Department of Veterans Affairs: Federal Gulf War Illnesses	 
Research Strategy Needs Reassessment (01-JUN-04, GAO-04-767).	 
                                                                 
More than a decade after the 1991 Persian Gulf War, there is	 
continued interest in the federal response to the health concerns
of Gulf War veterans. Gulf War veterans' reports of unexplained  
illnesses and possible exposures to various health hazards have  
prompted numerous federal research projects on Gulf War 	 
illnesses. This research has been funded primarily by the	 
Department of Veterans Affairs (VA), the Department of Defense	 
(DOD), and the Department of Health and Human Services. GAO is	 
reporting on (1) the status of research and investigations on	 
Gulf War illnesses, (2) the efforts that have been made by VA and
DOD to monitor cancer incidence among Gulf War veterans, and (3) 
VA's communication and collaboration with the Research Advisory  
Committee on Gulf War Veterans' Illnesses (RAC).		 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-767 					        
    ACCNO:   A10297						        
  TITLE:     Department of Veterans Affairs: Federal Gulf War	      
Illnesses Research Strategy Needs Reassessment			 
     DATE:   06/01/2004 
  SUBJECT:   Biological warfare 				 
	     Cancer						 
	     Cancer research					 
	     Chemical warfare					 
	     Federal funds					 
	     Hazardous substances				 
	     Health hazards					 
	     Investigations by federal agencies 		 
	     Research and development				 
	     Veterans						 
	     Persian Gulf War					 

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GAO-04-767

United States General Accounting Office

GAO	Report to the Chairman, Subcommittee on National Security, Emerging
Threats, and International Relations, Committee on Government Reform,
House of Representatives

June 2004

DEPARTMENT OF VETERANS AFFAIRS

        Federal Gulf War Illnesses Research Strategy Needs Reassessment

                                       a

GAO-04-767

Highlights of GAO-04-767, a report to the Chairman, Subcommittee on
National Security, Emerging Threats, and International Relations,
Committee on Government Reform, House of Representatives

More than a decade after the 1991 Persian Gulf War, there is continued
interest in the federal response to the health concerns of Gulf War
veterans. Gulf War veterans' reports of unexplained illnesses and possible
exposures to various health hazards have prompted numerous federal
research projects on Gulf War illnesses. This research has been funded
primarily by the Department of Veterans Affairs (VA), the Department of
Defense (DOD), and the Department of Health and Human Services. GAO is
reporting on (1) the status of research and investigations on Gulf War
illnesses, (2) the efforts that have been made by VA and DOD to monitor
cancer incidence among Gulf War veterans, and (3) VA's communication and
collaboration with the Research Advisory Committee on Gulf War Veterans'
Illnesses (RAC).

GAO recommends that the Secretary of VA conduct a reassessment of the
federal Gulf War illnesses research strategy, ensure that a liaison who is
knowledgeable about Gulf War illnesses research is appointed to routinely
share information with RAC, and ensure that VA's research offices
collaborate with RAC on Gulf War illnesses research program development
activities. VA concurred with the report's recommendations and cited
several actions it has initiated to address them.

June 2004

DEPARTMENT OF VETERANS AFFAIRS

Federal Gulf War Illnesses Research Strategy Needs Reassessment

Most federally funded Gulf War illnesses research projects and
investigations are complete, but VA-the agency with lead responsibility
for coordination of Gulf War illnesses issues-has not yet analyzed the
latest research findings to identify whether there are gaps in current
research or to identify promising areas for future research. As of
September 2003, about 80 percent of the 240 federally funded medical
research projects for Gulf War illnesses had been completed. In recent
years, VA and DOD funding for this research has decreased, federal
research priorities have changed, and interagency coordination of Gulf War
illnesses research has waned. In addition, VA has not reassessed the
extent to which the collective findings of completed Gulf War illnesses
research projects have addressed key research questions. The only
assessment of progress in answering these research questions was published
in 2001, when findings from only about half of all federally funded Gulf
War illnesses research were available. Moreover, it did not identify
whether there were gaps in existing Gulf War illnesses research or
promising areas for future research. This lack of comprehensive analysis
leaves VA at greater risk of failing to answer unresolved questions about
causes, course of development, and treatments for Gulf War illnesses. In a
separate effort, DOD has conducted 50 investigations since 1996 on
potential hazardous exposures during the Gulf War. Generally, these
investigations concluded that there were limited exposures by troops to
some hazards and, at most, limited short- or long-term adverse effects
expected from these exposures. As of April 2003, all investigations were
complete.

