were detonated in March 1991. If deemed possible, such clinical investigations
should be carried out;
Additional research on health-related issues arising from the Persian Gulf experience
but with potential for more general applicability to future conflicts is also
recommended, including:
Investigation of the risk factors for the development of stress-related disorders
including, but not limited to, post-traumatic stress disorder (PTSD);
Exploration of the development of practical, sensitive, and specific biomarkers of
exposure to chemical agents, including organophosphate nerve agents and
vesicants such as sulfur mustard;
Toxicological and, where feasible, epidemiological research on the potential for
long-term health effects resulting from low-level, subclinical exposures to
chemical agents, particularly organophosphate agents such as sarin;
Development of a strategic plan for research into the potential long-term health
consequences of exposure to low-levels of chemical warfare agents; and,
If a simple, sensitive and specific, as well as economic, test for L. tropica infection
becomes available, seroepidemiologic studies may be undertaken in Persian Gulf
veterans. Indeed, when feasible and practical, sera of veterans should be stored
in expectation of the possibility for such studies. Despite the declining
importance of L. tropica as a risk factor in Persian Gulf veterans, continued
research on tests for L. tropica infection is valuable for potential future
deployments.
In addition to a study of the feasibility of conducting epidemiological
investigations of the health of veterans present at Khamisiyah in March 1991, the RWG
is explicitly recommending more research on the potential toxic effects of low-level
chemical warfare agents. A Broad Agency Announcement from DoD in December
1996 solicits applications to conduct the aforementioned feasibility study, and it solicits
applications for toxicological research on the toxic effects of low-level chemical warfare
agent exposure. DoD is asking the scientific community to help us determine what mix
of human population and animal model studies will provide the best understanding of
this complex issue. The RWG agrees that population studies of low-level chemical
weapons exposure should consider a variety of exposed populations including U.S.
pesticide workers, civilians exposed to sarin in Japan during terrorist attacks in 1994
and 1995, as well as appropriate subsets of Persian Gulf veterans who may have been
exposed during the Persian Gulf War. Investigators with the VA are collaborating with
Japanese scientists on studies of the health of victims of the Tokyo subway incident in
1995.
The RWG also agrees that it should broaden its expertise base for consultations
on the health effects of nerve agents. As part of an effort to do this, the RWG sponsored
a Symposium on the Health Effects of Low-Level Exposure to Chemical Warfare Nerve
Agents as a part of the Annual Meeting of the prestigious Society of Toxicology held on
March 7 and 8, 1997. In the coming months the RWG will be developing a
comprehensive research strategy for studies of the toxic effects of low-level exposures
to chemical warfare agents. This strategy will be developed using input from
appropriate government and non-government experts.
Recommendation: Since a number of Gulf War risk factors are potential human
carcinogens that could result in increased rates of cancer beginning decades after exposure,
VA should continue to monitor Gulf War veterans through its ongoing mortality study for
increased rates of lung, liver, and other cancers.
Response: Concur. VA's Environmental Epidemiology Service is studying mortality
rates and cause-specific mortality among Gulf War veterans through December 1995.
VA plans to support periodic updates and long-term mortality studies on deployed and
non deployed Gulf era veterans.
Recommendation: Depleted uranium munitions are likely to be used in future conflicts
involving U.S. service personnel. To fully elucidate the health effects of depleted uranium
munitions, VA should conduct research that compares the health status of individuals with
embedded fragments of DU shrapnel with appropriate control groups.
Response: Concur. The depleted uranium health surveillance program is located at the
Baltimore VAMC. VA recognizes the importance of research and health surveillance
activities which will improve our knowledge of the potential health effects of human
exposure to depleted uranium. VA is committed to long-term monitoring of the health
of the Army veterans with retained depleted uranium fragments. Furthermore, the
RWG of the PGVCB will monitor and foster the research which is ongoing within the
U.S. Army and VA.
Recommendation: The government should continue to collect and archive serum
samples for U.S. service personnel when feasible.
