[House Hearing, 105 Congress]
[From the U.S. Government Publishing Office]



 
THE STATUS OF EFFORTS TO IDENTIFY PERSIAN GULF WAR SYNDROME: RECENT GAO 
                                FINDINGS
=======================================================================

                                HEARING

                               before the

                    SUBCOMMITTEE ON HUMAN RESOURCES

                                 of the

                        COMMITTEE ON GOVERNMENT
                          REFORM AND OVERSIGHT
                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED FIFTH CONGRESS

                             FIRST SESSION
                               __________

                             JUNE 24, 1997
                               __________

                           Serial No. 105-35
                               __________

Printed for the use of the Committee on Government Reform and Oversight





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              COMMITTEE ON GOVERNMENT REFORM AND OVERSIGHT

                     DAN BURTON, Indiana, Chairman
BENJAMIN A. GILMAN, New York         HENRY A. WAXMAN, California
J. DENNIS HASTERT, Illinois          TOM LANTOS, California
CONSTANCE A. MORELLA, Maryland       ROBERT E. WISE, Jr., West Virginia
CHRISTOPHER SHAYS, Connecticut       MAJOR R. OWENS, New York
STEVE SCHIFF, New Mexico             EDOLPHUS TOWNS, New York
CHRISTOPHER COX, California          PAUL E. KANJORSKI, Pennsylvania
ILEANA ROS-LEHTINEN, Florida         GARY A. CONDIT, California
JOHN M. McHUGH, New York             CAROLYN B. MALONEY, New York
STEPHEN HORN, California             THOMAS M. BARRETT, Wisconsin
JOHN L. MICA, Florida                ELEANOR HOLMES NORTON, Washington, 
THOMAS M. DAVIS, Virginia                DC
DAVID M. McINTOSH, Indiana           CHAKA FATTAH, Pennsylvania
MARK E. SOUDER, Indiana              ELIJAH E. CUMMINGS, Maryland
JOE SCARBOROUGH, Florida             DENNIS J. KUCINICH, Ohio
JOHN B. SHADEGG, Arizona             ROD R. BLAGOJEVICH, Illinois
STEVEN C. LaTOURETTE, Ohio           DANNY K. DAVIS, Illinois
MARSHALL ``MARK'' SANFORD, South     JOHN F. TIERNEY, Massachusetts
    Carolina                         JIM TURNER, Texas
JOHN E. SUNUNU, New Hampshire        THOMAS H. ALLEN, Maine
PETE SESSIONS, Texas                 HAROLD E. FORD, Jr., Tennessee
MICHAEL PAPPAS, New Jersey                       ------
VINCE SNOWBARGER, Kansas             BERNARD SANDERS, Vermont 
BOB BARR, Georgia                        (Independent)
ROB PORTMAN, Ohio
                      Kevin Binger, Staff Director
                 Daniel R. Moll, Deputy Staff Director
                       Judith McCoy, Chief Clerk
                 Phil Schiliro, Minority Staff Director
                                 ------                                

                    Subcommittee on Human Resources

                CHRISTOPHER SHAYS, Connecticut, Chairman
VINCE SNOWBARGER, Kansas             EDOLPHUS TOWNS, New York
BENJAMIN A. GILMAN, New York         DENNIS J. KUCINICH, Ohio
DAVID M. McINTOSH, Indiana           THOMAS H. ALLEN, Maine
MARK E. SOUDER, Indiana              TOM LANTOS, California
MICHAEL PAPPAS, New Jersey           BERNARD SANDERS, Vermont (Ind.)
STEVE SCHIFF, New Mexico             THOMAS M. BARRETT, Wisconsin

                               Ex Officio

DAN BURTON, Indiana                  HENRY A. WAXMAN, California
            Lawrence J. Halloran, Staff Director and Counsel
                Robert Newman, Professional Staff Member
                       R. Jared Carpenter, Clerk
                    Cherri Branson, Minority Counsel
                 Elizabeth Mundinger, Minority Counsel










                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on June 24, 1997....................................     1
Statement of:
    Heivilin, Donna, Director of Planning and Reporting, General 
      Accounting Office, accompanied by Kwai Chan, Director of 
      Special Studies and Evaluation Group, General Accounting 
      Office; and Sushil Sharma, Assistant Director of Special 
      Studies and Evaluation Group, General Accounting Office....    34
Letters, statements, etc., submitted for the record by:
    Gilman, Hon. Benjamin A., a Representative in Congress from 
      the State of New York, prepared statement of...............    24
    Heivilin, Donna, Director of Planning and Reporting, General 
      Accounting Office, prepared statement of...................    41
    Pappas, Hon. Michael, a Representative in Congress from the 
      State of New Jersey, prepared statement of.................    32
    Sanders, Hon. Bernard, a Representative in Congress from the 
      State of Vermont, prepared statement of....................     7
    Shays, Hon. Christopher, a Representative in Congress from 
      the State of Connecticut, prepared statement of............     3
    Towns, Hon. Edolphus, a Representative in Congress from the 
      State of New York, prepared statement of...................    22












THE STATUS OF EFFORTS TO IDENTIFY PERSIAN GULF WAR SYNDROME: RECENT GAO 
                                FINDINGS

                              ----------                              


                         TUESDAY, JUNE 24, 1997

                  House of Representatives,
                   Subcommittee on Human Resources,
              Committee on Government Reform and Oversight,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10:20 a.m., in 
room 2154, Rayburn House Office Building, Hon. Christopher 
Shays (chairman of the subcommittee) presiding.
    Present: Representatives Shays, Snowbarger, Pappas, 
Sanders, Kucinich, and Allen.
    Staff present: Lawrence J. Halloran, staff director and 
counsel; Robert Newman, professional staff member; R. Jared 
Carpenter, clerk; Cherri Branson and Elizabeth Mundinger, 
minority counsels; and Ellen Rayner, minority chief clerk.
    Mr. Shays. I'd like to call this hearing to order and first 
apologize to my colleagues. It's my practice to start the 
hearings on time. And I was at the Budget Committee giving the 
two reconciliation bills to the committee on behalf of Mr. 
Kasich, and I was not allowed to leave by the committee. So I'm 
a little late and I apologize.
    I did want the subcommittee to wait because I consider this 
an extraordinary hearing today and wanted to participate in all 
of it.
    In March 1996, we began these hearings on Gulf war 
illnesses because many veterans were telling us the Federal 
response to their plight was blind and passive. They found the 
research unfocused, their diagnoses skewed toward stress, and 
their treatments inconsistent or ineffective.
    It became clear to us very quickly our veterans were right 
on all counts.
    The subcommittee's goal, like theirs, is to see that all 
Gulf war veterans are properly diagnosed, effectively treated, 
and fairly compensated.
    Today the General Accounting Office [GAO] will discuss 
their report, ``Gulf War Illnesses: Improved Monitoring of 
Clinical Progress and Re-examination of Research Emphasis are 
Needed.'' Significant findings in this report confirm what sick 
veterans, physicians, research scientists, and others have been 
telling this subcommittee consistently over the course of eight 
previous hearings.
    This GAO report, much of our earlier testimony, and more we 
will hear on Thursday, all speak of an official approach to 
Gulf war illnesses still permeated by diffidence, denial, and a 
desire to embrace preordained, unsubstantiated conclusions.
    Sadly, the diffidence, denials, and desire to jump to 
convenient conclusions continue. The official response to this 
report by the Department of Veterans' Affairs [VA] and the 
Department of Defense [DOD] betray the same arrogance and 
myopia that blinded them to the obvious probability of low-
level chemical warfare agent exposures until just last year, 
when Khamasiyah forced their eyes to open slightly.
    In response to the findings and recommendations in this 
report, the VA and DOD attempted to ignore the message and 
attack the messenger, challenging GAO's methodology and 
expertise. It is disappointing the departments took defensive, 
even petulant, exception to GAO findings and recommendations to 
improve the quality of health care for Gulf war veterans and 
refocus the research agenda on treatment.
    Just as distressing was the position taken on this report 
by the President's Advisory Committee on Gulf War Veterans' 
Illnesses [PAC]. GAO challenged the PAC's conclusions 
supporting stress as a major cause of Gulf war illnesses, 
minimizing the threat of Leishmaniasis, and dismissing the 
long-term health effects of organo-phosphates exposure.
    DOD and, to a lesser extent, the VA endorse these 
conclusions. By entering into a joint defense of the status quo 
with the very departments they are charged by the President to 
oversee, I fear the PAC may have lost sight of a solution and 
become part of the problem.
    When the President's Advisory Committee issued their final 
report in January, the Special Assistant to the President and 
Senior Director for Gulf War Illnesses, Rear Admiral Paul 
Busick, said the administration's future mission for the PAC 
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.''
    Yet, when the GAO, complying with a congressional mandate, 
reports persistent flaws in that process ``are likely to 
prevent researchers from providing precise, accurate and 
conclusive answers regarding the causes of veterans' 
illnesses,'' the administration's watchdog only growls at the 
messenger. This report, and the telling responses it has 
evoked, add weight to the argument that the riddle of Gulf war 
veterans' illnesses will never be solved from inside the 
Pentagon or the VA.
    Today, on Thursday, and in the weeks ahead, this 
subcommittee will discuss how issues affecting the health of 
Gulf war veterans can be liberated from the constraints of 
military doctrine and medical bureaucracy and how the Gulf war 
research agenda might be more effectively controlled by an 
independent body veterans and others can trust.
    As in the past, the GAO plays an important role in those 
discussions. And we welcome their testimony.
    At this time the chair would recognize Mr. Sanders.
    [The prepared statement of Hon. Christopher Shays follows:]
    [GRAPHIC] [TIFF OMITTED] T3150.001
    
    [GRAPHIC] [TIFF OMITTED] T3150.002
    
    Mr. Sanders. Thank you very much, Mr. Chairman. And let me 
just express to you my pride in working with you and my belief 
that you have taken this whole issue as far as it has gone, 
plus you've worked in a nonpartisan way. You've been 
extraordinarily persistent. So I congratulate you and your 
staff for all of the work that they have done.
    With your permission, Mr. Chairman, I would like to submit 
a document for the record. And this document is a letter to the 
Presidential Advisory Committee dated June 20, 1997, drafted by 
my office and signed by 86 Members of the Congress. And in this 
letter, 86 Members of the Congress agreed that the Presidential 
Advisory Committee needs to reassess its conclusion that 
``current scientific evidence does not support a causal link 
between Gulf veterans' illnesses and exposures while in the 
Gulf region to the following environmental risk factors 
assessed by the committee: pesticides, chemical and biological 
warfare agents, vaccines, pyridostigmine bromide, infectious 
diseases, depleted uranium, oil well fires, and smoke and 
petroleum products.''
    In other words, when I took this letter around to our 
colleagues, I found very few Members who believed that stress 
and stress alone was the cause of Persian Gulf illness. I think 
all of us recognize the important role that stress plays, but 
very few Members--and I think very few people in the United 
States of America--believe that stress alone, as the 
Presidential Advisory Committee suggested, is the cause of 
Persian Gulf illness.
    While we have not yet received a formal response from the 
Presidential Advisory Committee, as you indicated in your 
comments, once again, they are defensive, and, once again, they 
continue to go forward and suggest that anybody who is talking 
about the role that chemicals have played doesn't understand 
what they are talking about. I think--let me just give you a 
couple of examples of the problems that I've had with the 
Presidential Advisory Committee.
    A couple of weeks ago I wrote a letter to the committee 
because I noticed that, interestingly enough, the DOD in 1995 
did a study. And you know what their study concluded? Their 
study concluded that pyridostigmine bromide combined with DEET 
and combined with hermathrine has a synergistic effect much 
more than the additive effect. When you combine the three it 
has a significant effect on lethality. I found it very 
interesting that in the Presidential Advisory Committee final 
report, the word ``significant'' was changed, and it became a 
``slight.'' The word ``significant'' went to ``slight.'' I 
found it interesting in reading New York Times articles that 
when the DOD itself had done the right research--New York 
Times, Wednesday, May 14 headline: ``Study Links Memory Loss to 
Nerve Gases in Gulf.'' Interestingly enough, the researcher, 
Dr. Pender-gast, says, ``I don't think it's too early to draw 
conclusions. The type of exposure regime that we employed in 
the animals and the type of exposures that our troops 
experienced in the Gulf are analogous. And the types of memory 
deficits that we've seen in the animals and those reported by 
Gulf War patients are extremely similar.''
    In other words, the DOD researcher says, I think we're 
making progress. What does the DOD say in response to their own 
study? ``In a statement today the Pentagon praised the 
experiments as important, but the Department said, `These 
initial findings require replication in other species, 
including non-human.' ''
    ``The Pentagon also questioned whether the experiments in 
which the rats were infected with the chemicals over a 2-week 
period offered many clues to the health problems of the 
veterans. `The shroud of administration and duration of 
exposure does not parallel any known human exposure to troops.' 
''
    So in other words, you have this irony. The DOD does the 
research. The guy that does the research says, I think we've 
made an important finding. And the DOD attempts to minimize 
what their own research has done. On and on we have had 
testimony from witnesses here who have told us they were--Dr. 
Tucker, remember Dr. Tucker? Fired because he had the courage 
to go outside of the parameters established by the PAC.
    Dr. Mira Sheyavitz, who is a physician who formerly worked 
at the VA hospital, Northampton, MA, believed that chemicals 
played a role. She developed a protocol for treatment--did not 
get her research funded.
    Dr. Claudia Miller, who you have had before this committee, 
also was in line to receive funding to look at chemicals; did 
not get funded.
    Dr. James Morse, after concluding that PB and DEET, when 
combined, produce toxic effects on cockroaches, was terminated 
from his employment with the Department of Agriculture.
    On and on and on it goes. When conclusions arise that seem 
to go beyond the paradigm established by the DOD and VA, those 
researchers get the short shrift. I agree with you, Mr. 
Chairman. I think the time is now to say, thank you very much, 
DOD and VA, you've had your opportunity, you've had the last 5 
years--you haven't done it. I think we've got to go outside the 
DOD and the VA. I think we need a Manhattan-type project, as 
I've said before.
    I think the National Institute of Environmental Health 
Studies might be a good start. They are interested in looking 
at the role that chemicals have played. And I also want to 
conclude simply by congratulating the GAO for their research 
and in helping us understand the failures of what the DOD and 
the VA have done. Thank you very much, Mr. Chairman.
    [The prepared statement of Hon. Bernard Sanders and the 
letter referred to follow:]
[GRAPHIC] [TIFF OMITTED] T3150.003

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[GRAPHIC] [TIFF OMITTED] T3150.016

    Mr. Shays. Before recognizing other Members, I would just 
like to ask unanimous consent that all members of the 
subcommittee be permitted to place any opening statement in the 
record and that the record remain open for 3 days for that 
purpose. And without objection, so ordered. And further ask 
unanimous consent that all witnesses be permitted to include 
their written statements in the record. And without objection, 
so ordered.
    [The prepared statements of Hon. Edolphus Towns and Hon. 
Benjamin A. Gilman follow:]
[GRAPHIC] [TIFF OMITTED] T3150.017