Federal agencies have funded seven research projects related to cancer
incidence among Gulf War veterans. However, several limitations exist that
affect research related to cancer incidence. For example, some cancers may
take many years to develop and be detected. In addition, some research
projects studying cancer incidence have not studied enough Gulf War
veterans to reliably assess cancer incidence. Research may also be impeded
by incomplete federal data on the health characteristics of Gulf War
veterans.

RAC's efforts to provide advice and make recommendations on Gulf War
illnesses research to the Secretary of VA may have been hampered by VA
senior administrators' incomplete or unclear information sharing and
limited collaboration on research initiatives and program planning. VA and
RAC are exploring ways to improve collaboration, including VA's hiring of
a senior scientist who would both guide VA's Gulf War illnesses research
and serve as the agency's liaison for routine updates to the advisory
committee. However, most of these changes had not been finalized at the
time of our review.

www.gao.gov/cgi-bin/getrpt?GAO-04-767.

To view the full product, including the scope and methodology, click on
the link above. For more information, contact Janet Heinrich at (202)
512-7119.

Contents

Letter

Results in Brief
Background
Most Federally Funded Gulf War Illnesses Research Projects and

Investigations Are Complete, but VA Has Not Collectively Analyzed Research
Findings to Determine the Status of Key Research Questions

Some Efforts Are Under Way to Monitor Cancer Incidence among Gulf War
Veterans, but Research Limitations May Impede Reliability of Results

RAC's Efforts to Provide Advice May Be Hindered by VA's Limited
Information Sharing and Collaboration, but Several Changes to Address
These Issues Have Been Proposed

Conclusions
Recommendations for Executive Action
Agency Comments and Our Evaluation

                                       1

                                      2 4

11

17

22 27 27 28

Appendix I Scope and Methodology

Appendix II Key Gulf War Illnesses Research Questions

Appendix III 	Charter for VA's Research Advisory Committee on Gulf War
Veterans' Illnesses

        Appendix IV Comments from the Department of Veterans Affairs 36

Tables

Table 1: Research Related to Cancer Incidence in Gulf War Veterans (GWV)
19 Table 2: Twenty-one Key Gulf War Illnesses Research Questions 31

Figures

Figure 1: Evolution of Interagency Committees That Coordinated
Federal Gulf War Illnesses Research from 1993 through
2004

Figure 2: DOD Entities Responsible for Gulf War Exposure
Investigations from 1995 through 2004
Figure 3: Cumulative Number of Ongoing and Completed Federal
Gulf War Illnesses Research Projects by Year
Figure 4: Funding Share for Gulf War Illnesses Research by Agency
and Fiscal Year
Figure 5: Funding for Gulf War Research Projects, Fiscal Years
1994-2003
Figure 6: Organizational Relationships between VA and RAC, as of
April 2004

6

9 12 13 14 25

Abbreviations

CRADO Chief Research and Development Officer
DHSD Deployment Health Support Directorate
DHWG Deployment Health Working Group
DOD Department of Defense
GWV Gulf War veterans
HEC VA/DOD Health Executive Council
HHS Department of Health and Human Services
MVHCB Military Veterans Health Coordinating Board
NIH National Institutes of Health
NSTC National Science and Technology Council
OSAGWI Office of Special Assistant for Gulf War Illnesses
OSAGWI-MRMD Office of Special Assistant for Gulf War Illnesses

Medical Readiness and Military Deployments PGIIT Persian Gulf Illnesses
Investigation Team PGIRCC Persian Gulf Interagency Research Coordinating

Council PGVCB Persian Gulf Veterans Coordinating Board RAC Research
Advisory Committee on Gulf War

Veterans' Illnesses RWG Research Working Group VA Department of Veterans
Affairs

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separately.