Response: Concur. Currently, DoD is finalizing a medical surveillance policy which
will require serum collection for specified deployments. This policy will be in place
during 1997. The RWG recommends that when feasible, all research studies should
collect and archive serum samples.
Finding 2-24: The efforts of the PGVCB's RWG would benefit from the active
participation of additional representatives from other federal agencies with relevant
expertise, such as the National Institutes of Health and the Agency for Toxic Substances and
Disease Registry.
Recommendation: The RWG should more thoroughly consult with other federal agencies
with relevant expertise--such as the National Institutes of Health (NIH) (particularly the
National Institute of Environmental Health Sciences) and the Agency for Toxic Substances
and Disease Registry--on basic, clinical, and epidemiologic research and on risk
communication.
Response: Concur. The PGVCB will work with the other members of the RWG to
obtain the active participation of appropriate expert representatives from NIH and
ATSDR as well as experts from other agencies within the next three months. The
RWG's current membership includes the following Departments and Agencies:
Department of Veterans Affairs
Office of Research and Development
Office of Public Health and Environmental Hazards
Department of Defense
Office of the Assistant Secretary for Health Affairs
Office of Defense Research and Engineering
Division of Environmental and Life Sciences
Department of Health and Human Services
Office of Public Health and Science
Centers for Disease Control and Prevention
Agency for Toxic Substances and Disease Registry
National Institutes of Health
National Institute of Environmental Health Sciences
Environmental Protection Agency
National Center for Environmental Assessment
These members will be supplemented by a broader membership with the
expertise from a wider range of government agencies.
Finding 2-25: VA's November 1996 establishment of a new Environmental Hazards Center
focused on reproductive health and developmental outcomes from environmental exposures
is an important step forward in developing policies for the treatment of veterans and
addressing their concerns.
Response: Concur. With the increasing number of women veterans, VA recognizes the
growing need to understand the potential consequences of military service on
reproductive health and outcomes in both men and women. VA research historically
has not focused on these areas. However, in the Spring of 1996, VA issued a
solicitation for a fourth Environmental Hazards Research Center focusing on potential
reproductive and developmental outcomes associated with toxic exposures during
military service. After a comprehensive and competitive scientific peer review, VA
announced in November 1996 the award of this new Environmental Hazards Research
Center to the Louisville VA Medical Center in collaboration with the University of
Louisville. The new Center is an important step to enhance VA's research efforts in
these important research areas.
Findings and Recommendations Regarding Chemical and Biological Weapons
Finding 2-26: In the face of credible evidence of the presence or release of chemical warfare
agents, low-level exposure of U.S. personnel at the affected site must be presumed while
efforts to develop more precise measures of exposure continue.
Finding 2-27: The evidence of chemical warfare agent release at Khamisiyah is
overwhelming, and low-level exposure to troops within a 50 kilometer radius should be
presumed while efforts to develop more precise measures of exposure and more detailed
knowledge of the demolition activities continue.
Recommendation: All U.S. service personnel assigned to units near the Khamisiyah
demolition activity should be notified and encouraged to enroll in VA's Persian Gulf Health
Registry or DoD's Comprehensive Clinical Evaluation Program. In determining the extent
of possible chemical warfare agent exposure at Khamisiyah and any other sites that future
investigations uncover, the government should use the best theoretical and practical
assessment tools available. The Committee recognizes the large number of variables that
can affect the outcome of any determination, but identifies the following as essential
principles:
Where objective, unrebutted evidence suggests the release of chemical warfare agents in
the vicinity of U.S. troops, every effort should be made to identify the source of the
agent and to model the downwind footprint of the potential distribution of agent at
the general population exposure level (or lower threshold, if appropriate);
When a downwind footprint is established, a conservative, presumptive exposure area
should be defined that reflects the uncertainties of the modeling effort. The
presumptive-exposure area should, at a minimum, include all sites within a circle
that has a radius equal to the length of the downwind footprint; and
Troops within the presumptive-exposure area should be notified and encouraged to
enroll in the CCEP or Registry.