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[GRAPHIC] [TIFF OMITTED] T3150.024

    Mr. Shays. And at this time, the vice chairman of the 
subcommittee, Mr. Snowbarger.
    Mr. Snowbarger. Thank you, Mr. Chairman. With the 
opportunity to place opening statements in the record, I'm 
anxious to hear what the witnesses have to say today. And I'll 
pass on an opening statement.
    Mr. Shays. I thank the gentleman. Mr. Kucinich, you have 
the floor.
    Mr. Kucinich. Thank you very much, Mr. Chairman, members of 
the committee. I want to thank you again for your persistent 
efforts in this area of studying the Gulf war syndrome. As I've 
had the opportunity to be on this committee and to hear the 
Chair's appeal for more information, I keep thinking about the 
men and women who were called to serve this country and who do 
serve this country, and how when they move forward to defend 
this country, if they become hurt as a result or injured or ill 
as a result of that defense, then it's the country's 
responsibility to defend them.
    And it's very clear from the evidence which has been 
presented that our country has failed to defend the people who 
have defended this country. The Department of Defense, in its 
many years of dealing with this, has become twisted in its 
approach. As it focuses its efforts in protecting America's 
interests against outside enemies, when confronted with the 
serious possibility of its own ineptitude, its own failures, 
its energies have become twisted and rechanneled to calling our 
very own troops an enemy. And the insistence of our troops on 
simple justice somehow becomes an impediment to the working of 
the Department of Defense.
    It's unfortunate that those who have handled this issue in 
the Department of Defense have not had the perceptiveness or 
the concern to determine the true causes of the Gulf war 
syndrome as this study has done. And you know, Mr. Chairman, as 
I think about it, you wonder, what does this say about the 
ability of those who are running the Department?
    Because I don't think we can look at these things in 
isolation. Because if we would take something as important as 
the treatment of our very own soldiers, or in this case, the 
mistreatment, and use that as a measure of how the Department 
is run, it really raises questions much larger than the scope 
of this committee about the Nation's defense. How do we treat 
our soldiers? How do we treat our veterans? Do they deserve the 
kind of cover-up which has ensued throughout the history of 
dealing with this Persian Gulf syndrome?
    I'm grateful to be on a committee which has the integrity 
and the willingness to look into questions that other branches 
of the Government haven't. And I'm looking forward to the 
presentation of the GAO report. And once again, I want to thank 
Chairman Shays for his dedication to the American people and to 
veterans and to those in the service who really rely on you and 
on this committee for an opportunity to receive some simple 
justice. Thank you.
    Mr. Shays. Thank the gentleman. Mr. Allen.
    Mr. Allen. Thank you, Mr. Chairman.
    Mr. Shays. I'm sorry. Mr. Pappas, you would be recognized. 
Excuse me, Mr. Allen.
    Mr. Pappas. Thank you, Mr. Chairman. I want to thank the 
folks for being here today. And Mr. Chairman, I want to commend 
you for calling this hearing, which is really the continuation 
of an effort that you began, I know, prior to my serving in 
Congress. But certainly I've been fortunate to participate in 
other hearings concerning the Persian Gulf war syndrome.
    The recent GAO report that has been issued on the subject 
is, quite frankly, very disturbing. The notion that both the 
Department of Defense and the Department of Veterans' Affairs 
did not do a thorough job in addressing the health concerns of 
our Gulf war veterans unfortunately is not surprising when one 
considers it took the Pentagon to admit that at least 20,000 
soldiers were presumed to be exposed to chemical weapons.
    Mr. Chairman, in past hearings conducted by the 
subcommittee, veterans have testified about their difficulty in 
getting a proper diagnosis and treatment from both the DOD and 
the VA doctors. Unfortunately, many of them, it was suggested 
that they are just suffering from some mental illness. But this 
report underscores the need to have an independent panel review 
this evidence and help address the concerns of our Nation's 
veterans.
    I look forward to hearing the testimony by the GAO today on 
their study. I hope corrective measures can begin soon to help 
our veterans, who are coping with their illness. We certainly 
owe it to them. I thank the chairman.
    [The prepared statement of Hon. Michael Pappas follows:]
    [GRAPHIC] [TIFF OMITTED] T3150.025
    
    Mr. Shays. I thank the gentleman. I'm sorry, Mr. Allen. You 
do now have the floor.
    Mr. Allen. Thank you, Mr. Chairman. I appreciate your 
leadership, that of Mr. Sanders and the other members of this 
committee, in examining the effectiveness of the Federal 
Government, especially Departments of Defense and Veterans' 
Affairs, in identifying the causes and the appropriate 
treatment for the deteriorating health of so many of our 
veterans who served in Desert Storm.
    There are about 697,000 men and women of our armed forces 
who served in the Persian Gulf. And hundreds of thousands are 
suffering from a series of debilitating ailments. And it is 
disheartening and alarming that the Federal agencies 
responsible for their medical care have failed on three fronts, 
according to this recent GAO report.
    The GAO found that, No. 1, that the Departments of Defense 
and Veterans' Affairs have failed to determine whether ill 
veterans have improved or deteriorated since their first 
diagnostic examination. Second, the current research will not 
provide precise, accurate, and conclusive answers because of 
the formidable methodological problems. And this research also 
lacks a precise, focused approach. Third, the President's 
Committee reached several conclusions in its final report 
without sufficient evidence. It seems clear to me that the 
Federal Government has failed in its efforts to address the 
cause and treatment of Gulf war illnesses, and renewed efforts 
must be undertaken to improve the monitoring of clinical 
progress and to explore new avenues in medical research.
    I do not underestimate the difficulty of this project, 
because the causation of these kinds of illnesses is so much 
more complex than the kinds of illnesses that most doctors, 
including military doctors, are trying to deal with on a normal 
basis. It requires more information, more comprehensive 
information from a wider variety of sources than is typical. 
But nevertheless, the fundamental point is, we sent our men and 
women to the Persian Gulf. We have ignored their concerns and 
their complaints for too long. And it is time to figure out how 
to set the record straight, how to take care of the veterans 
who have been suffering, how to figure out what happened, and 
now what we do about it.
    And I want to thank those who are here to testify today. I 
look forward to hearing your testimony. Thank you, Mr. 
Chairman.
    Mr. Shays. I thank the gentleman. At this time we will call 
our first and only panel. That's Dr. Donna Heivilin, Director 
of Planning and Reporting, General Accounting Office, 
accompanied by Mr. Kwai Chan, Director of Special Studies and 
Evaluation Group, and Dr. Sushil Sharma, Assistant Director of 
Special Studies and Evaluation Group. All three are at GAO.
    [Witnesses sworn.]
    Mr. Shays. For the record, all three have responded in the 
affirmative. Please be seated. I extended my apology to the 
committee for being late, and I would like to extend my apology 
to the three of you and to our guests as well. It is good to 
have you here today. And thank you. Dr. Heivilin, we're not 
going to put a clock on your testimony. This is just one panel. 
And by the way, we will be having the DOD and the VA come 
before us on Thursday, so I'm sure we will be hearing more 
about their view of your report. But we want you to give your 
testimony, maybe not in its entirety, but almost.

    STATEMENTS OF DONNA HEIVILIN, DIRECTOR OF PLANNING AND 
REPORTING, GENERAL ACCOUNTING OFFICE, ACCOMPANIED BY KWAI CHAN, 
   DIRECTOR OF SPECIAL STUDIES AND EVALUATION GROUP, GENERAL 
  ACCOUNTING OFFICE; AND SUSHIL SHARMA, ASSISTANT DIRECTOR OF 
SPECIAL STUDIES AND EVALUATION GROUP, GENERAL ACCOUNTING OFFICE