United States General Accounting Office Washington, DC 20548

June 1, 2004

The Honorable Christopher Shays

Chairman

Subcommittee on National Security, Emerging Threats, and International
Relations, Committee on Government Reform House of Representatives

Dear Mr. Chairman:

More than a decade after the end of the 1991 Persian Gulf War, there is
continued interest in the federal government's response to the health
concerns of Gulf War veterans. While about 700,000 U.S. military personnel
were deployed during this conflict, casualties were relatively light
compared with previous major conflicts. However, approximately 80,000
veterans have reported various symptoms in the years following the war,
and scientists have agreed that many veterans have unexplained illnesses.
Gulf War illnesses are characterized by one or more symptoms that do not
conform to a characteristic diagnosis. Such symptoms commonly include
fatigue, muscle and joint pains, headaches, memory loss, skin rash,
diarrhea, and sleep disturbances. In addition to concerns about
unexplained illnesses, many Gulf War veterans also have elevated concerns
that possible exposures to chemical or biological warfare agents, or
environmental contaminants, may be associated with an increased risk of
developing cancer. Past research projects have found associations between
some of these substances and different types of cancers.

Gulf War veterans' reports of illnesses have prompted numerous federal
research projects on the nature, extent, and treatment of Gulf War
illnesses. Federal Gulf War illnesses research projects have been funded
primarily by the Department of Veterans Affairs (VA), the Department of
Defense (DOD), and the Department of Health and Human Services (HHS). Each
agency separately sponsors and funds research projects, though a few are
conducted jointly. In 1993, the President made the Secretary of VA
responsible for coordinating research activities undertaken or funded by
the executive branch of the federal government on the health consequences
of service in the Gulf War. In 2002, a congressionally mandated federal
advisory committee-the VA Research Advisory Committee on Gulf War
Veterans' Illnesses (RAC)-was established to provide advice on federal
Gulf War illnesses research needs and priorities

to the Secretary of VA. The committee is made up of members of the general
public, including non-VA researchers and veterans' advocates.

Separately from this research, DOD has conducted investigations on
specific events that took place during the Gulf War to identify possible
exposures to potentially hazardous chemical agents, such as sarin,
mustard, and benzyl bromide. In addition, DOD has conducted investigations
of potential occupational and environmental hazards, including depleted
uranium from munitions, smoke from oil well fires, pesticides, petroleum,
and fuels. DOD has published a number of reports that discuss the findings
of these Gulf War investigations.

Because of these concerns, we are reporting on (1) the status of federal
research and investigations on Gulf War illnesses, (2) the efforts that
have been made by VA and DOD to monitor cancer incidence among Gulf War
veterans, and (3) VA's communication and collaboration with RAC.

To examine these issues, we interviewed senior officials within VA and DOD
and senior managers with each agency's relevant research offices. We
analyzed pertinent agency documents, including annual reports to
congressional committees describing research priorities, ongoing and
completed projects, and agency funding. Additionally, we interviewed RAC
officials, attended a RAC meeting, and reviewed RAC reports and
recommendations. We conducted our work from September 2003 through May
2004 in accordance with generally accepted government auditing standards.
(See app. I for further detail.)

                                Results in Brief

While the federal focus on Gulf War-specific research has diminished,
VA-the agency with lead responsibility for coordination of Gulf War
illnesses issues-has not yet analyzed the latest research findings to
identify whether there are gaps in current research or to identify
promising areas for future research. As of September 2003, about 80
percent of the 240 federally funded medical research projects for Gulf War
illnesses had been completed. In recent years, VA and DOD have decreased
their expenditures on Gulf War illnesses research and have expanded the
scope of their medical research programs to incorporate the long-term
health effects of all hazardous deployments. Interagency committees formed
by VA to coordinate federal Gulf War illnesses research evolved to reflect
these changing priorities, but these entities have ultimately been
dissolved or have become inactive. In addition, VA has not reassessed the
extent to which the collective findings of completed Gulf War illnesses
research projects have addressed key