Response: Concur. DoD initiated a notification program in August 1996 for all service
members assigned to units thought to have participated in the operation at Khamisiyah.
The total number of individuals assigned to these units, and therefore included in this
notification program, totaled ,168. This telephone outreach program informed service
members assigned to these selected units of the incident and of the medical evaluation
programs available to them through VA and DoD.
During this period, the Central Intelligence Agency (CIA) attempted to model
the conditions at Khamisiyah in order to estimate the dispersion of any chemical agents.
Preliminary information from the model indicated exposures which could produce
immediate health effects, may have occurred as far as 25 km from Khamisiyah on the
date of the "pit" demolition, March 10, 1991. To cover the dates surrounding the bunker
and "pit" demolitions and to build a larger margin for error, the notification program
expanded to include service members attached to any unit within a 50 kilometer radius
of Khamisiyah at any time on or between the dates of March 1-15, 1991. These
parameters were considered conservative enough to absorb any possible variation in the
geographic and temporal distribution of chemical agents modeled by the CIA. This
action increased the number of veterans to be notified to 20,867. A letter was mailed
notifying the involved individuals of the incident and encouraging them to participate in
the medical evaluation programs available to them through the VA or DoD. In addition,
a survey to gather information to better understand the events surrounding the
Khamisiyah demolition and Gulf War illnesses has been mailed to all affected
individuals.
In order to better understand any relationship between the demolitions, potential
exposure and subsequent illness, DoD and VA are sponsoring epidemiological studies
and funding research.
For any other sites that may be identified in the future and for any other service
members who may have been exposed, similar steps will be taken with respect to
notification, evaluation, care and research.
Finding 2-28: Other site-specific exposures of U.S. troops to low levels of chemical warfare
agents cannot be ruled out. A theater-wide time/distance analysis is insufficient to address
positive detections by Fox reconnaissance vehicles and M256 kits.
Recommendation: All reports of positive M256 kits and Fox detections must be
thoroughly investigated. Where unit logs record positive detections by either type of
equipment, members of that unit should be notified and encouraged to enroll in VA's Persian
Gulf Health Registry or DoD's Comprehensive Clinical Evaluation Program.
Response: Concur. All confirmed positive detections that meet the standard of
Recommendation 2-27 will be thoroughly investigated. DoD will examine records to
encourage all veterans of units in the vicinity of these detections to enroll in the VA's
Persian Gulf Health Registry or DoD's Comprehensive Clinical Evaluation program as
was done for the Khamisiyah incident. The current list of possible detections should not
be taken as definitive. DoD intends to apply the PAC's standard stated in
Recommendation 2-27 and adopt a conservative and cautious approach with regard to
possible detections. DoD's improved veterans outreach program may uncover
additional information of possible detections. Each reported detection will be
investigated. In order to better understand any relationship between the demolitions,
potential exposure and subsequent illness, DoD and VA will sponsor appropriate
epidemiological studies and research.
DoD's Office of the Special Assistant has established a new case management
structure to ensure a thorough and complete investigation of all events surrounding a
case. Reported detections are only one piece in the analytical process surrounding a
particular incident.
The PGVCB will incorporate this knowledge into its activities including clinical
care, research and risk communication.
Finding 2-29: DoD has conducted a superficial investigation of possible chemical warfare
agent exposures, that is unlikely to provide credible answers to veterans' questions.
Recommendation: To ensure credibility and thoroughness, further investigation of possible
chemical or biological warfare agent exposures during the Gulf War should be conducted by
a group independent of DoD. Openness in oversight activities -- including public access to
information and veteran participation -- public notice of meetings, opportunity for public
comment, and regular reporting are essential. Full public accountability is critical.