    Ms. Heivilin. All right. Mr. Chairman, members of the 
subcommittee, I'm very pleased to be here today. Thank you for 
the invitation. I will submit the full statement for the record 
and I will summarize somewhat. I'll skip a few of the areas, 
like background.
    In our work which we released yesterday, which was mandated 
by the 1997 National Defense Authorization Act, we addressed 
three issues. The first issue was the DOD and VA provisions for 
following up on the illnesses of the Gulf war veterans. The 
second, we looked into the coherence of the Government's 
research strategy. And the third issue we looked at was the 
consistency of key official conclusions with the available data 
on the causes of the Gulf veterans' illnesses.
    I'd like to summarize our conclusions about those three 
issues and then provide a little more detail. First, regarding 
the first issue, DOD and VA have made no provisions to followup 
on the condition of the Gulf war veterans. We found neither DOD 
nor VA have any means of knowing whether the Gulf war veterans 
who are ill are better or worse off than when they were first 
examined.
    As to the second issue, which is the coherence of the 
Government's research strategy, we believe that the Federal 
research has not been pursued proactively. Although health 
problems surfaced in the early 1990's, the vast majority of the 
research was only started in 1994 or later. And some will not 
be completed until the year 2000 or beyond. About 80 percent of 
it is still ongoing. The majority of the research--close to 
one-half--is focused on descriptive epidemiological studies as 
prevalence of cause. Little of the research is looking into 
effective treatments.
    The epidemiological research is to determine the nature and 
cause of a particular illness. And the objective is to develop 
clues as to the treatment through building hypotheses and 
refining them and improving them. An example where this worked 
really well was research that was done into cholesterol, in 
which the researchers were able to relate higher blood levels 
of cholesterol to heart disease. And from there they went on to 
develop hypotheses and treatment for people who had high 
cholesterol so that their susceptibility would be lower in the 
future.
    The problem, when we looked at the epidemiological research 
that's going on with the Gulf war veterans, is that there are 
scanty records on who was exposed to what, when, or on the 
vaccines or doses of drugs and amounts that were given to 
individual veterans. And their memories are unreliable or they 
may not have known what they were exposed to at the time that 
they were exposed. Consequently, it's quite likely that many of 
the epidemiological studies will produce results that are 
inaccurate or difficult to interpret when they're finished.
    Another large number of the studies--about a third of 
them--are pursuing the hypotheses that stress is a major 
contributing factor to the illnesses. We didn't find this 
research supportive of the Presidential Advisory Committee's 
conclusion that stress is a major contributing factor to the 
range of symptoms the veterans are reporting. And some 
hypotheses, such as symptoms are due to exposure to pesticides 
and chemicals used in the Gulf war, were initially funded only 
with private funds.
    The bottom line is that not much of the research as 
currently being carried out is going to result in answers on 
how best to treat these illnesses. And it is unlikely to reveal 
the causes of the illnesses when the research is finished.
    Our third issue drew the most controversy. We found the 
support for some official conclusions regarding stress, 
Leishmaniasis, and exposure to chemical agents was weak or 
subject to alternative conclusions. We believe you should not 
close the doors prematurely to causes without evidence. Six 
years after the war, we know little about the causes of the 
illnesses conclusively. The link between stress and the 
veterans' physical symptoms is not well-established. The 
prevalence of post traumatic stress disorder may be 
overestimated.
    Leishmaniasis needs to continue to be considered as a 
possible future risk, since it can lie dormant for up to 20 
years. And there is substantial evidence that organophosphate 
compounds, which were in pesticides used during the war and in 
chemical nerve agents Iraq possessed, might be associated with 
delayed or long-term health effects. A number of the veterans 
were evidently exposed to chemical fallouts. And although we 
have no evidence that they used it, Iraq had weaponized the 
biological agent aflatoxin, whose health effects appear years 
after exposure, generally in the form of liver cancer.
    I would like to spend a little bit of time talking about 
the methodology we used in doing our research. To address the 
first evaluation question--whether DOD and VA had a way of 
following up and knowing whether the veterans were in better 
health now or worse health than they were when they were first 
examined--we reviewed the literature, agency documents, 
conducted structured interviews with DOD and VA officials. We 
asked some questions designed to identify and contrast their 
methods for monitoring the quality and outcomes of treatment 
and diagnostic programs and the health of the registered 
veterans.
    For our second objective, which concerns the coherence of 
the research strategy of the Government, to answer the question 
we conducted a systematic review of pertinent literature and 
agency documents and reports. We also interviewed 
representatives of the Persian Gulf Veterans Coordinating Board 
research working group and officials of VA, DOD and the Central 
Intelligence Agency. We surveyed primary investigators--over 70 
percent of them--who were doing the epidemiological studies.
    And because of different methodology standards applied to 
various types of research and because of the overwhelming 
majority of federally-sponsored researches categorized as 
epidemiological, we limited our survey to those responsible for 
those studies.
    With the help of an expert epidemiological consultant, we 
devised a questionnaire which assessed critical elements of 
those studies, including quality of exposure measurement, 
specificity of the case definition, steps taken to ensure 
adequate sample size, and specific problems that the primary 
investigators may have encountered in implementing their 
studies.
    We also reviewed and categorized descriptions of all 91 
projects which were identified by April 1997, based on their 
apparent focus and primary objective. And finally, to review 
the progress of the major ongoing research efforts, we visited 
Walter Reed Army Institute of Research, the Navy Health 
Research Center, and two of VA's environmental hazards research 
centers.
    On the third objective, we reviewed the major conclusions 
of the PGVCB and the Presidential Advisory Committee to 
determine the strength of evidence supporting their major 
conclusions. The purpose of this review was not to critique 
their efforts, per se, but rather, to describe the amount of 
knowledge about the illnesses that has been generated by 
research 6 years after the war. We reviewed these conclusions 
because they are the strongest statements that we found on 
these matters by any official body.
    The Presidential Advisory Committee's report was 
significant because the panel included a number of recognized 
experts. It was assisted by a large staff of scientists and 
attorneys. And in addition, they conducted an extensive review 
of the research. Thus, we believed that evaluating those 
conclusions would provide important evidence about how fruitful 
the Federal research had been thus far.
    We reviewed scientific literature and we consulted experts 
in the field of epidemiology, toxicology, and medicine. To 
ensure that the staff conducting this work had the appropriate 
backgrounds, we staffed this job with staff who had expertise 
in epidemiology, psychology, environmental health, toxicology, 
engineering, weapon design, program evaluation and methodology.
    And in addition, using the process we have to bring in 
experts that we don't have assigned full-time on a job but 
whose expertise we can use when needed in conducting our 
research, we included experts from our organization who have 
expertise in chemical and biological warfare and military 
health systems. We also had medical experts review our work. 
And we had extensive discussions with experts in academia in 
each of the substantive fields relevant to the issue.
    And finally, we talked to a number of authors of the 
studies that we cited in the report to ensure that we had 
correctly interpreted their findings. And we had independent 
experts review our draft report. In addition, we were in 
compliance with all of the general practices and policies that 
we have inside of GAO to ensure that we had quality assurance 
in doing our work.
    I will now spend some time talking about the fact that DOD 
and VA have no systematic approach to monitoring the Gulf war 
veterans' health after the initial examination. Over 100,000 of 
about the 700,000 Gulf war veterans have participated in the VA 
and DOD examination programs. Nearly 90 percent have reported a 
wide array of health complaints and disabling conditions.
    Most commonly reported symptoms are fatigue, muscle and 
joint pain, gastrointestinal complaints, headaches, skin rash, 
depression, neurological and neurocognitive impairments, memory 
loss, shortness of breath, and sleep disturbances. Officials in 
both DOD and VA claim that regardless of the illnesses, the 
veterans are receiving the appropriate treatment.
    Both agencies have tried to measure and ensure the quality 
of their initial examinations through standards such as 
training that is given to medical physicians and the standards 
for physician qualification. However, these mechanisms don't 
ensure a given level of effectiveness for the care that is 
provided or permit identification of the most effective 
treatments.
    We found they had no monitoring mechanisms for determining 
the quality, the appropriateness or the effectiveness of the 
care that they're getting after the initial examinations.
    We believe such monitoring is important because undiagnosed 
conditions are not uncommon among the ill veterans, and 
treatment for the veterans with undiagnosed conditions is based 
on their symptoms. And veterans with undiagnosed conditions or 
multiple diagnoses may be seeing multiple providers. And 
without the followup, we cannot say whether these ill veterans 
are any better or worse today than they were when they were 
first examined.
    The issue--I'll spend a little time now delving a little 
deeper into the second issue, which is that the Federal 
research strategy lacks a coherent approach. As I said earlier, 
we do not believe that the illness and the factors that might 
have caused the problems have been pursued proactively. And 
although the health problems began surfacing in the 1990's, the 
vast majority of the research was not initiated until 1994 or 
later.
    Although many of the--we have about 91 studies ongoing--
over four-fifths of them are not yet complete. And many of the 
results will not be available until the year 2000. We found 
that some of the hypotheses received early emphasis while some 
hypotheses were not initially pursued. The research on the 
exposures to stress received early emphasis. And research such 
as research on low-level chemical exposure was not pursued 
until it was legislated, in 1996.
    The failure to fund some research cannot betray us to the 
absence of investigator submissions. There were proposals. 
According to the DOD officials, three recently funded proposals 
on low-level chemical exposure had previously been denied 
funds. And we found that additional hypotheses were pursued in 
the private sector. A substantial body of research suggests 
that low-level exposure to chemical warfare agents or 
chemically related compounds such as pesticides is associated 
with delayed or long-term health effects.
    Regarding the delayed health effects of organophosphates, 
the chemical family that's used in many pesticides and chemical 
warfare agents, there is evidence from animal experiments, 
studies of accidental human exposures and epidemiological 
studies of humans at low-level exposures that certain of these 
compounds, including sarin nerve agents, to which some of the 
troops may have been exposed, cause delayed chronic neurotoxic 
effects.
    It has been suggested that the ill-defined symptoms 
experienced by the veterans may be due in part to 
organophosphate-induced delayed neurotoxicity. This hypothesis 
was tested in a privately supported study. In addition to 
clarifying the patterns among veterans' symptoms by using 
statistical factor analysis, the study demonstrated that vague 
symptoms of the ill veterans are associated with objective 
brain and nerve damage compatible with the known chronic 
effects of exposure to low levels of organophosphates.
    And it further linked their illnesses to exposure to a 
combination of chemicals, including nerve agents, pesticides, 
and flea collars, DEET, which is a roll-on insect repellant, 
and PB tablets. Toxicological research indicates that PB, which 
the Gulf veterans took to protect themselves against the 
immediate life-threatening effects of nerve agents, may alter 
the metabolism of organophosphates in ways that activate 
delayed chronic effects on the brain.
    Moreover, exposure to combinations of these chemicals has 
shown in animal studies to be far more likely to cause 
morbidity and mortality than any of the chemicals acting alone. 
We found that the bulk of the ongoing research in the illnesses 
focuses on the epidemiological study of the prevalence and the 
cause of the illnesses. I discussed that earlier, so I will 
move on into some of the things that we have noted as 
challenges to the researchers who are conducting these studies.
    First, as I said, they found it difficult to gather 
information about exposures to such things as oil well fire 
smoke and insects carrying infection. DOD has acknowledged that 
the records of the use of PB and vaccinations to protect 
against chemical and biological warfare exposures were 
inadequate. There is research going on right now to try to find 
the majority of the records, which seem to be missing.
    Gulf war veterans were typically exposed to a wide array of 
agents. And it's difficult to isolate and characterize the 
effects of the individual agents or to study their combined 
effects. Most of the studies on the Gulf war veterans' 
illnesses have relied only on self-reports for measuring most 
of the agents to which they have been exposed. And it is 
difficult years after the war to be accurate and not to be 
biased about the recollection of what in fact they were exposed 
to during the time that they were over in the Gulf.
    As a result, the findings from these studies may be 
spurious or equivocal. Classifying the symptoms and identifying 
illnesses of Gulf war veterans has been difficult. From the 
outset symptoms reported by the veterans have been varied and 
difficult to classify in one or more distinct illnesses. 
Moreover, several different diagnoses may provide plausible 
explanations for some of the specific health complaints.
    It has thus been difficult to develop a case definition--
that is, a reliable way to identify individuals with a specific 
disease. And this is a criterion for doing effective 
epidemiological research.
    In summary, as I stated earlier, the ongoing 
epidemiological research will not be able to provide precise, 
accurate, and conclusive answers regarding the causes of the 
illnesses because of these formidable methological problems.
    I'll move now to our last area of investigation, which was 
the support for key Government conclusions, which we found to 
be weak and subject to alternative interpretations. As I had 
mentioned, we looked at the conclusions drawn by the 
Presidential Advisory Committee because this is the major 
printed statement about the Gulf war illness and the research 
that was being endorsed.
    DOD endorsed the Committee's conclusions about the 
likelihood that exposure to 10 commonly cited agents 
contributed to the explained and unexplained illnesses of the 
veterans. We found evidence to support three of these 
conclusions either weak or subject to alternative 
interpretations. And I'll discuss those now.
    First, the Committee concluded that stress is likely to be 
an important contributing factor to the broad range of 
illnesses currently being reported by the Gulf war veterans. 
But while stress can induce physical illness, the link between 
stress and these veterans' physical symptoms has not been 
firmly established. For example, a large scale federally funded 
study concluded that for those veterans who deployed to the 
Gulf war and currently reported physical symptoms, neither 
stress nor exposure to combat or its aftermath bear much 
relationship to their distress.
    The Committee stated that epidemiological studies to assess 
the effects of stress invariably found higher rates of post 
traumatic stress disorder in Gulf war veterans than among 
individuals in nondeployed units or in the general U.S. 
population of the same age. Our review indicated that the 
prevalence of PTSD among the veterans may be overestimated due 
to problems in the methods they use to identify it.
    Specifically, these studies to which the Committee refers 
have not excluded other conditions such as neurological 
disorders that produce symptoms similar to PTSD and can also 
elevate scores on the key measures of the PTSD. Also the use of 
broad heterogeneous groups of diagnoses in data from DOD's 
clinical program may contribute to overestimation of the extent 
of the serious psychological illnesses among the Gulf war 
veterans.
    Second, the Committee concluded that it's unlikely that 
infectious diseases endemic to the Gulf region are responsible 
for long-term health effects on the forward veterans except in 
a small number of known individuals. Similarly, the PGVCB 
concluded that because of the small number of reported cases, 
the likelihood of Leishmania tropica as an important risk 
factor widely reported has diminished. While this is the case 
for observed symptomatic infection with a parasite, the 
prevalence of asymptomatic infection is unknown.
    And such infection may re-emerge in cases in which the 
patient's immune system becomes deficient some time in the 
future. As the Committee noted, the infection may lie dormant 
up to 20 years in the human system. And because of this long 
latency, the infected population is a hidden population and 
even in classic forms of Leishmaniasis, it's difficult to 
recognize. We believe that it should be retained as a potential 
risk factor for individuals who suffer from immune deficiency.
    Third, the Committee concluded that it's unlikely that the 
health effects reported by many of the veterans were the result 
of biological or chemical warfare agents, depleted uranium, or 
oil well fire smoke, pesticides, petroleum products, and PB or 
vaccines. However, our review of the conclusions indicated that 
while the Committee found no evidence that biological weapons 
were deployed during the war, the United States lacked the 
capacity to promptly detect biological agents, and the effects 