research questions. The only assessment of progress in answering these
research questions was published in 2001, when findings from only about
half of all federally funded Gulf War illnesses research were available.
As a result, VA has not determined whether previously identified research
questions have been answered or whether they remain relevant. This lack of
comprehensive analysis leaves VA at greater risk of failing to answer
unresolved questions about causes, course of development, and treatments
for Gulf War illnesses. In a separate effort, DOD has conducted 50
investigations since 1996 on potential hazardous exposures during the Gulf
War. Generally, these investigations concluded that there were limited
exposures by troops to some hazards and, at most, limited short- or
long-term adverse effects expected from these exposures. As of April 2003,
all investigations were complete.

Federal agencies have funded seven research projects related to cancer
incidence among Gulf War veterans. However, several limitations exist that
affect research related to cancer incidence. For example, some cancers may
take many years to develop and be detected. In addition, some research
projects have not studied enough Gulf War veterans to reliably assess
cancer incidence. Research may also be impeded by incomplete federal data
on the health characteristics of Gulf War veterans.

RAC's efforts to provide advice and make recommendations on Gulf War
illnesses research may have been hampered by VA senior administrators'
incomplete or unclear information sharing and limited collaboration on
Gulf War illnesses research initiatives and program planning. For example,
VA failed to inform RAC about its 2002 major research program announcement
that included Gulf War illnesses research. Similarly, VA did not seek
RAC's review of a draft of the 2002 annual report to congressional
committees describing current federally funded Gulf War illnesses
research. VA and RAC are exploring ways to improve information sharing,
including VA's hiring of a senior scientist who would both guide VA's Gulf
War illnesses research and serve as the agency's liaison for routine
updates to RAC. However, most of these changes had not been finalized at
the time of our review.

We are making recommendations to the Secretary of VA to improve federal
efforts to plan and coordinate Gulf War illnesses research. Specifically,
we recommend that VA conduct a reassessment of the federal Gulf War
illnesses research strategy to ensure its continued validity and to
identify promising areas for future research. We also recommend that VA
improve its sharing of research information and its collaboration with
RAC.

Background

In commenting on a draft of this report, VA concurred with the report's
recommendations and said that it has begun a preliminary assessment of the
federal Gulf War illnesses research strategy, including an evaluation of
the 21 key research questions. The agency also noted that it has
undertaken various steps, such as coordinating its most recent request for
Gulf War research applications with RAC, in order to better collaborate
with the advisory committee.

Following Iraq's invasion of Kuwait in August 1990, the United States and
other allied nations sent troops to the Persian Gulf region in Operation
Desert Shield. In the winter of 1991, the allied forces attacked Iraq in
an air campaign and subsequent invasion by ground forces (Operation Desert
Storm). Despite the harsh environment, illness, injury, and death rates
among approximately 700,000 U.S. military personnel were significantly
lower than in previous major conflicts. Yet, shortly after the war, some
veterans began reporting health problems that they believed might be due
to their participation in the war. VA, DOD, HHS, and other federal
agencies initiated research and investigations into these health concerns
and the consequences of possible hazardous exposures.

In 1993, the President designated VA as the lead coordinator of research
activities on the health consequences of service in the Gulf War.
Subsequently, in 1998, the Congress expanded VA's coordination to include
all Gulf War health-related activities. These activities include ensuring
that the findings of all federal Gulf War illnesses research are made
available to the public and that federal agencies coordinate outreach to
Gulf War veterans in order to provide information on potential health
risks from service in the Gulf War and corresponding services or benefits.
The Secretary of VA is required to submit an annual report on the results,
status, and priorities of federal research activities related to the
health consequences of military service in the Gulf War to the Senate and
House Veterans' Affairs Committees. VA has provided these reports to
congressional committees since 1995. In May 2004, VA issued its annual
report for 2002.1 VA has carried out its coordinating role through the
auspices of interagency committees, which have changed over time in
concert with federal research priorities and needs. The mission of these

1See Deployment Health Working Group Research Subcommittee, U.S.
Department of Veterans Affairs, Annual Report to Congress: Federally
Sponsored Research on Gulf War Veterans' Illnesses for 2002 (Washington,
D.C.: 2004).

interagency committees has evolved to include coordination for research on
all hazardous deployments, including but not limited to the Gulf War. (See
fig. 1.)