Response: Concur in part. Consistent with the principle of independent oversight, on
January 30, 1997, the President signed Executive Order 13034 extending the
Presidential Advisory Committee on Gulf War Veterans' Illnesses. The Executive
Order directed the Committee to provide "oversight of the ongoing investigation being
conducted by the Department of Defense with the assistance, as appropriate, of other
executive departments and agencies, into possible chemical or biological warfare agent
exposure during the Gulf War." The Committee was also assigned the role of evaluating
the Federal government's plan for and progress towards the implementation of all of the
Committee's recommendations set forth in its Final Report. Finally, the Executive
Order established two milestones for the Committee with respect to providing advice
and recommendations related to its two principal roles: an interim status report by April
30, 1997; and a final supplemental report by October 31, 1997.
DoD is fully committed to a comprehensive and credible investigation of Gulf
War veterans' illnesses, and has pledged a thorough investigation and will share the
results of that investigation with our veterans and the American people. DoD is
committed to ensuring a successful resolution of this issue for those Gulf veterans who
served as well as those who will serve in future operations. DoD is morally obligated to
provide our veterans an explanation that maintains the confidence of the force and the
support of parents whose sons and daughters wear the uniform of our country. The
expertise and knowledge to investigate, analyze and to understand what happened
resides in the Pentagon.
DoD welcomes oversight and is committed to openness, communication and
truthfulness. As indicated, the Office of the Special Assistant has an office for a PAC
representative within our complex and will make available, as necessary, space for other
oversight activities.
Committee Findings and Recommendations Regarding Coordination
Finding 2-30: Many issues related to post-conflict health concerns of Gulf War veterans are
common to the aftermath of other military engagements. Governmental responsibility to
address such concerns spans the missions of several federal departments and agencies, but it
is a priority for no agency. Resolving these issues in a timely and effective manner requires
interagency coordination at the highest levels of government.
Recommendation: A Presidential Review Directive (PRD) should be issued to instruct the
National Science and Technology Council to develop an interagency plan to address health
preparedness for and readjustment of veterans and families after future conflicts and
peacekeeping missions. The President's Committee of Advisors on Science and Technology
and other nongovernmental experts, as appropriate, should be asked to review the plan 12
months after the PRD is issued and again at 18 months to ensure national expertise is
brought to bear on these issues.
Response: Concur. VA, DoD and DHHS support a Presidential Review Directive
(PRD) process to address the many post-deployment health concerns highlighted by the
Gulf War experience including the conduct of relevant research efforts. A draft PRD,
entitled "Development of Interagency Plans to Address Health Preparedness for and
Readjustment of Veterans and their Families After Future Deployments," has been
drafted by the Office of Science and Technology Policy in the White House. That draft
is currently circulating for final interagency clearance; it is anticipated that the clearance
process will be completed by the end of March 1997.
Once the directive responding to the PAC's recommendation is approved, the
relevant agencies will be asked to review policies and programs and identify relevant
actions that may be taken by the Federal government to better safeguard those
individuals who risk their lives and well-being on deployments to defend our Nation's
interests. The PRD will be specifically addressed to the following officials: the Vice
President; the Secretaries of Defense, Health and Human Services, and Veterans
Affairs; the Director of the Office of Management and Budget; the Assistant to the
President for National Security; and the Assistant to the President for Science and
Technology. If the PRD process within a given agency generates recommendations to
support higher priority budgets, programs or policies, then the responsible official must
include in the agency report a specific strategy on how these recommendations can be
accommodated within and among the balance of the agency's budget priorities.
All of the agency-specific inputs with respect to the issues identified by the PAC
will be integrated into a comprehensive report by the National Sciences and Technology
Council (NSTC) within one year after the issuance of the PRD. The President's
Committee of Advisors on Science and Technology (PCAST) will provide input for the
report review process, then take cognizance of the report for final review and approval.
CHAPTER 3: NATURE OF GULF WAR VETERAN'S ILLNESSES
Finding 3-1: Gulf War veterans have experienced no excess mortality from natural causes
during or after the war. Gulf War veterans have experienced excess mortality from external
causes such as injuries, which is consistent with the experience of veteran populations from
previous conflicts.