of one agent, aflatoxin, would not be observed for many years. 
And this agent was weaponized by the Iraqis.
    Evidence from various sources indicates that chemical 
agents were present at Khamasiyah, Iraq and elsewhere on the 
battlefield. The magnitude of the exposure to chemical agents 
has not been fully resolved. And as we recently reported, 16 of 
the 21 sites categorized by the Gulf war planners as nuclear, 
biological, and chemical facilities were destroyed.
    However, the United Nations Special Commission found after 
that war that not all the possible NBC target had been 
identified by U.S. planners. The Commission has investigated a 
large number of the facilities suspected by the U.S. 
authorities as being NBC-related. And regarding those, the 
Commission has not yet inspected, we determined that each was 
attacked by coalition aircraft during the Gulf war. And one of 
these sites is located within the Kuwait theater of operation 
in close proximity to the border where coalition ground forces 
were located.
    Also, exposure to certain pesticides can induce a delayed 
neurological condition without causing immediate symptoms. And 
available research indicates that exposure to PB can alter the 
metabolism of organophosphates. This is the chemical family of 
some of the pesticides that were used in the Gulf war as well 
as certain chemical warfare agents. The metabolism can be 
altered in ways that enhance chronic effects of the brain.
    In our report we have three recommendations coming from the 
work that I have just described. First, because of the number 
of Gulf war veterans who continue to experience illnesses and 
that these illnesses may be related to their service in the 
war, we recommended that the Secretary of Defense and the 
Secretary of Veterans' Affairs set up a plan for monitoring 
their clinical progress so that we can help promote effective 
treatment, better direct the research agenda, and we also 
recommended they give greater priority to research on effective 
treatment for the ill veterans and on low-level exposures to 
chemicals and their interactive effects and less priority to 
further epidemiological studies.
    We also recommended that the Secretaries of Defense and 
Veterans' Affairs refine the current approaches of the clinical 
and research programs for diagnosing PTSD consistent with 
suggestions recently made by the Institute of Medicine. The 
Institute noted the need for improved documentation of 
screening procedures and patient histories, including their 
occupational and their environmental exposures and the 
importance of ruling out alternative causes of impairment.
    Mr. Chairman, this concludes my prepared remarks and Dr. 
Sharma and Mr. Chan will be happy to help me answer questions 
that you may have at this time.
    [The prepared statement of Ms. Heivilin follows:]
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    Mr. Shays. Thank you very much for your testimony. I'm 
struck by the fact that you broke a basic rule of investigators 
that are trying to get at the truth in this sense: An 
individual who is investigating political corruption in a 
community and determined that there were about 250 people who 
had been corrupted by the process of civil service, getting 
promotion, buying their way; he said he succeeded because in 
the end what he did was just went after one at a time. And the 
others hid behind the rocks. And then he tipped that rock. 
Finally, they realized that he was going after all of them, but 
by then it was too late.
    You have had a very clear criticism of not just the VA but 
the DOD and the Presidential Advisory Commission on Gulf War 
Illnesses. I don't think you have many friends left in that 
community. And I'm concerned about it, frankly. But I 
congratulate you for your courage. And I know that your report 
will be thoroughly digested by many. In the end, I think that 
it will result in some significant progress. So I really am in 
awe of your courage, frankly.
    In your statement on page 18--let me just say one more 
thing. It is no accident that this committee is the one that 
has had now our ninth hearing on Gulf war illnesses. And the 
reason is that we oversee the Department of Veterans' Affairs 
for waste, fraud, and abuse. We're not the statutory committee 
that provides legislation. We're not the appropriators.
    I have found a tremendous reluctance in Congress on the 
part of the Armed Services Committee in the House and the 
Senate to thoroughly examine the DOD and its work because of 
the relationship that exists between that committee and the 
DOD. I have found a surprising reluctance on the part of the 
Veterans' Administration Committee to thoroughly examine what 
the Veterans' Administration has done. I have found a 
reluctance on the part of individuals to look at what the CIA 
has done, and, frankly, the Advisory Committee as well--the 
President's Commission. So this is a very refreshing 
opportunity for us to have you look at all three and point out 
some very, very serious problems with the work of these 
departments.
    Now, on page 18 you talk about--actually it begins on 17. 
You talk about ``evidence from various sources indicates that 
chemical agents were present at Khamasiyah, Iraq, and elsewhere 
on the battlefield. The magnitude of the exposures to chemical 
agents has not been fully resolved. As we recently reported, 16 
of the 21 sites categorized by Gulf war planners as nuclear, 
biological, and chemical facilities were destroyed.'' And then 
you go on. ``However, the United Nations Special Commission 
found after the war that not all the possible NBC targets had 
been identified by U.S. planners.''
    What do you mean first by that? What do you mean, had not 
been identified? There are more than 16?
    Mr. Chan. Let me try to explain the number system here.
    Mr. Shays. Yes.
    Mr. Chan. One is the 21 targets that we're talking about, 
the sites. Those were the sites considered before the war as 
NBC targets. And I cannot talk about what the combination--how 
many of each. At the same time----
    Mr. Shays. I'm not looking for a breakdown of nuclear, 
biological, or chemical.
    Mr. Chan. Right.
    Mr. Shays. But there were 21 sites before the war.
    Mr. Chan. But in fact, what we did is found out after the 
war, that DOD had identified 34 so-called suspected sites where 
chemical weapons could have been either stored or placed 
somewhere. And it's with those 34 sites that we went to the 
CIA, the DIA, and UNSCOM to ask, how many of these sites had 
been inspected and what did they find in those sites.
    It is through that process we found that not all the sites 
had been inspected by the United Nations. You don't want me to 
go through that litany over what happened, but----
    Mr. Shays. Not all of the 34 sites?
    Mr. Chan. Right.
    Mr. Shays. How many were inspected?
    Mr. Chan. Initially CIA told us a number.
    Mr. Shays. They did not tell you a number?
    Mr. Chan. Yes, they did. But then they decided it's secret, 
classified, subsequently.
    Mr. Shays. OK.
    Mr. Chan. So I cannot tell you how many were not inspected.
    Mr. Shays. Right.
    Mr. Chan. Whereupon, they identified the sites. And since 
they obtained the information by UNSCOM they classified those 
uninspected sites as secret NONFOR. That means no foreigners 
can see it. So as a result, we went back to the U.N. and asked 
them to tell us. And they directed us to the DIA for that set 
of information. DIA, in turn, said, no, you're incorrect, CIA 
didn't tell you the accurate numbers--in fact, all 34 sites 
have been inspected.
    Whereupon, they directed us to a specific person in CIA to 
confirm that fact. And we went back to CIA, and CIA sent us a 
memo saying, we stand by from our first letter that was sent to 
you, which was classified. So, we are left with two sets of 
information. And whereupon, I sent a letter to the U.N. asking 
them, listing all the sites and saying, to check the ones they 
inspected.
    And they came out with a different set of numbers, which is 
a little more than the CIA, but confirmed, in fact, these were 
uninspected sites. So what I did is ask our own staff to 
investigate and look at the data in terms of bombing. In our 
own study for a different one we have over one point some-odd 
million pieces of data on every single bomb wherever it was 
dropped and when and so on. And we confirmed that those 
uninspected sites had been bombed by allied aircraft.
    So as a result, we said, OK, then, why weren't they 
inspected if they were bombed and they were suspected chemical 
sites? Whereupon, United Nations basically said, you know, the 
inspection criteria is our own, not of the United States, which 
we accept. But in our report to you, in this report we issued 
today, basically, we just said that we left that issue open. 
Because we really don't know--one--whether there were, in fact, 
chemicals stored in that place. And we were disallowed in 
telling you where it is, because while we were told it was not 
really classified, per se, but, in fact, it's highly sensitive 
for people to know what it is. And so that's the language we 
arrive at in our final report. Did I answer your question? I'm 
just as confused.
    Mr. Shays. Well, no. We're not going to be confused by the 
time we're done here. Maybe not today.
    Mr. Chan. OK.
    Mr. Shays. Really, what you're describing to me is as 
blistering as your report appears to be, you left out a lot of 
very interesting information that needs to be examined.
    Mr. Chan. Yes.
    Mr. Shays. And what you can say on the record--and we'll 
sort out the differences and what's secret and what isn't 
later--that originally we went in thinking there were 21 sites. 
We realized during the process of the war there were 34 
potential sites. And that right now we do not have a clear 
picture as to how many of those sites were actually examined 
after the war. Is that correct?
    Mr. Chan. Right. And the United Nations basically agrees 
that some of these sites were not inspected by them.
    Mr. Shays. And let me just say, so not only do we not know 
if all of them were done, we do know that some weren't.
    Ms. Heivilin. Right.
    Mr. Chan. Right. Correct.
    Mr. Shays. I mean that's fair. So therein lies the next 
Khamasiyah potentially.
    Mr. Chan. Right.
    Mr. Shays. If any of them particularly were in the theater 
of the Kuwait battle. Now, were any of those sites in that 
theater?
    Mr. Chan. No. They were not.
    Mr. Shays. None of those sites were?
    Ms. Heivilin. In Kuwait? Was that your question?
    Mr. Shays. Pardon me?
    Mr. Chan. They were not in Kuwait.
    Ms. Heivilin. They are not in Kuwait.
    Mr. Chan. In Iraq.
    Mr. Shays. No, but in the Kuwait theater.
    Mr. Chan. Oh, theater of operation. Yes.
    Ms. Heivilin. Yes.
    Mr. Shays. So in other words, our troops went outside of 
Kuwait, obviously. I care where our troops were.
    Mr. Chan. Yes.
    Mr. Shays. Where our troops were, I call that the Kuwait 
theater.
    Mr. Chan. Theater of operation, yes.
    Mr. Shays. Theater of operation. OK. Were any of those 
sites in that theater of operation?
    Ms. Heivilin. Yes.
    Mr. Chan. Yes.
    Mr. Shays. In addition to Khamasiyah?
    Mr. Chan. Yes.
    Mr. Shays. Now, in Khamasiyah, the only reason that was 
known today was that a veteran actually who was there in the 
demolition team----
    Mr. Chan. Mm-hmm.
    Mr. Shays. Because the difference in some of these sites 
is--that in some of these sites we bombed them and destroyed 
them that way.
    Mr. Chan. Correct. Yes.
    Mr. Shays. So we were kind of a ways from it. Then the 
question was, which way did the plumes go? And we know they 
went in some direction. And we're pretty sure they didn't all 
go in the direction we originated before.
    Now, the significance of Khamasiyah is, that that was the 
site where our soldiers actually went right up to it and laid 
the charges and blew it up.
    Mr. Chan. Mm-hmm.
    Mr. Shays. And when they blew it up, some originally were 3 
miles away or closer--much closer in fact--and as they blew 
this up they started to go farther away because you had 
artillery shells and so on going 6 miles and beyond. You had 
rockets that were going beyond the 6 miles. And you had a 
soldier who had pictures and identified the fact that this was 
also a chemical depo.
    The reason why this information became public was that this 
soldier was invited to our hearing, had the video, had gone to 
the media, and was to testify on a Tuesday. On a Friday 
afternoon, at 4 o'clock after an announcement that the DOD 
would have an important announcement at 12--at 4 o'clock on a 
Friday afternoon--announced for the first time that our troops 
may have been exposed to chemicals--defensive.
    Now, what's fascinating is that the CIA Director at the 
time had said that there was no offensive exposure to 
chemicals, which is a wonderful work that allows him to not be 
in violation technically of the law because the difference 
between offensive and defensive. We blew up this depo. Now, is 
your testimony that there were other chemical plants 
potentially or biological plants or depots in the Kuwait 
theater of operation that may not have been examined?
    Mr. Chan. Yes. But let me correct it. This is in regards to 
chemical sites only, not biological sites.
    Mr. Shays. OK. A chemical site like Khamasiyah.
    Mr. Chan. Yes.
    Mr. Shays. So the word is still out as to whether there's 
another Khamasiyah?
    Mr. Chan. I think one can draw the conclusion that we don't 
know what is there since it wasn't inspected. And our report 
states that we intend to address this question and find out the 
reason why.
    Mr. Shays. Who intends to examine this question? I missed 
who he said.
    Ms. Heivilin. We're still looking into it.
    Mr. Chan. It's an open question in our report that's 
incomplete. And this is a different report. And I left the 
language saying, there's an open question, we--implying GAO--
will examine it, because it's open. I didn't want--it may be 
nothing, it may be something. And that's the implication.
    Mr. Shays. OK. At this time let me call on Mr. Sanders.
    Mr. Sanders. There's so much to discuss and so little time. 
Mr. Chairman, let me briefly, before I ask our guests a 
question, let me briefly summarize something. And then I would 
like them to respond to it. The Presidential Advisory Committee 
ruled that stress is the likely cause of Persian Gulf illnesses 
and that chemicals and other types of exposure are likely not 
to have caused the problem. Very briefly, let me read very 
short summaries of a number of studies.
    Robert Haley, M.D., University of Texas: This research 
project that he did concluded that many veterans are suffering 
from three primary syndromes due to subtle brain, spinal cord, 
and nerve damage, but not distress. You dealt with--I know you 
talked to Dr. Haley.
    Muhammad Abudonia, a Duke pharmacologist--his summary 
conducted on hens concluded that pyridostigmine bromide in 
combination with DEET and hermathrine cause neurological 
deficits in the test animals which are similar to those 
reported by Gulf war veterans. You've talked to him as well, I 
believe, or at least studied his work, right?
    In 1995, the DOD published its own study which concludes, 
``There is a significant increase in the lethal effects in rats 
given pyridostigmine bromide, hermathrine and DEET 
simultaneously.'' You may have been familiar with that study, 
as well, right?
    More recently, Dr. Abudonia conducted another research 
project. And this showed that when rats were given 
pyridostigmine bromide and then put in stressful conditions--
which, God knows, is what existed in the Persian Gulf--
pyridostigmine bromide was able to cross the blood brain 
barrier leading to suppressed ACHE levels.
    Another study conducted by Friedman, Coffer, Shemer and 
others at the Hebrew University in Israel presents evidence 
that stress may make the blood brain barrier permeable to PB. 
Dr. Garth Nicholson, University of Texas, conducted research 
which indicates that many of the symptoms of Gulf war syndrome 
may be caused by chronic pathogenic microplasma infections.
    Dr. Satu Somani, who testified before this committee, sat 
just where you do--he writes or tells us that ``Experimental 
proof and historical evidence of symptoms such as impaired 
concentration and memory, headache, fatigue and depression of 
the workers who worked in the organophosphate industry with 
those considerations, I consider that illness associated with 
Gulf war veterans may be due to low-dose sarin exposure and 
intake of pyridostigmine and exposure to pesticides and other 
chemicals.''
    And on and on and on it goes. So my first question: Given 
what amounts to over a dozen different studies, how does the 
DOD, the VA, and the Presidential Advisory Committee continue 
to believe that stress alone is the cause of Persian Gulf 
illness?
    Ms. Heivilin. That's the question we have also. And I don't 
think we really have an answer to why they continue to believe 
as they believe. Actually, what you're suggesting goes to the 
conclusion, and the recommendation we have that they move their 
research so that they are putting less emphasis on 
epidemiological studies and more emphasis on treatment and 
causes of the nature that you are suggesting.
    Mr. Sanders. I mean, are these researchers and the others, 
are they quacks? Are they dummies? Are they not held up in 
respect in the scientific community? Should we throw out all of 
that research, or is this useful research?
    Mr. Chan. Well, I think if I can go back to the PAC's 
comment to our report and also to their own report, which is 
one of the criteria that they use in selecting research 
articles that they examine and include in their findings--in 
fact, peer review reports. And the list you have, many of them 
are, in fact--were peer reviewed. And so it does not satisfy 
the requirement why they were excluded. And I think if you look 
at on page 44 and 45, we list over a dozen-and-a-half different 
articles that we cite similar to what you have stated. And we 
found that at least there are plausible evidence that suggest 
otherwise.
    I must add a quick comment in your question is that why we 
don't know the reasons why they included and excluded articles. 
It's certainly our criteria, our methodology is--is that when 
one draws these conclusions, one must ask, are there 
conflicting data and results out there? And when we found that, 
we try to reserve behind it and examine those information, 
speak with the authors and so on, make sure we didn't 
misinterpret their stuff, and ultimately raise the question is, 
when something is uncertain, we would leave that stone still 
assume is unturned. OK? And that's the way we approach it.
    And maybe that's why we used the word ``possibly'' open for 
interpretation, because we did not try to attempt to see why 
some of these articles were excluded.
    Mr. Sanders. Thank you. One of the areas of frustration--
and I think you make this point in your report--is that we have 
lost so much time.
    Ms. Heivilin. Yes.
    Mr. Sanders. So much time. Let me mention something to you. 
And I would appreciate if you might comment. In 1993, in 
invited testimony before the Subcommittee on Oversight and 
Investigations of the Committee on Veterans Affairs, Dr. 
Claudia Miller, who is at the University of Texas, called for a 