Figure 1: Evolution of Interagency Committees That Coordinated Federal
Gulf War Illnesses Research from 1993 through 2004

Indicates length of time
Indicates overlap of major committees or councils
Source: VA. Note: GAO analysis of VA data, public laws, and presidential
directives. aFederal agencies are VA, DOD, and HHS.

Federal research efforts for Gulf War illnesses have been guided by
questions established by the interagency Research Working Group (RWG),
which was initially established under the Persian Gulf Veterans
Coordinating Board (PGVCB) to coordinate federal research efforts. From
1995 through 1996, RWG identified 19 major research questions related to
illnesses in Gulf War veterans. In 1996, the group added 2 more questions
regarding cancer risk and mortality rates to create a set of 21 key
research questions that serves as an overarching strategy in guiding
federal research for Gulf War illnesses. (See app. II for the list of key
questions.) The 21 research questions cover the extent of various health
problems, exposures among the veteran population, and the difference in
health problems between Gulf War veterans and control populations. In
1998, RWG expanded federal Gulf War illnesses research priorities to
include treatment, longitudinal follow-up of illnesses, disease
prevention, and improved hazard assessment; however, RWG did not add any
new research questions. With regard to veterans' health status, the
research questions cover the prevalence among veterans and control
populations of

o  symptoms,

o  symptom complexes,

o  illnesses,

o  altered immune function or host defense,

o  birth defects,

o  reproductive problems,

o  sexual dysfunction,

o  cancer,

o  pulmonary symptoms,

o  neuropsychological or neurological deficits,

o  psychological symptoms or diagnoses, and

o  mortality.

With regard to exposure, the research questions cover

o  Leishmania tropica (a type of parasite),

o  petroleum,

o  petroleum combustion products,

o  	specific occupational/environmental hazards (such as vaccines and
depleted uranium),

o  chemical agents,

o  	pyridostigmine bromide (given to troops as a defense against nerve
agents), and

o  	psychophysiological stressors (such as exposure to extremes of human
suffering).

Separately from these research efforts, DOD is responsible for
investigating and reporting incidents of possible chemical and biological
agent exposures and other potential occupational and environmental
hazards. Within DOD, the entities responsible for overseeing Gulf War
exposure investigations have also evolved over time. (See fig. 2.)

  Figure 2: DOD Entities Responsible for Gulf War Exposure Investigations from
                               1995 through 2004

Indicates length of time Source: DOD. Note: GAO analysis of DOD data.

In 2002, VA established RAC to provide advice to the Secretary of VA on
proposed research relating to the health consequences of military service
in the Gulf War.2 RAC, which is composed of members of the general public,
including non-VA researchers and veterans' advocates, was tasked with
assisting VA in its research planning by exploring the entire body of Gulf
War illnesses research, identifying gaps in the research, and proposing
potential areas of future research. VA provides an annual budget of about
$400,000 for RAC, which provides salaries for two fulltime employees and
one part-time employee and supports committee operating costs. RAC's
employees include a scientific director and support staff who review
published scientific literature and federal research updates and collect
information from scientists conducting relevant research.3 RAC's staff
provide research summaries for discussion and analysis to the advisory
committee through monthly written reports and at regularly scheduled
meetings. RAC holds public meetings several times a year at which
scientists present published and unpublished findings from Gulf War
illnesses research. In 2002, RAC published a report with recommendations
to the Secretary of VA. It expects to publish another report soon.

2VA was required to establish RAC by the Veterans Programs Enhancement Act
of 1998, Pub. L. No. 105-368, S: 104, 112 Stat. 3315, 3323.