Recommendation: Research on possible causes and methods of prevention of excess
mortality from external causes among veterans should receive high priority.
Response: Concur. Long-term mortality follow-up studies concerning external causes
are important to determine the cause of excess rates among deployed troops compared
to other troops. As a result, DoD and DHHS will collaborate with VA investigators to
conduct these long-term mortality studies with the goal to identify risk factors and
develop appropriate interventions.
The mortality study carried out by VA's Environmental Epidemiology Service
found that Gulf War veterans experienced a small, but significant increased death rate as
compared to non-deployed Gulf era veterans. However, this increased risk was almost
entirely accounted for on the basis of external causes, such as automobile accidents.
There was no difference in death rates due to medical conditions and Gulf War and non-
deployed Gulf era veterans had almost half the mortality rate of the general U.S.
population.
This increased risk of accidental death was also seen in Vietnam veterans. VA's
Environmental Epidemiology Service has already begun a feasibility study of mortality
due to external causes. In addition, VA's Environmental Epidemiology Service is
completing an extension of the mortality study results through December 1995.
PGVCB made research in this area a priority in its recently published 1996 update of
the Working Plan and is committed to continuing this work.
Finding 3-2: Information from the clinical programs indicates musculoskeletal conditions
and ill-defined conditions are common components of Gulf War veterans' illnesses.
Recommendation: Research on Gulf War veterans' illnesses should emphasize
investigating the causes and methods of prevention and treatment of musculoskeletal
conditions.
Response: Concur. Musculoskeletal disorders have been an important source of
morbidity in all veteran populations, including the Persian Gulf War. As a part of their
broader research agendas, both VA and DoD have significant resources devoted to
musculoskeletal disorder research.
The PGVCB agrees that research on causes and methods of prevention and
treatment of musculoskeletal conditions is an important area for investigation. In
funding future research, VA and DoD will look for opportunities that would increase
understanding of causes, prevention and treatment of these health problems.
Finding 3-3: Data from the clinical programs and epidemiologic studies indicate
stress-related disorders are common components of Gulf War veterans' illnesses.
Recommendation: Research on Gulf War veterans' illnesses should emphasize
investigating the causes and the methods of prevention and treatment of stress-related
disorders.
Response: Concur. Traumatic and non-traumatic stress-related disorders may be an
important contributing factor to Gulf War veterans' illnesses. Research will be solicited
which investigates the possible association of traumatic and non-traumatic stress and
Gulf War veterans' illnesses. We agree that research on causes and methods of
prevention and treatment of stress-related disorders is an important area for
investigation. In funding future research, the government will look for opportunities
which would increase understanding of causes, prevention and treatment of these health
problems.
Finding 3-5: Stigmatization of psychosomatic illness seriously interferes with some
veterans seeking care.
Recommendation: Since the stigmatization of mental illness continues to be a problem for
society at large, DHHS should place a priority on developing public education outreach
programs that note the indissoluble association between the mind and the body. DoD and
VA should make a special effort to address and target such needed educational outreach to
their communities.
Response: Concur. DHHS believes that there unfortunately continues to be societal-
wide stigmatization of those with mental illnesses. DHHS, principally through the
National Institute of Mental Health and the Substance Abuse and Mental Health
Services Administration, has been working diligently for several decades to improve the
awareness of all Americans about the nature of mental health. Significant strides have
been made since 1990 when DHHS launched its "Decade of the Brain" theme,
providing a focus not only on neuroscience, but on improving public awareness and
understanding of a broad range of diseases, including psychosomatic and stress induced
conditions. Much of the integrative efforts of the program are directed toward making
precisely the mind-body linkage recommended in the Committee's report.