specialized research facility, an environmental medical unit, 
in order to test scientifically whether ill Gulf war veterans 
were sensitive to very low levels of common chemicals, as many 
of them were reporting.
    Although congressional appropriations for half the cost of 
the facility were obtained through a bipartisan effort and DOD 
agreed to fund the remainder, DOD failed to implement the 
project. No such research facility currently exists that would 
allow physicians to diagnose or rule out chemical sensitivity 
in the veterans.
    She came forward with this proposal which received initial 
approval in 1993. This is 1997. We still have not even done 
that. Would you want to comment on that?
    Ms. Heivilin. Well, it's impossible for us to audit or to 
evaluate and know precisely the motivations of people. What we 
look at--and that's what you're telling us about--is we look at 
the actions and we look at the programs and we look at the 
results of those actions and programs. And again, when we 
looked at the research, we found that the research was very 
heavily focused in a couple of areas and there was very little 
research going after the kinds of things that you've just been 
describing to us.
    As to what the motivations were for the agencies in doing 
what they did do, we really can't attest to that.
    Mr. Sanders. OK. Now, I'm going to ask you a really hard 
question. I think one thing--you know, as I've said a million 
times, this chairman over here is responsible for as many of 
the breakthroughs as any Member of Congress, and I'm delighted 
to serve with him. And I think what neither he or I or any 
other member of this committee wants to do if we come back here 
is 2 years and 4 years from now go over the same discussion 
again, and beat up on the DOD and beat up on the VA and so 
forth and so on.
    Ms. Heivilin. Mm-hmm.
    Mr. Sanders. Now, I personally--and I speak only for 
myself--have reached the conclusion that for whatever reason--
and we can speculate something, for example, that there is 
reluctance for the DOD to go forward in this area because they, 
in fact, administered, among other things, pyridostigmine 
bromide. Right? And we all know that nobody ever intended to do 
any harm to our own people. There's no question about that.
    But if they are the folks who administered pyridostigmine 
bromide to hundreds of thousands of vets, there may in fact be 
consciously or unconsciously a reluctance to go forward, which 
might suggest that that drug in combination with other 
chemicals may be part of the problem.
    Whatever the case may be, do you think, based on your 
analysis, that DOD and VA are in fact capable of getting to the 
root of the problem, capable not only of giving us an 
understanding of the cause of the problem, but of developing, 
more importantly, a treatment? One of the frustrations that 
many of us have had--we want treatments. Maybe not all the 
treatments will work. But I have mentioned, and others know of, 
different treatments out there which might be experimental.
    When I talk to veterans who are hurting, they say, hey, 
give us a shot at it, maybe it works, maybe it doesn't work. 
But why don't we have the opportunity to take advantage of 
those treatments?
    Now, I have reached the conclusion that the DOD and VA, for 
whatever reason, are not going to be able to do the right 
thing. Do you want to give us your view? Do you think that 
they're capable? Should we continue to go forward with them or 
look or other agencies?
    Ms. Heivilin. We're certainly not seeing evidence of a 
nature that says that they're moving out smartly on these 
issues. Maybe as an example in a related area--there were two 
other reports we did as a result of this mandate in the armed 
services legislation last year. And one of them was to look at 
what the progress was in coming up with vaccines or anti-agents 
for future chemical and biological agents that our soldiers, 
sailors, and airmen might encounter in the future.
    It's a classified report, but I'll talk about what I can in 
an unclassified way. Basically, we looked at all of the known 
biological agents held by nations that we could possibly go to 
war with or that are unfriendly with us, not only that hold, 
but ones that could be quickly produced. And we looked at where 
DOD was in having FDA approved drugs--investigational drugs--
and only something in R&D.
    And in the last few years, there has been absolutely no 
progress. Over a number of years, there has been no progress. 
We made a recommendation that they move out smartly, so to 
speak. And they agreed with us. But as I said, there's been no 
progress over the last few years.
    Mr. Sanders. Mr. Chairman, I'm going to stop speaking here 
in a moment.
    Mr. Shays. You have the floor.
    Mr. Sanders. Oh, I have the floor. Let me just say this, 
Mr. Chairman. You know, when a coach on a basketball team or a 
manager on a baseball team continues to produce a losing 
record, we can sit down and talk to the coach or the owners of 
the team sit down and talk to the manager, but finally at a 
certain point you make the conclusion whether that individual 
is capable of doing the right thing for his team.
    Well, we are the owners of this team. And we have an 
obligation to tens and tens of thousands of men and women who 
put their lives on the line defending this country to do the 
right thing by them. And I have concluded, not with a great 
deal of happiness, that, for whatever reason, the VA and the 
DOD are not going to do the right thing.
    I think it is a waste of our time to keep kicking and 
prodding and pushing and questioning them. We can do that for 
the next 20 years. I think ultimately we have got to conclude 
that there are some serious researchers out there, some people 
with minimal research who have done some cutting edge work. 
There are perhaps institutes within our own Government, such as 
the National Institute of Environmental Health Sciences, who 
want to go forward.
    I think other Members of Congress share our frustration. I 
would think that the best thing that we can probably do right 
now is conclude that the DOD and the VA are not going to do the 
right thing, for whatever reason, find people in Government and 
in the private sector who can work together on an emergency 
basis. One of the frustrations that I've had--and I think I 
hear that from you as well--is that there is no sense of 
urgency.
    Studies come out which indicate something. And what's the 
plan? ``Well, we'll continue to do studies. And maybe in 5 
years we'll have another study.''
    Where does it end? Where are the--unless I am missing 
something, Mr. Chairman, one would have thought that after all 
of this time, we would be hearing reports of a dozen different 
treatment protocols, some of which may be working, some of 
which may not be working. Right? It seems to me what we would 
have been hearing if one believed that there was a sense of 
urgency.
    And I don't think that the DOD or the VA have that feeling. 
So I think we owe it to work with our colleagues in the House 
to go outside of the DOD and VA, develop a sense of urgency, 
get some funding, get some time lines for those people who are 
willing to look at many of the questions that the GAO have 
asked. And I just, at this point, want to thank all of you. 
Yes, Mr. Chan?
    Mr. Chan. Let me give a different perspective. I think so 
far what we have been discussing may be sort of half of the pie 
and not the entire thing. And I'm sensing that a lot of the 
criticisms that we're making on the health research, they are 
what scientists call systematic, deliberate, bring the evidence 
forward and arrive at some conclusions.
    And that's a very noble approach to solve a problem. The 
trouble that we're seeing that when you have multiple agents 
with mixes that everybody agrees, to solve the factorial 
answer, what are the various combinations without knowing the 
dose response and all that stuff, we're saying that, basically, 
you can't take step 1 to 2 to 3 to 4, but you may have to jump 
over the hoop of No. 3 because we cannot establish cause and 
effect.
    Now, it's the paradigm you go through to examine these 
things in that light. And what a lot of the official agency's 
comment was, we have not seen evidence of this, so, therefore, 
we don't do the research. Now, there's a different side of that 
pie, which is pushing without much debate, is, in fact, what 
exactly happened in that war? What are the operational 
possibilities? What is it that the enemy, the Iraqis, what they 
could have done? Could they have used chemicals? Could they 
have used biological?
    And it suggests something a little different. Now, one can 
take that and say, let's make that assumption and move ahead 
with research rather than re-examining potential--we need the 
existence of such things before we go and prove cause and 
effect. And I think what we are hearing--myself, anyway--from 
the veterans, is that, ``I was there. I saw the depleted 
uranium being hit and burned and so on.''
    Well, one can take that and say, well, there may be 10 
cases or none, I don't know. But why can't we just take that 
and fire the weapon, see if, in fact, the smoke can have 
particles like that, see if, in fact, there's a health effect 
as a result of toxic exposure, rather than saying, well, we 
found only a handful and it's not showing up in the health 
status of these people right now, without really due 
consideration on how well the protocol is in determining 
whether they're really sick of those things.
    So you have sort of a mismatch that, I think--it's very 
difficult to--I don't think that the DOD and the VA--I think 
that they're doing the best kind of research they can given the 
evidence, but I think they're using very strict criteria and 
research at arriving at those conclusions. So you may be right. 
And our concern is, if you can't jump these hoops, then maybe 
we'll never get there.
    Mr. Sanders. That's right. And let me just mention 
something. Again, I say this as somebody who is not a 
scientist. And I defer to you with your scientific backgrounds. 
A couple of months ago, sitting right up there was a gentleman 
named Major Donnelly from Connecticut, I think. And we heard a 
very sad and tragic story. And he is ill with Lou Gehrig's 
Disease right now.
    And one of the things that he said which moved me is that 
he said that his symptoms became exacerbated--if my memory is 
correct--when he was out jogging at a military base and they 
were spraying for pesticides. It was triggered. Again, I'm not 
a scientist, but that does tell me something that we might want 
to investigate.
    I went home, and last month we had a conference in Vermont, 
in the State of Vermont, which we focused on Persian Gulf 
illness--and Bob Newman, by the way, of your staff, was there 
and did a wonderful job in speaking to our vets about what he 
knows about the problem. And I was in the room with about 15 
vets in my small State who are hurting. And I asked him a very 
simple question. I said, tell me something, when you go out 
into unfriendly environments, do your symptoms flare up?
    Very simple question. I'm not a scientist. One guy said--he 
started laughing, because his wife was sitting next to him. He 
said, ``Yeah, whenever my wife puts on perfume I get sick.''
    OK? Another guy says, ``Yeah, I used to work in a service 
station. I was a mechanic. I can't work around fuel anymore. 
The fumes from fuel get me sick.''
    Another guy said--no offense to anybody from New Jersey--
``I was in New Jersey recently, around the petrochemical 
plants, and I got really sick when I was exposed to that.''
    Almost everybody in the room said that their symptoms 
flare. And what got me, and really concerns me is, I'm 
wondering tens of thousands of men and women who were over 
there are full of these toxins right now who could at least be 
helped if we could avoid--maybe this type of pesticide in your 
food may make you more ill. I don't know.
    But to get back to your point, Mr. Chan. I think those are 
the questions that need to be pursued. We also learned in some 
of the studies that I indicated--there are at least two studies 
that now indicate--Dr. Haley being one--that there may be 
actual neurological damage. All right. Now, that is something 
that is pretty definitive, right? If somebody has neurological 
damage, why aren't we testing now 10,000 people to see if 
there's neurological damage and if it correlates to what we 
call Persian Gulf illness? Mr. Chan.
    Mr. Chan. Well, I think the DOD comment about that study is 
that it's sample size is small, it's not generalizable and so 
on. And I thought that when DOD responded that way, I thought, 
well, then replicate it.
    Mr. Sanders. Exactly. If it's too small a study then do a 
big study.
    Mr. Chan. If it cannot be, then we end up proving the case. 
I don't understand that. In a logical way of research, there's 
a hypothesis. And maybe it's localized to that particular unit.
    Mr. Sanders. Right.
    Mr. Chan. And in fact, because of their movement, they were 
exposed to something entirely different while another group may 
have totally very healthy groups. I don't know.
    Mr. Sanders. And in Great Britain there was also another 
study which indicates neurological damage. Isn't that correct? 
It would seem to instead of criticizing----
    Mr. Shays. You asked him a question.
    Mr. Sanders. OK. You think I should give him a chance to 
answer the question I asked him? OK. Why not?
    Mr. Chan. Someone behind me wants to answer the question?
    Mr. Sanders. No. You.
    Mr. Chan. I just said that, you know, the idea of 
epidemological studies is really to generate new hypotheses and 
so on. And I have no doubt their limitations in a very small 
study that you refer to. And our own team basically said, 
instead of rejecting, let's try it out somewhere else. And it 
may work, it may not work. That's the approach I think we've 
been taking in regards to this report.
    Mr. Sanders. Thank you very much.
    Mr. Shays. I thank the gentleman. We're going to be coming 
back again. But Mr. Sanders has been an early and active 
participant in these committees and really has been an equal 
partner with me in this effort. There's no Republican or 
Democrat in this process. Mr. Sanders, thank you. And Mr. 
Allen, you have been extraordinarily patient. And I appreciate 
it very much.
    Mr. Allen. Thank you, Mr. Chairman. I appreciate the chance 
to be here and hear what you have to say. And I'm pleased with 
the direction this conversation is going right now. Because I 
think we need a paradigm shift here. So many people think about 
diseases or symptoms as being caused by a single agent. There's 
a virus, there's a bacterium, and it produces the same kinds of 
symptoms in particular people. And you figure out the 
causation. You figure out the appropriate treatment. And the 
treatment works for everyone. But what we have with the Gulf 
war syndrome, what we have with the illnesses that are reported 
are a wide variety--almost 700,000 people went there. They were 
exposed to different chemical and biological agents at 
different times. And in their subsequent life, they come in 
contact with--whether it's perfume or insecticide or whatever 
it may be--other kinds of chemicals that may set off a chain 
reaction.
    So in this case, the complicating factor, it seems to me, 
is that every case is somewhat different from every other case. 
And until we recognize that and accept it, we are going to be 
in trouble. And that's why I thought, Mr. Chan, your suggestion 
for research. You know, even if you have only a few cases, 
we're not looking for one common cause here. That's not what 
these studies are about. We're trying to figure out a 
combination of causes that may have certain kinds of effects, 
and then get to the basic point, which is how do we help the 
veterans who are suffering through these illnesses.
    So what I would like to do is to talk for a minute about 
your recommendations, particularly the first two 
recommendations. Where do we go from here? And setting aside 
for a moment Mr. Sanders' suggestion that we just give up on 
the VA and the Department of Defense, let's look at--someone's 
got to do this. And one of your recommendations is that DOD and 
Veterans' Affairs set up a plan for monitoring the clinical 
progress of Gulf war veterans. Can you take that a step 
further?
    I mean, we have hundreds of thousands of veterans out there 
being treated by doctors all around the country. How do we 
manage this? What steps would you take to implement that 
recommendation?
    Ms. Heivilin. I think that in responding to that, the VA, 
particularly, thought we were asking for a much more 
complicated system than we were asking for. But recognizing 
just what you said, not all of them are being treated in either 
DOD or the VA. It would require that you have some system for 
maybe statistically sampling. Or, if you think we need to get 
larger numbers in the group, going to all of them for periodic 
examinations, collecting information on how they're being 
treated, and whether in fact they're getting better or not. And 
if you had information on their symptoms and their treatment, 
and if they're better or not, you could then do some 
comparison.
    You could go into the data base and pull out clusters of 
people that have the same symptoms, look to see if they're 
being treated the same way and if they're better, and you may 
identify from that some treatment that is working better than 
other treatments for certain set groups of symptoms. We're not 
asking--at least initially--for anything really complicated.
    But it would require a system for doing that. It would 
require that we get information from each of the people who 
have registered--maybe from their doctors--or have them fill 
out a form, periodically on what I said--follow up on what the 
symptoms look like, are they better or worse, and what 
treatment are they getting. And then we can do some comparison, 
some studies.
    Mr. Allen. So if I understand what you're saying, you're 
not saying you have to look at all 700,000, but you try to 
cluster some symptoms and look at groups that have similar 
symptoms and then try to work from that base? Is that fair?
    Ms. Heivilin. Yes.
    Mr. Chan. Right now, with all the information, it looks 
like a sort of a randomized trial going out there--everybody 
treating everybody and not knowing any results. And some people 
may go outside the system and go to private physicians for the 
information. The illness analysis is not the illnesses but the 
individual. OK? That's what you're looking for.
    And then the question is, what are the combination of 
illnesses they have. Not that she has headaches and I, in the 
control group, also have headaches. But she may have multiple 
symptoms which I don't have, but somebody else has. Let's say, 
joint pains and so on. The question becomes, if they are being 
treated symptomatically, what is working out there? What is not 
working? How do we make sure that in fact that can be shared 
among others and so on? What's the right way to do that?
    I don't think we know if there are multiple symptoms out 
there--then there's no magic bullet to solve these things. But 
if it's going on already--they're being treated--it seems like 
it's one way to capture the information by which one can 
determine other successes that would be helpful for others.
    I think we sort of start off thinking not very ambitiously 
how this is. And I must say I was quite disappointed by the 
agencies' disagreement with these particular points.
    Mr. Allen. Let me turn to the second recommendation. You 
suggest we should give greater priority on research on 
effective treatment for ill veterans and on low-level exposure 
to chemicals and their interactive effects, and less priority 
to further epidemiological studies. Can you talk to me a little 
bit about the epidemiological studies?
    I mean, they're designed to try to figure out causation. 
That's partly what we're talking about. But is it because those 
studies, you feel, have been on the wrong track? You said 
earlier that one-third of them have been related to stress, 
which, in light of everything that was going on out there, you 
can understand. But that does seem overweighted.
    What kinds of research are you recommending that is 
different from the kinds of studies that have been done before 
and would be focused on effective treatment for veterans and on 
dealing with these low-level exposure to chemicals kinds of 
issues?
    Ms. Heivilin. Well, first, the epidemiological studies--you 
were asking about the problem with them. And I'm going to 
separate them from the stress studies. The epidemiological 
studies, the primary problem, because they're descriptive, is 
trying to figure out what the symptoms are and figure out the 
causes related to the exposures that the soldiers and sailors 
and airmen had. The problem is that the data is not accurate. 
The records from the Gulf on who took what vaccine when and who 
took what drug when is scanty.
    The records about exposures is scanty, also. And when you 
try to rely on memories of people who have been there and you 
start asking them, say, 4 years after it happened there are 
problems. I was there a month after the war and if you asked me 
exactly where I was on any particular day, I'd have to go back 
to my diary and hope that I had noted where I was and then try 
to remember what I was exposed to. But I'm sure I don't know 
what I was exposed to. I have maybe a little idea. But I 
wouldn't even know if there was something in the air some place 
I was, other than if I had happened to be in Kuwait, which I 
wasn't, I was hearing people talking about how bad the air was 
up there when they were up there because of the oil fires.
    But that is what is, in our minds, resulting in or going to 
result in epidemiological studies that will have very little 
use, because we'll have a lot of questions about the accuracy 
of the conclusions.
    The other group was the stress, and we had different--
looking at stress is a primary focus, and we have problems with 
other things in looking at stress. Then your other issue was, 
what kind of work----
    Mr. Allen. What next. Where should we go?
    Ms. Heivilin. I don't think we're recommending that they 
stop the funding of anything that's ongoing. What we're 
suggesting is that they shift the future funding in this area 
to studies that will do something like what we were describing 
for tracking the wellness or the illness of the veterans who 
were exposed. We could use that data and then pull out--
hopefully there would be clusters of symptoms of people that 
are experiencing better health than other people with the same 
symptoms, and take a look at what kind of medications, what 
kind of treatments they're getting. That would be one set of 
the studies.
    Then the other set would be looking at and experimenting, 
probably with animals, on what is the effect of some of the 
combination of chemicals that were being experienced by some of 
our people that were over in the Gulf. There is the possibility 
of using accidental exposures, if, in fact, that data is 
available for human beings. There's always the problem that 
accidental exposures may not be and probably isn't exactly like 
the exposures that the veterans experienced, and they may not 
have all of the combinations. So animal research is probably 
the area that we have to move into.
    Mr. Allen. Just going back to your first recommendation. 
Shouldn't we have a major outreach effort? One of the things 
that strikes me is, when we had Major Donnelly here, who said, 
it acts up when we go out and go running. And it was a base 
down in Texas where they had just sprayed for mosquitoes, I 
think he was saying----
    Ms. Heivilin. Mm-hmm.
    Mr. Allen. There may be a lot of veterans who suffer 
symptoms who don't have a clue what the cause is. And they 
might be helped by some sort of outreach effort that said, 
look, you were in the Gulf, a lot of people have experienced 
certain kinds of symptoms--here are the kinds of things that 
may set off, that may have ill effects on you that you would 
never attribute to your past exposure. But for example, whether 
it's pesticides, whether it's perfume, whether it's something.
    So that some of the veterans who are out there--and they 
may not have even gone to a doctor yet. They just know that 
sometimes they feel lousy and they don't know why they feel 
lousy. But it would be a way to call their attention to things 
in their environment that might help them.
    Ms. Heivilin. I think the more we can do of that nature, 
the better. We had some concerns. And we did write about it in 
the report that the registry is likely to not be complete. Some 
of the people who are on active duty might not want to register 
because they think that might affect their efficiency rating or 
the way they're looked upon by their superiors.
    There might be other people that say, I just don't want to 
do it. I'll go to my own private doctor. I don't trust whoever. 
It's not going to do anything for me. But Dr. Sharma, I would 
like to invite you to comment a little bit more about the 
research that we were talking about.
    Mr. Allen. Yes.
    Mr. Sharma. Let me first answer your question about the 
first recommendation. We find it quite interesting that on the 
one hand we hear that the DOD and VA really don't know what 
caused this illness. The purpose of the Federal research 
strategy is to identify the natural course of the disease or 
diseases that veterans are experiencing. Now, how do you study 
the natural course of the disease? Obviously, you follow the 
patient over time to ascertain, whether they are getting better 
or worse. Whether should we do it through a research project or 
through the research that they're getting, the fact of it is, 
the veterans are ill, they are receiving treatment--some of 
them from the VA system, some of them from the Federal system 
and DOD system, others are going on their own. That's not the 
issue. The issue here is, those people who are within the 
system, do we know are they better or worse? And if we do 
monitor their clinical progress, not only will we have some 
clues about what made them better or worse, but also it will 
provide us some understanding of the natural course of the 
disease.
    During the war, veterans were exposed to multiple agents. 
We will never be able to figure it out--to what and at what 
level and for how long. But at least we can then try to follow, 
try to understand whether they're getting better or worse.
    Now, as far as your second point is concerned about the 
type of research, VA, in particular, seemed to be making a 
point of clinical trial. And I wanted to re-emphasize here, we 
are really not talking about clinical trials.
    We are not talking about--veterans are not receiving 
treatment that are unproven therapies. They are receiving 
symptomatic treatment for something very specific, whether it 
be tension headaches or joint pains or whatever. The issue here 
is: are those traditional, proven therapies working on them? If 
they are not working, then that suggests something, that 
perhaps it is something very unique. It's not a common tension 
headache. Perhaps it's not a common gastrointestinal problem. 
This is something very unique.
    We seem to find this wall that from the VA's side that 
``This is the protocol. This is the only way one could study.'' 
We find this very difficult to accept. What we are proposing is 
something very simple, something very logical, something that's 
not going to cost a lot of money, something that most health 
care providers should be and must be interested in--finding out 
whether, as a result of their clinical services, are people 
getting better.
    Mr. Allen. Mm-hmm.
    Mr. Sharma. This is an issue of accountability. What are we 
doing? As a result of our efforts, are we being responsive to 
the public or not? That's the very simple issue that we are 
addressing here in this recommendation.
    Mr. Allen. Thank you very much. Mr. Chairman, I have one 
more question. I just wonder if we're doing any better in 
Bosnia in terms of recording what chemicals our troops may be 
exposed to over there. Because, although it's not the same 
situation, it seems to me something to think about, something 
to deal with.
    Ms. Heivilin. We've looked at whether they're doing a 
better job on the records of what kind of medicines and what 
kind of vaccines the troops are getting in Bosnia than they did 
in Saudi Arabia. And it is better, but it's not good enough. 
And we have a report that we put out May 13 that discusses 
that.
    Mr. Allen. Good. Thank you very much. Thank you, Mr. 
Chairman.
    Mr. Shays. I thank the gentleman very much for his 
questions. I'm trying to sort out a few issues and have them a 
part of the public record. And I think I'd like to go back to 
where Mr. Sanders was just a bit. In the third hearing, on June 
25, 1996, Dr. Stephen Joseph appeared before us. Now, he is now 
the former Assistant Secretary of Defense for Health Affairs.
    And one of the points that he made that just rings in my 
ear--because it seems to me if you have this philosophy, then 
you're really not going to go into a certain room that you need 
to go into. He said, ``The most important thing that I really 
have to say about this is that the current accepted medical 
knowledge is that chronic symptoms or physical manifestations 
do not later develop among persons exposed to low levels of 
chemical nerve agents if they did not first exhibit acute 
symptoms of toxicity.''
    Now, in your statement you rightfully point out that the 
Congress--that basically, support for some--in your report, you 
point out that we didn't look at low-level exposure to 
chemicals until 1996, when it was mandated by Congress to do 
that. So before then, there was simply no work done by the DOD 
or VA.
    Now, the VA accepted the fact--wrongly, but accepted the 
fact--that the DOD was correct when they said our troops 
weren't exposed to chemicals. But even if they thought they 
might have been exposed to low levels of chemicals, it was the 
person in charge of health affairs for DOD who said that 
basically there's no accepted medical knowledge that chronic 
symptoms or physical manifestations do not later develop among 
persons exposed to low levels of chemical nerve agents.
    Now, in my work as a State legislator, one of the most 
active things we did in the State legislative bodies was to 
deal with environmental chemicals in the workplace. And we were 
very strict in not allowing businesses to expose their workers 
to low-level chemicals because we felt, based on medical 
science, that low-level exposure over time results in serious 
illness.
    Have you all examined this issue in any way, and if so, 
would you respond to it?
    Mr. Sharma. We looked at, first of all, the Federal 
research protocol, and we found that indeed there were at least 
three proposals that were submitted prior to 1996 but were not 
funded. And the argument that was given to us at the time was, 
because obviously they were not aware of Khamasiyah, and since 
there was no exposure, what's the point of studying or funding 
those studies.
    The second thing was that the research evidence is not as 
clear-cut. If you take a look at the PAC report--the research 
they have cited--and the research that we have cited, we have 
an interesting finding. For whatever reason, the research that 
we looked at, that we examined, which was peer-reviewed, very 
clearly suggests--and based on that we have concluded that 
there's substantial evidence that animals exposed to low levels 
of chemicals do exhibit symptoms that are very similar to the 
kinds of symptoms that Gulf war veterans are experiencing.
    Now, one of the criticisms that the agencies had about this 
type of research after we sent them the draft--``Well, you 
can't extrapolate those results from animals to humans.'' The 
fact is the symptoms are very similar to Gulf war veterans. 
Obviously there are some ethical issues. You cannot do that 
kind of research on human beings knowing that exposures have 
very adverse effects. So you have to follow the next best 
model.
    Can you learn something? We have some evidence from 
accidental exposure research. Indeed, DOD had some funded----
    Mr. Shays. Did you look specifically at the basic principle 
that was exposed by Mr. Joseph that said that current 
acceptable medical knowledge is that chronic symptoms of 
physical manifestations do not later develop among persons 
exposed to low levels of chemical nerve agents?
    That's the question I'm really asking. That was the guiding 
principle that basically let the DOD say, ``We're not going to 
look.''
    If people weren't literally dying on the field, then they 
weren't exposed to chemicals in any serious way. And if they 
were exposed to low-level chemical exposure it's meaningless. 
Now, I'm just interested to know if you got into this issue. 
Did you all start with the premise that low-level exposure is 
serious or not serious? Enlighten me a little bit here.
    Ms. Heivilin. I think we started with the premise that 
nothing should be ruled out unless you had conclusive evidence 
that it wasn't important or that it was not something that 
happened.
    Mr. Shays. OK. So what we have in testimony before our 
hearings is that soldiers said continuously that alarms went 
off, detecting some level of chemical exposure. Now, DOD will 
tell you that all of them were false alarms. All of them. That 
they were all false alarms. The Czechs are the only ones who 
seem to have some credibility in terms of their detection and 
because of their followup.
    We had individuals who were in the FOX vehicle with the 
better equipment who came in, said they detected it. And DOD 
minimizes and totally refutes the testimony of their own 
soldiers who were trained. Now, the bottom line is that the DOD 
has said from day 1 that, in essence, if you didn't have acute 
symptoms, if they didn't see people drop on the battlefield 
because of chemical exposure, they really weren't exposed to 
any serious chemical exposure because low level doesn't result 
in serious illness in the future.
    That is one hell of an assumption to me. Now, we have 
soldiers who come and testify that tell us why animals were 
just dead all around with no insects on them. And when we had 
veterans who came and testified of actually having the alarms 
go off and going into a bunker, then being told they can come 
out of the bunker. They come out and there's a mist in the air, 
they start coughing up blood, throwing up--except those who had 
the protective gear still on--and they went right back into the 
bunker.
    They're being told later by the DOD that they weren't 
exposed to chemicals. And one of the feelings that I get from 
your report is, listen to the veterans. The veterans, as far as 
I'm concerned, have been voices in the wilderness with no one 
listening. So I'd like you to just comment on that whole area.
    Ms. Heivilin. We've heard some of the same stories you 
have. And important to this area, we have a request that we're 
looking at from the House Veterans' Affairs Committee to look 
at the lost records, the lost documents known as CINCCOM NBC 
logs. Most of them have not been found. What we've found in 
going after that question is that the Defense Criminal 
Investigative Service is conducting a major investigation into 
the whereabouts and the handling of these logs, which would be 
an important piece of what you're talking about.
    Mr. Shays. My concern is that when they do their work, 
they'll then label it top secret. I don't mean to be facetious, 
but whenever we go down an interesting little area, then we 
aren't able to publicly pursue it.
    Ms. Heivilin. What we are doing--and this won't be top 
secret--is we're looking at all of the various groups that are 
looking into different questions in this area. And we're going 
to fairly quickly have a matrix that is going to tell you and 
tell us exactly who is looking at what in this area, trying to 
come up with information and what they think their estimated 
time is for getting that information. We will then look at the 
gaps in the investigations going on, which will give us a piece 
of information about what needs to be done.
    It may not answer the questions you're asking. One of the 
things that I think we believe is there's going to be a lot of 
questions unanswered for a very long time, maybe forever in 
this area.
    Mr. Shays. The one thing that I am absolutely convinced of 
is that we are going to hold everyone accountable, including 
Congress and ourselves, that if some people feel that it's 
going to take so long that no one is going to care in the end, 
and they can just outlast the various investigations, they're 
just wrong. They're just wrong.
    Pyridostigmine bromide--PB--and you did what I usually do, 
since I can't say it well, I just say PB--was to protect 
against sarin exposure. This is a drug that is used for 
degenerative nerve disease. And it's not to be used in the way 
that DOD used it unless they had permission from the FDA. It 
becomes, in essence, because it is a drug used for another 
reason, an experimental drug.
    This experimental drug was--the FDA gave the DOD permission 
to use PB. They had only two requirements. One is that they 
warn the soldiers that it is an experimental drug, which, by 
the way, our soldiers were ordered to take, which astounds me--
an experimental drug which our soldiers were ordered to take. 
They had one other requirement besides notifying our soldiers. 
They were supposed to keep records. Did you uncover in your 
work that our troops were notified or not notified?
    We have testimony from others that they were not notified 
in every instance--in most instances. And that we have 
testimony that they were not--that the DOD did not keep any 
accurate records on who ended up taking this drug and who 
didn't. Was this something that in your work you came across, 
and can you comment?
    Mr. Chan. I think we have seen reports on it. We did not 
look into the recordkeeping of who took----
    Mr. Shays. I'm not expecting that you were. This is not an 
evaluation of your report.
    Mr. Chan. Right.
    Mr. Shays. I'm just asking if you have. I want it to be 
part of the record. Yes.
    Ms. Heivilin. In looking into that, many of the veterans 
were not notified. We were told that the reason they weren't is 
that the United States didn't want the Iraqis to know what we 
were protecting the troops against, what we were doing.
    Mr. Shays. The DOD basically, because they felt that low-
level exposure was not harmful to chemicals, basically began 