To heighten awareness of the nature of mental health, improve the public's
understanding of these illnesses, and bring focus to the legitimacy and treatability of
psychological conditions, DHHS has taken the initial steps to commission a Surgeon
General's Report on Mental Health. DHHS believes that this report, along with its
ongoing educational efforts, will positively impact how society approaches issues of
mental health and stress-associated problems. DHHS is fully supportive of the
Committee's recommendation.
DoD concurs with this recommendation and sees the release of the DoD
Directive on combat stress in 1997 as a landmark directive, the first that the Department
will have published on combat stress. The integration of psychological assessment into
the overall physical assessment for predeployment examinations should help to
destigmatize the psychophysiologic processes. In addition, a Directive on Mental
Health Assessment should help to further destigmatize the use of mental health services.
The publication of these directives will be further enhanced by educational outreach
efforts suggested above.
VA, DoD, and DHHS will incorporate this issue into the 1997 comprehensive
risk communication plan.
Finding 3-4: Among the subset of the Gulf War veteran population examined in the ongoing
clinical and research programs, many veterans have illnesses likely to be connected to their
service in the Gulf. Currently, the extent of service-connected illness in the population is
unknown.
Finding 3-6: It is unlikely that exposures in the Gulf War theater are responsible for
the birth defects of children born to veterans.
Finding 3-7: VA's examination program for spouses and children of Gulf War veterans has
little or no value as a research program and offers no incentive for participation, thus raising
expectations about the government's ability to respond to health care needs in veterans and
their families that are impossible to meet.
Recommendation: Since Congress has extended VA's examination program for spouses
and children of Gulf War veterans, VA should formulate what it intends to do with the
results and consider mechanisms to reimburse travel and other costs.
Response: Concur in part. Section 107 of PL 103-446 did not grant VA general
authority to treat or provide medical care to the spouses and children of Persian Gulf
veterans. In addition, the study conducted under this section can only render data of
limited scientific value, because of the inherent limitations of the required study design.
More specifically, under section 107 of Public Law 103-446, VA medical evaluations
can be offered to any individual who:
is the spouse or child of a veteran, who (a) is listed in the Persian Gulf War Veterans
Registry established under Public Law 102-585, and (b) is suffering from an illness
or disorder;
is suffering from, or may have suffered from, an illness or disorder (including a birth
defect, miscarriage, or stillbirth) which cannot be dissociated from the veteran's
service in the Southwest Asia theater of operations; and
has granted VA permission to include in the Registry relevant medical data from the
evaluation.
Given the limited authority provided by this law, VA established a program that
provides standardized medical evaluations and establishes a Registry database for health
surveillance. The Department plans to analyze this database in a manner comparable to
the VA Persian Gulf Registry database and the DoD CCEP database. This analysis will
maximize our ability to compare the examination results of PGW veterans' spouses and
children with the existing VA and DoD Persian Gulf health registries.
In the absence of authority to reimburse travel costs for participants in this
program, VA is exploring means to reduce this burden and increase access to the
program. In January 1997, VA increased the participating examination centers to 33
sites nationwide and is encouraging VHA Network Directors to add additional sites.
It should also be noted that VA's National Persian Gulf Veterans Health Survey
is studying the health status of Persian Gulf veterans, their spouses and children, and
VA will be providing physical examinations of veterans and family members during
Phase III of this study. This randomized, controlled study will allow VA to assess the
health status of Persian Gulf veterans and their families in a scientifically valid manner.
Finding 3-8: The absence of baseline data regarding the reproductive history and health of
military personnel makes determinations of the effects of exposures during deployments
more complex and difficult.
Recommendation: The government should consider methods for routinely sampling
military populations regarding reproductive health so that an appropriate baseline exists for
evaluating reproductive outcomes following deployment. In particular, DoD should consult
with the National Center for Health Statistics and strongly consider implementing its
National Survey of Family Growth and related methodologies for collecting data.
Response: DoD agrees and is considering several options to establish appropriate
reproductive outcome baseline data including survey instruments, adverse birth
outcomes registries and other reproductive outcomes surveillance systems. As part of
these deliberations over the next twelve months, DoD will be consulting with a number
of outside organizations, including the National Center for Health Statistics.