new studies after Congress ordered them to in 1996 and after 
Khamasiyah became public, which, by the way, they knew before 
it became public. This is not information that was new to them 
when it was new to the public. The only difference was that 
they were forced to acknowledge it, again, because a soldier, 
besides his word, had a video that documented it. That's the 
only reason they came forward.
    Now, what's interesting to me is, the VA have very few 
people who have any expertise in chemical exposure. When we 
have asked the VA to produce a document of the thousands of 
doctors who have the expertise, practically no one showed up on 
that list.
    Now, I'm interested to know if you got into this area as 
well. Did you get into the ability of the VA to properly 
diagnose and treat chemical exposure? Was that an area that you 
looked in?
    Ms. Heivilin. No, we did not.
    Mr. Chan. We didn't look at that.
    Mr. Shays. Has any committee asked you to look into this?
    Ms. Heivilin. Not that I'm aware of. I don't think so.
    Mr. Chan. No.
    Mr. Shays. There are only two countries in the world, to 
our knowledge, that have any expertise in chemical exposure. 
One of them, I believe, is Denmark.
    Mr. Sharma. That is correct.
    Mr. Shays. And the other I am certain is Israel.
    Mr. Sharma. That is correct.
    Mr. Shays. Dr. Sharma, do you have any knowledge of these 
two countries and this?
    Mr. Sharma. I'm aware that both these countries do have 
very good protection. But we do not know the details. In the 
course of our investigation we became aware of this issue. I 
would just make a comment to your statement that in the VA 
there is no expertise. And while we did not look at the VA, we 
did look at one research--actually two: the research by Dr. 
Haley and by Dr. Zamal of England.
    And they point out something very interesting. And that 
is--this is a message that sort of has been missed in 
critiquing these studies--that when you do normal physical 
exams or medical exams, you will miss the subtle signs of brain 
damage that these people are experiencing, which suggests that 
when you are looking at these people you need different types 
of protocols that are more sensitive to detecting these kinds 
of changes that we are seeing in veterans.
    Again, as I can tell you, we did not look at, but we do 
know from the research point of view that the current medical 
exams would not be able to see changes and they would not be 
adequate.
    Mr. Shays. In the VA facility in West Haven, CT, they 
change their protocol a little earlier than some because the 
doctors that participate from Yale--one of them had a 
background in environmental health. And so they then had a bit 
more sensitivity to that issue. And that's really the only 
reason why one facility went forward. Now, you mentioned 
visiting two VA facilities where there seemed to be some 
expertise. Do you remember what those two facilities in your 
statement--on chemical exposure? You went to two VA 
facilities----
    Mr. Sharma. No. Those were two VA research centers.
    Mr. Shays. OK.
    Mr. Sharma. But they were not--we did not look at 
specifically.
    Mr. Shays. And you went to them because why?
    Mr. Sharma. Because we wanted to see what kind of research 
they were doing and the kinds of problems that they were 
experiencing. We had a protocol that we used. We wanted to talk 
to some of the primary investigators of those large studies.
    Mr. Shays. Right. And so it was not your intention that, 
we're going to just go and we'll pick out two VA facilities and 
look at the great job they're doing? These were two that were 
charged to get into this area?
    Mr. Sharma. Yes.
    Ms. Heivilin. Yes.
    Mr. Shays. I just want the record to show that.
    Ms. Heivilin. Right.
    Mr. Shays. Thank you. Mr. Sanders.
    Mr. Sanders. Thank you, Mr. Chairman. Let me pick up on the 
point that Chris was making. And then if you could tell us, in 
your research, whether you see this as a pattern in terms of 
the DOD and the VA. The chairman mentioned that we heard for 5 
years that there was no chemical exposure in the Persian Gulf 
theater. And then, in fact, it was as a result of probing from 
this committee which finally got the DOD to acknowledge that 
there was an exposure at Khamasiyah. And I believe at one 
recent hearing Bernard Rostker, who represents the DOD, freely 
acknowledged that there may well have been other exposures as 
well. And I think that's where we are right now.
    But from the very beginning there was a reluctance and--I 
think it's fair to say--cover up in that area of acknowledging 
that. The chairman just mentioned that this all took place 
despite the fact that alarms were going off all over the 
theater. And the conclusion reached by the authorities that, 
``Yeah, we have highly trained technicians who are manning the 
instruments. The alarms went off, but, hey, despite all of the 
alarms, the conclusion is there was no other additional 
exposure in that area.''
    We heard testimony--and I'd like you to maybe comment on 
this--at a recent hearing from Dr. Tiedt, who is a 
pharmacologist in Maryland--and I'm sorry, I can't remember 
exactly where. And he said that there were past studies done in 
fact by the DOD, if my memory is correct, dealing with the 
potentially dangerous effects of pyridostigmine bromide. And he 
was very, very concerned about the use of that drug.
    I think the DOD official position, and the VA, is that 
based on everything that they know, it will not cause a 
problem. I was very interested. And the reason I'm asking these 
things is that it seems to me that there is a pattern out 
there. But I want you to comment on that based on your 
research. I mentioned earlier and I want to repeat something 
that I thought was interesting.
    In 1995, the DOD itself did a study at Fort Detrick. This 
is the finding. ``The principal finding is there is significant 
increase on the lethal effects of rats given pyridostigmine 
bromide, hermathrine and DEET simultaneously.''
    Now, you know what was very interesting to me--when that 
study was commented on in the PAC final report, you know what 
happened to the word ``significant?'' It came out: ``A 1995 DOD 
study with rats reported that PB caused a slight increase in 
lethality of DEET and hermathrine when compared to expected 
additive values.'' The word ``significant'' went to the word 
``slight.''
    We have seen instances where researchers lost their jobs. I 
don't know that today there is a conclusion or an 
understanding. And I'd like you to help me on this one. Dr. 
Jonathan Tucker, Ph.D. served on the Presidential Advisory 
Committee staff as senior policy analyst responsible for 
investigating incidents of chemical and biological agent 
exposures. He was summarily dismissed after aggressively 
attempting to understand the extent of chemical exposures.
    In other words, instance after instance, people come up 
with ideas. We have amazing things. One more thing--and I'd 
like you to comment on this. New York Times--April 17, 1996 
headline: ``Chemical Mix May Be Cause of Illness in Gulf War.'' 
``Researchers from two universities suggested yesterday that 
Gulf war syndrome might have been caused by exposure to 
ordinary harmless doses of two or more chemicals that together 
might cause nerve damage.''
    Six paragraphs down the line from the New York Times--``The 
Department of Defense said that the new report raised `some 
interesting hypotheses' but that the Department had no direct 
knowledge of the details of the work.''
    A year earlier, the DOD itself had done a study which came 
up with almost exactly the same conclusion. Why would they not 
have said, ``Gee, that's interesting. We did similar work a 
year ago. We've got two separate studies coming up with similar 
conclusions. Boy, we should get going.''
    My point, and I think the point that the chairman was 
making, is that it seems to us that wherever evidence comes 
forward that might suggest that the cause of the problem has 
something other to do than stress, those conclusions, that 
analysis, is dismissed. Researchers who are working on that are 
given short shrift--in some cases, actually fired. Is that a 
kind of pattern that you detected in your study of the DOD and 
the VA?
    Mr. Sharma. We found similar kinds of experience with some 
of the studies. And I will just use one. For example, Dr. 
Duffey, who testified here. His work was indeed supported by 
DOD. They were aware of the fact of what one would expect with 
low-level exposure to certain agents. They were some other 
reports that we cited. They were not considered. At least we 
have not seen that they have looked at. There are a lot of 
instances where we have found that work has been published. 
It's quite good work. The issue is the perspective.
    I mean, you can do 100 studies and still say questions 
remain and we need to do more.
    Mr. Sanders. Right.
    Mr. Sharma. Or, in the absence of no contrary evidence, if 
you have a few studies, it leads you to believe that, yes, 
there is some suggestion that we are dealing with--how much is 
enough or exclusion of certain types of research when it is 
indeed there. And I agree with you.
    Mr. Sanders. So the examples that I have given and that the 
chairman has given, you have found to be not untypical of the 
approach of the DOD and the VA. Is that what I'm hearing you 
saying?
    Mr. Sharma. Yes.
    Mr. Chan. I think in a broader sense, what we have tried to 
do--we found often more questions were raised rather than the 
doors closed--and that we finish answering that question. The 
example that you and Mr. Chairman keep bringing out about the 
FOX vehicle and the detection--and, as I said, that's the other 
side of the pie, that I don't think the research is being 
looked into.
    But it opens more questions about the sensitivity of our 
detection equipment. If they are very sensitive, and that, for 
some reason, we adjusted our equipment that way, which 
basically implies that we're trying to reduce the operational 
effectiveness of our soldiers, because every time an alarm is 
sounded, that means I have to put on the gear. And I've tried 
those things. Maybe I'm a little small in stature to carry 
those things. But you can't even put your finger into the 
trigger to fire something.
    So in a way, from an operational point of view, you're 
defeating yourself. That's the first point. The second point 
is, that if, in fact, it's set up in such a way that other 
agents may trigger such alarms, then I think it's important for 
the Department of Defense to investigate and find out what is 
the possible false alarm rate that can create these things.
    What it implies is that the enemy can use other agents to 
create these things to disrupt operation of the war and the 
battle itself, which is not a reasonable thing to do because 
that's not a very good piece of equipment. Because if every 
time tear gas can generate some alarm that you stop the 
operation and say, everybody put on a suit, that doesn't serve 
the soldier well. Because after a while, the soldier is going 
to ignore those alarms.
    So it opens up a whole set of questions. And when you turn 
around to the other end--from a doctrinal point of view, the 
question is, would the enemy use full, pure chemical against us 
knowing that our response will be severe against them. So that 
question--you see what I'm saying--it opens up another set of 
questions.
    I mean, they would be not very intelligent to use that kind 
of thing against us knowing that we'd retaliate, not 
necessarily in kind, but in massive retaliation against 
whatever, because that's our doctrine. So the next possible 
question is, well, if you're the enemy, you don't want that to 
happen, what would you do? Possibly reduce the purity? One 
other question is, could that be a possibility? Could we in 
fact design systems whereby it can trigger our equipment while 
at the same time does not achieve the immediate acute response 
that one would expect, so that there's no incident that 
triggers the entire sequence of events that they don't wish on 
themselves. I'm talking about the enemy here.
    So what I'm saying is, these things you can test. You can 
try it out. When we captured the equipment through the United 
Nations, did we look into the purity of those chemicals and see 
what mixture is being used? If they were destroyed, why were 
they destroyed before we have a chance? And we enter with a 
whole tree of questions there. And this is beyond the health 
issues.
    And we were stuck, to be honest with you. And that's why we 
said, OK, even in looking at the bomb sites, the inspected 
stuff, it doesn't quite make sense to us. We reach a certain 
impasse and we say, OK, we don't understand. We need to 
investigate further.
    Mr. Sanders. Let me change gear a little bit here and ask 
you another question. It would seem to me that we have a 
difficult problem. No question about that. Solutions are not 
easily arrived at. But it would seem to me fairly common-
sensical that the VA and DOD would be as aggressive as they 
could in trying to look at whatever safe, at least, treatment 
protocols there were out there.
    Mr. Chan. Mm-hmm.
    Mr. Sanders. In other words, I talk, again, to the vets in 
the State of Vermont who said, ``We're willing, as long as it's 
not going to make us worse, we're willing to look at 
alternatives. We know that maybe they won't cure us. But we're 
really hurting right now. We can't go to work. Give us 
something. Give us an option. Maybe it fails.''
    Mr. Chan. Mm-hmm.
    Mr. Sanders. It seems to me--I know--that there are 
treatment protocols out there. And I think the VA and the DOD 
will tell us, well, they don't know if they're going to work. 
That may be true. But don't you think we owe it at least to the 
vets to allow them to take advantage of different types of 
treatments. And then we can learn from that. In other words, if 
there is a treatment out there and we send vets to it and it 
doesn't work, it doesn't work. But then we know it doesn't 
work.
    But doesn't that make more sense than saying, well, we 
don't have enough evidence yet to suggest that this could work. 
Am I missing something here? What do you think in terms of--
what I'm asking is, in looking at different treatment 
protocols, is the VA and the DOD looking at alternative 
treatments even if they're not 100 percent guaranteed right 
now?
    Ms. Heivilin. You're talking about human clinical trials.
    Mr. Sanders. Yes, right.
    Ms. Heivilin. In order to do that you have to have a 
hypothesis and a proposed treatment.
    Mr. Sanders. Sure.
    Ms. Heivilin. And I don't think anything that's been done 
has gotten that far yet.
    Mr. Sanders. Well, there has been. I know. For example, Dr. 
William Ray of the Environmental Health Center in Dallas has 
claimed that he has treated dozens and dozens of Persian Gulf 
veterans. That's what he says. He says he has had some success. 
We know veterans who have gone to him. Is his treatment 
effective or not? I don't know. But I think that we should at 
least try it out. The evidence is that nobody gets worse as a 
result of this treatment.
    I know, because I entered into the record of one of our 
past hearings. Again, Dr. Mira Sheyavitz in Northampton VA 
hospital based her treatment on a diagnosis of multiple 
chemical sensitivity. She claimed--and I read some testimony 
from some of the veterans themselves. They said, ``Yeah, I 
underwent this treatment. I felt better.''
    Now, in the long run, will that treatment work? I don't 
know. But it would seem to me that if you have even some 
inkling that there might be some success--Nicholson is another 
example. Why would we not go forward so long as we knew that 
people were not going to become ill, obviously. Am I missing 
something here?
    Mr. Chan. This is consistent with our first 
recommendation--what are the health effects and whether they 
are improving or not. And in doing so, hopefully, as we 
responded earlier, to say, let's find out are there things that 
appear to be working, even for a small percentage of people. 
And examine it that way.
    Ms. Heivilin. Mm-hmm.
    Mr. Sanders. Right.
    Mr. Chan. And I think we're not coming out with new 
hypotheses and so on. But try to gather the data out there 
first, and they might capture some of those cases that you 
mentioned.
    Mr. Sanders. OK. I would just conclude that line of 
questioning by saying, Mr. Chairman, that we owe it to the vets 
at this point to begin to look at alternative types of 
treatment, to monitor the success or failure of those 
treatments, rather than just say, well, we're not 100 percent 
sure that treatment can work, we don't want to look at it.
    Mr. Chan. Mm-hmm.
    Mr. Sanders. OK. I yield back, Mr. Chairman.
    Mr. Shays. Thank you. I think we're going to get you out in 
the next 15 or so minutes. I'd like to ask you, though--as it 
related to the issue of the various sites that may have had 
chemical or biological agents that were destroyed, you 
mentioned that the numbers are difficult to determine of what 
sites were actually looked at and what weren't after the war. 
You said some of it was classified information. You were having 
a hard time sorting out the numbers.
    We'll get to that even if I have to have confidential 
briefings. But it raises the question of whether there's 
anything--let me back up and say to you, one of my frustrations 
in this hearing is that I know of studies that were done on 
protective gear that are classified. I can't talk to you or 
publicly disclose information about the protective gear that 
our soldiers use because it's classified.
    Is there anything in your report that would have been 
better had you not been limited by classification? By better I 
mean stronger, more specific.
    Mr. Chan. Well, I think that it does help if it's 
declassified. This will allow us to tell you where those sites 
are.
    Mr. Shays. Is there anything else in your report?
    Mr. Chan. I'm sorry.
    Mr. Shays. No. That's clear there.
    Mr. Chan. Yes, sir.
    Mr. Shays. I mean, it would be very helpful to know that. 
Anything in addition to? Any other area that you walked down 
and you had walked back or you decided you couldn't make 
certain points because you couldn't back it up because the 
information was classified?
    Mr. Chan. Yes, I did.
    Mr. Shays. Pardon me?
    Mr. Chan. Yes.
    Mr. Shays. OK. The answer is yes?
    Mr. Chan. Yes.
    Mr. Shays. OK. I want you to say it in a full sentence.
    Mr. Chan. I'm sorry. Yes----
    Mr. Shays. You don't need to apologize. You've just 
answered yes. Now I want you to tell me what ``yes'' means.
    Mr. Chan. That there is other information that would make 
the report stronger if we could discuss it in an unclassified 
manner.
    Mr. Shays. I have one other area. Well, actually, a few 
more. In your report, which you provide the agencies to have a 
response. And I think it's very appropriate that you did. The 
Department of Veterans' Affairs' comments to the General 
Accounting Office report. They respond on page 6 of their 
response; they say, ``The VA strongly disagrees, though, with 
assertions contained within the GAO report that the 
epidemiological research to date has been inappropriate and is 
not likely to yield definitive conclusions.''
    It's on page 84 of your document. It's on page 6 of the 
document they submitted to you. Then they say:

    The pursuit of epidemiological research has led to some of 
the most important findings and conclusions regarding Persian 
Gulf veterans illnesses to date. Epidemiological studies have 
shown so far that:
    1. Persian Gulf veterans have not experience a high disease 
specific mortality rate in comparison to their non-deployed 
counterparts;
    2. Persian Gulf veterans in the military have not been 
hospitalized more than their non-deployed counterparts;
    3. Based on a study of military hospitalization records 
birth outcomes among spouses of Persian Gulf veterans and among 
female Persian Gulf veterans are no different than among their 
non-deployed counterparts; and
    4. Persian Gulf veterans are experiencing a greater 
prevalence of self-reported symptoms.

    Then they go on to say, ``Were it not for these 
epidemiological studies, we would still lack answers to vital 
questions about Gulf war veterans' illnesses.''
    I have a big question mark by that. Because it says, ``We 
will still lack answers to vital questions.'' What answers do 
we have from what I just read? What answers do we have? Or let 
me put it this way. Do you want to comment in general about 
this response to your report, this area here?
    Mr. Chan. Yes. We did a general comment. And I think we can 
answer it specifically about these references. One of the 
recommendations made by the President's Advisory Commission is 
that they need to look at the population broadly to determine 
are there prevalence. And we don't disagree with that. And the 
idea behind those is to generate hypotheses whereby one can 
focus on further research. And we don't disagree with that.
    The problem that we find--I think I will just use one 
example of it. It's easier to discuss one research rather than 
all four of them. And I'm sure my colleague can add more. 
Initial studies that were done--and it's done peer review in a 
perfectly reasonable way and scientifically and so on. OK?
    Now, if I take myself out of that research and ask the 
question, what have I gained out of this, what was done was 
really taking the entire 600-and-some-odd thousand veterans of 
Gulf war and comparing them to a control group, which is the 
people who didn't go to the war. First, we don't know what kind 
of people these people have, in fact, whether they actually 
landed on shore or not, were they exposed to anything of these 
690,000 people.
    The scientific paper basically recognized a couple of 
things. This is on mortality. I'm sorry. I'm talking without 
telling you what it is. Basically they arrive at the fact that 
when we compare them, there's no significance in terms of 
higher mortality with the exception that after the war they're 
subject to post-war problems and stress and all that.
    I personally, as a researcher, I look at it--and my 
colleague may disagree with me--that the paper recognized that 
before the war began--that there's self-selection going on. 
That means those who went to the war were healthier. So you 
start with the health measures that's higher than the other 
cohorts that you're comparing. And when they finish the war, 
they're equal.
    So I don't know the delta of better health that they begin 
with. Now, the authors recognize that this is one of the 
problems they had, which is a perfectly reasonable assumption. 
But when one concludes in public that there is no higher 
prevalence of mortality with the Gulf war veterans as a result 
of this paper, I think it's not quite correct to say that.
    An example, could they have done--taken a control group and 
go through the same screening before they went to--even though 
they didn't go to the Gulf war--could we use them in the 
control group--will we reduce the number? Could we do a pre-
post? That means, if they were healthy, can we compare them 
that's a single treatment, which is the war, and after the war, 
are they worse off? And that's another way to measure.
    So I think it's open up to a lot of interpretations with 
these four studies. But ideas generate hypotheses. And we're 
not quite sure what hypotheses they generate with the exception 
that now the mortality is not any higher or significantly 
higher than the control group.
    Ms. Heivilin. Can I comment, too? It's important in each of 
these--and we didn't look at every single study and we didn't 
evaluate every single study. In fact, we were looking at 
whether hypotheses were generated from the studies. But we did 
look a little bit at the birth outcomes among the spouses. And 
that population--it's kind of important to note that that 
population excludes the most at risk population. It was births 
that were taking place in the DOD hospitals.
    And when a pending birth is declared at risk, they're 
usually sent somewhere else outside of the DOD general 
hospitals. And of course, the veterans who were not still 
married and in active duty, which would probably also include 
some of your highest at risk population, your illest veterans--
would not be included.
    Mr. Shays. So, you responded, first, Mr. Chan, to the 
mortality. And you're responding to the----
    Ms. Heivilin. Birth defect piece.
    Mr. Chan. Birth.
    Mr. Shays. Now, there are really two issues here. One is 
that high risk pregnancies are less likely to take place in a 
military hospital.
    Ms. Heivilin. Right.
    Mr. Shays. The second, though, is to me--veterans don't go 
to military hospitals as a general rule. They're veterans.
    Ms. Heivilin. Right. If they're out.
    Mr. Shays. If they're out.
    Ms. Heivilin. Well, of course, in that registry, you have 
people that are still in the service, too.
    Mr. Shays. No, but that's the point. It's only people who 
are still in the service.
    Ms. Heivilin. Right.
    Mr. Shays. We're talking about most who don't have access 
to the military hospital.
    Ms. Heivilin. Right.
    Mr. Shays. It strikes me--and this is my primary point--it 
strikes me that the VA's approach to the causes of Gulf war 
illnesses, this research program is designed to find out what 
it isn't, not what the problem is. In other words, it's almost 
like they check off a list and say, well, it's not this, it's 
not this, it's not this.
    I have a general feeling that the DOD and VA basically 
don't believe our veterans. That's the bottom line. So it's 
almost as they're trying to say, ``OK. You're wrong. Because 
it's not this. You're wrong because it's not this and it's not 
this.''
    They're not coming to say, ``OK. It's not this, this or 
this, therefore it is this.''
    I'm just curious to know, is this the typical way their 
research happens?
    Ms. Heivilin. Well, the researchers undoubtedly exposed all 
of the limitations of their study--if you would read the actual 
outcome of the research. You're asking what----
    Mr. Shays. I'm asking something a little different.
    Ms. Heivilin. Right.
    Mr. Shays. If you don't know the answer to my question, I'm 
not asking you to----
    Ms. Heivilin. No. I understand. Do they typically do that? 
And----
    Mr. Shays. The question that strikes me--and I'm just 
interested if you had that same view--that the VA, in 
particular, basically is justifying their good work by saying, 
``We've learned it's not this and we've learned it's not this 
and we've learned it's not this.''
    Now, I may even question what they learned, because I don't 
think they learned that. But it's an interesting--it's not 
like, ``We've learned it is this. We've learned it is that.''
    Ms. Heivilin. Mm-hmm.
    Mr. Shays. Maybe in my unscientific mind, I'm just simply 
observing that's not all that significant. If it was, I was 
curious to have a response.
    Mr. Chan. Well, if one does research in this manner--let me 
say that if you look at prevalence and find no high prevalence 
and conclude that the case is closed--yes, I agree with you. 
Because, in a way, the concept behind the current research is 
generally new--you know, you look at a broad population of 
people. You've decided it didn't happen with them. Then you 
look at a subpopulation. That's possibly the next step you 
take.
    Now, as I said before, when you have these steps of 
research you go through, at some you have to look at cause and 
effect and treatment--the etiology and all that. If you stop 
right up front and say there's no high prevalence, then it's 
over. You see what I'm saying.
    And I think that's sort of the problem. Because, you know, 
it won't generate new----
    Mr. Shays. Mr. Chan, you're really making a very important 
point, it seems to me. What I think I'm hearing you say is that 
the VA is basically saying there's not a problem.
    Mr. Chan. Well, in regards to these, they certainly have 
expressed to us that finally this issue had been addressed in 
terms of birth defects and----
    Mr. Shays. It's not a problem. There's no greater 
mortality. There's not a problem.
    Mr. Chan. Well, I can read it in the web site--and this is 
from the GULFLink, which basically said June 12, 1997: The 
latest medical study on----
    Mr. Shays. Who is this and who is writing this right now?
    Ms. Heivilin. VA web site.
    Mr. Chan. It's Mr. Rostker's web site.
    Mr. Shays. OK.
    Ms. Heivilin. DOD. I'm sorry.
    Mr. Shays. DOD.
    Mr. Chan. DOD. I'm sorry.
    Mr. Shays. Yes.
    Mr. Chan. ``The latest medical study on birth defects among 
the children of veterans demonstrates that children of Gulf war 
veterans do not have an increased risk of birth defects.''
    Mr. Shays. It seems like all our--OK.
    Mr. Chan. If you go to the second page--it basically sets 
the limitations of the studies, which is what----
    Mr. Shays. And the limitations of the study, in some cases, 
discredit the study.
    Ms. Heivilin. Yes. I think it gets to our bottom line--you 
don't close out possible causes and possible treatments until 
you're absolutely sure. So you would close out this group of 
the population as not having problems. Let's look at--just as 
you said--let's look at the next group. Let's look at another 
group.
    Mr. Shays. OK.
    Mr. Chan. But in this case here, let me add, though, that 
they said, ``The limitation of this study being addressed in 
other research projects on reproductive health that are 
currently underway.'' So----
    Mr. Shays. But it sounds to me, again, like the VA is using 
its resources to make studies to prove what it isn't.
    Mr. Chan. Mm-hmm.
    Mr. Shays. In spite of the fact that some of their 
assumptions call into question the validity of their report.
    Ms. Heivilin. Well----
    Mr. Shays. But the whole emphasis is proving what it isn't, 
which then applies--well, why are we even going through this 
process? Instead of saying, ``We know that our veterans are 
sick. What is it?''
    Now, let me just ask two more points unless you want to 
make another comment. I just----
    Ms. Heivilin. Can I just make one?
    Mr. Shays. Sure.
    Ms. Heivilin. I can see value of this kind of a study if 
you have--which you may have--many of your active duty people, 
personnel, who were in the Gulf, who are worried about this 
possibility. So it would be researched to see if, in fact, you 
could put that worry to rest or not.
    Mr. Shays. Well, if I was a family giving birth to a child, 
and either my wife or it served in the Persian Gulf, I would 
take no comfort whatsoever that the VA had done a study in a 
military hospital that showed that there was no greater defect 
rate in births, given that it is military active personnel, and 
given that in most cases, the acute births are not going to be 
done in military hospitals.
    Ms. Heivilin. Right. I was just commenting about the value 
of such a study.
    Mr. Shays. Right. Well, let me just take the last two 
points. Given what we have learned of the handling of this 
whole process by DOD and the VA, should we assume that if 
similar conflicts occur in the future, would our forces still 
be at risk the same way they are now? Are there protocols in 
effect that you have learned of that say basically in the 
future this won't happen?
    It relates the Bosnia question that was asked by Mr. Allen, 
but I wanted to ask it more generically.
    Ms. Heivilin. We're getting into classified information. 
And we have recent studies that we could talk about in----
    Mr. Shays. When we're done with this public hearing, I'd 
love it if you would meet with Mr. Sanders and I just for a few 
minutes, just to have a clear sense of where your limits are.
    Ms. Heivilin. I can't discuss that answer in an 
unclassified forum.
    Mr. Shays. No. I understand. Let me just put it this way.
    Ms. Heivilin. OK.
    Mr. Shays. I don't want any more generic conversation about 
this issue in private.
    Ms. Heivilin. OK.
    Mr. Shays. Let me just--first, and finally say to you, is 
there any question you wish we had asked, any area that you 
wish we had gotten into? If there is then let's do it now. 
Let's not have you tell me afterwards, why didn't you ask this 
question?
    You ask a question I should have had the good sense to ask 
and then answer it or forever hold your peace. I'm serious 
about this. This is not even meant to be funny. I don't want to 
learn later that you wanted me to protect you; be asking a 
question that you didn't want to voluntarily come forward with. 
Is there any question that I could have asked in this very 
important hearing that we didn't ask, an area that we should 
have gotten into?
    Mr. Sharma. I think there is a question that I often ask 
myself.
    Mr. Shays. OK.
    Mr. Sharma. If I was a veteran, what does this all mean to 
me?
    Mr. Shays. Very good.
    Mr. Sharma. I have Congress----
    Mr. Shays. Dr. Sharma, if you were a veteran, what does 
this all mean to you? Probably the best question I've asked all 
day.
    Mr. Sharma. I think I would be, I would be very confused 
and disturbed. On the one hand I hear about the very people who 
are caring for me are giving some contradictory information. 
Research is not going to be conclusive. I don't know what's 
going to happen to me. And I think that's an issue that is 
facing the veterans. And we all must try to address that 
concern.
    Mr. Shays. Mr. Chan.
    Mr. Chan. I think that the question that concerns me is, at 
what point, timewise, will these things be resolved? And I 
think one of the real problems that you have posed before about 
taking a different approach to look at this problem--and I was 
thinking, if I'm a veteran, I want to have a group--be it VA, 
DOD or anybody else you're talking about--that, as a veteran, 
the credibility itself has to be based on the fact that if this 
group tells me that there's nothing there, that's an acceptable 
answer to me, then I think the matter would be closed.
    It's a very difficult thing to say. But I don't know how to 
say it.
    Mr. Shays. You said it.
    Mr. Chan. OK.
    Ms. Heivilin. My concern in this whole area is how the 
military personnel feel about the credibility of the 
organization to protect them, take care of them, and respond to 
their needs. And a lot of what we're talking about here looks 
like there hasn't been the kind of response you would expect 
there to be. And I think it's important that in the future, 
starting right today, that in this kind of a situation, that 
there be a credible response.
    Mr. Shays. Mr. Sanders.
    Mr. Sanders. Mr. Chairman, just let me thank all of our 
guests for their testimony and their very hard work, which is 
very helpful to us. Just one question. And maybe you have 
researched it and maybe you haven't.
    When I spoke to vets in the State of Vermont and in 
testimony that we have heard before this committee, we have 
heard from women who believe that they have been made ill with 
symptoms not dissimilar from their husbands' as a result of 
sexual contact or whatever. There is a case in Vermont of a 
woman who was jogging, I guess, 5 miles a day, and then after a 
while became so ill she could hardly walk without help.
    Is that anecdotal? Is that just something that happens to 
people or have you, in your research, developed any patterns to 
suggest that women or maybe even kids--we heard some testimony, 
you recall, from a woman whose kids were ill as well. Do you 
have any conclusions on that?
    Mr. Sharma. In this study we did not do any original 
research. We looked at the research that has already been 
published in context of the conclusions that have been reached, 
in context of some other issues that were relevant. We did not 
collect original information from veterans.
    Mr. Sanders. Based on your review of the research, what 
should I tell some women in the State of Vermont who believe 
that they have been made ill? Is there research to suggest that 
that is, in fact, the case or that there is no correlation?
    Mr. Sharma. It's quite possible. They were exposed to a 
wide variety of exposure agents. We do not understand the 
precise mechanisms. And it's quite possible that their symptoms 
might be due to those exposures.
    Mr. Sanders. But that's a question that remains unanswered, 
like many others.
    Ms. Heivilin. Right.
    Mr. Sanders. Mr. Chairman, let me just thank our guests 
very much for their efforts.
    Mr. Shays. I thank the gentleman. We just want to get 
together with you for about 2 minutes after the hearing in a 
room.
    Mr. Chan. Sure.
    Ms. Heivilin. OK.
    Mr. Shays. But let me just, as my closing statement, say 
that I truly appreciate the findings of the GAO report, because 
it provides, really for the first time, a peer review opinion 
to so many concerns of the thousands of veterans who have 
contacted our committee or appeared before our committee.
    So I thank you for your work. I'm sure you'll conclude that 
there are parts that aren't perfect. I, too, found it good that 
you made it Gulf war illnesses instead of Gulf war illness. And 
I have some criticisms like that. But for the most part, you 
have been a very
impressive panel. And you have, I think, been extraordinarily 
helpful to this committee.
    Mr. Chan. Thank you.
    Mr. Shays. And with that, we will close this hearing.
    [Whereupon, at 12:55 p.m., the subcommittee was adjourned.]

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