CHAPTER 4: SCIENTIFIC ANALYSIS OF GULF WAR RISK FACTORS
Finding 4-1: Although some veterans clearly have service-connected illnesses, current
scientific evidence does not support a causal link between the symptoms and illnesses
reported today by Gulf War veterans and exposures while in the Gulf region to the following
environmental risk factors assessed by the Committee: pesticides, chemical warfare agents,
biological warfare agents, vaccines, pyridostigmine bromide, infectious diseases, depleted
uranium, oil-well fires and smoke, and petroleum products. Some of these risk factors
explain specific, diagnosed illness in a few Gulf War veterans, for example, leishmaniasis
has been diagnosed in 32 individuals. Prudence requires further investigation of some areas
of uncertainty, such as the long-term effects of low-level exposure to chemical warfare
agents and the synergistic effects of exposure to pyridostigmine bromide and other risk
factors.
Response: Concur. Prudence dictates a continued investigation of all potential risk
factors in which scientific evidence does not clearly indicate that health effects in
Persian Gulf veterans are unlikely. Furthermore, the PGVCB recognizes that findings
from these investigations will have relevance to the health consequences of future
military deployments and to the health of the civilian community as well. Therefore,
the RWG believes that a broad based research agenda is prudent, warranted, and
ultimately beneficial to both military service members and civilians.
Finding 4-2: A number of Gulf War risk factors -- e.g., mustard gas, aflatoxin, and certain
petroleum products--are potential human carcinogens that could cause increased rates of
cancer beginning decades after exposure.
Recommendation: DoD and VA should perform long-term mortality studies of Gulf War
veterans appropriate for investigating cancer rates in the Gulf War veteran population in the
coming decades.
Response: Concur. Long-term mortality follow-up studies are important and should
be funded to determine cancer rates among deployed troops compared to other troops.
Currently, VA's Environmental Epidemiology Service is collecting information
on the mortality experience and cause-specific mortality among Gulf War veterans
through December 1995. In the future, VA plans periodic updates and long-term
mortality study on deployed and non-deployed Gulf era veterans.
Finding 4-3: Stress is known to affect the brain, immune system, cardiovascular system, and
various hormonal responses. Stress manifests in diverse ways, and is likely to be an
important contributing factor to the broad range of physiological and psychological illnesses
currently being reported by Gulf War veterans.
Recommendation: The entire federal research portfolio should place greater emphasis on
basic and applied research on the physiologic effects of stress-related disorders.
Response: Concur. Stress may be an important, but not the exclusive, risk factor for
Gulf War veteran's illnesses. The PGVCB agrees on the need for a greater emphasis on
physiologic effects of both traumatic and nontraumatic stress in its research plan. This
issue was incorporated into the December 1996 update of the Working Plan. In
proceeding, the first step is to examine the research that is already being conducted,
learn from that research and identify gaps in research knowledge. The PGVCB agrees
about the need for a better understanding of the relationship between exposure to both
traumatic and nontraumatic stress and its role in physical and psychological illnesses.
In PTSD research alone, VA has invested nearly $7 million and VA investigations have
received another $4.5 million from non-VA sources, such as NIH. VA and DoD are
partnering in an effort to expand their resource portfolios on stress-related research
through the DOD/VA cooperative research program. It will be very important to
compile the ongoing and past research that is relevant to stress disorders in the format
used by the PGVCB: methods, completion date, findings. This would allow a current
review of areas that have and have not been addressed and an opportunity to better use
current research knowledge, as well as help determine future research priorities.
DoD, through the PGVCB, is actively participating in the process for finding
and selecting the best scientific proposals for funding involving the health outcomes
associated with stress. Two efforts are underway: proposals are being sought by a
formal Request for Proposals for researchers external to the federal government as well
as through via the VA intramural system.