3RAC's scientific director, a research associate professor, is also an
appointed member of RAC.

Most Federally Funded Gulf War Illnesses Research Projects and
Investigations Are Complete, but VA Has Not Collectively Analyzed Research
Findings to Determine the Status of Key Research Questions

More than 80 percent of the 240 federally funded Gulf War illnesses
research projects have been completed. In recent years, funding for this
research has decreased, federal research priorities have expanded to
incorporate the long-term health effects of all hazardous deployments, and
interagency coordination of Gulf War illnesses research has waned. In
addition, with respect to the federal research strategy, VA has not
reassessed the research findings to determine whether the 21 key research
questions have been answered or to identify the future direction of
federal research in this area. In a separate but related effort, as of
April 2003, all of DOD's Gulf War investigations were complete.

Most Federally Funded Since 1991, 240 federally funded research projects
have been initiated by Gulf War Illnesses VA, DOD, and HHS to address the
health concerns of individuals who Research Projects Are served in the
Gulf War. As of September 2003, 194 of the 240 federal Gulf

War illnesses research projects (81 percent) had been completed;
anotherComplete, and Funding Is 46 projects (19 percent) were ongoing. 4
(See fig. 3.)Decreasing as Research

Priorities Broaden

4Annual reports to congressional committees submitted by VA on federally
sponsored research on Gulf War veterans' illnesses identify projects as
completed when total project funding has concluded.

Figure 3: Cumulative Number of Ongoing and Completed Federal Gulf War
Illnesses Research Projects by Year

Number of projects

                                         250 225 200 175 150 125 100 75 50 25

0

240

1994a  1995 1996 1997 1998 1999 2000 2001 2002 2003 Year

Completed Gulf War research projects Ongoing Gulf War research projects

Source: VA. Note: GAO analysis of VA data.

aThis total includes ongoing projects from 1991through 1994.

From 1994 through 2003, VA, DOD, and HHS collectively spent a total of
$247 million on Gulf War illnesses research. DOD has provided the most
funding for Gulf War illnesses research, funding about 74 percent of all
federal Gulf War illnesses research within this time frame. Figure 4 shows
the comparative percentage of funding by these agencies for each fiscal
year since 1994.

Figure 4: Funding Share for Gulf War Illnesses Research by Agency and
Fiscal Year

Percentage 100

80

60

40

20

0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Fiscal year

HHS

VA DOD Source: VA. Notes: GAO analysis of VA data. Percentages may not add
to 100 percent because of rounding.

After fiscal year 2000, overall funding for Gulf War illnesses research
decreased. (See fig. 5.) Fiscal year 2003 research funding was about $20
million less than funding provided in fiscal year 2000.

    Figure 5: Funding for Gulf War Research Projects, Fiscal Years 1994-2003

Dollars in millions

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Fiscal year

Source: VA.

Note: GAO analysis of VA data. Only direct costs for each agency are
included. Direct costs cover the actual research activities and materials
and have not been adjusted for inflation.

This overall decrease in federal funding was paralleled by a shift in
federal research priorities, which expanded to include all hazardous
deployments and shifted away from a specific focus on Gulf War illnesses.
VA officials said that although Gulf War illnesses research continues, the
agency is expanding the scope of its research to include the potential
long-term health effects in troops who served in hazardous deployments
other than the Gulf War. In October 2002, VA announced plans to commit up
to $20 million for research into Gulf War illnesses and the health effects
of other military deployments. Also in October 2002, VA issued a program
announcement for research on the long-term health effects in veterans who
served in the Gulf War or in other hazardous deployments, such as
Afghanistan and Bosnia/Kosovo.5 As of April 2004, one new Gulf War
illnesses research project was funded for $450,000 under this program
announcement.

5The October 2002 research program announcement on deployment health
research remains open for researchers to submit proposals.

Although DOD has historically provided the majority of funding for Gulf
War illnesses research, DOD officials stated that their agency currently
has no plans to fund new Gulf War illnesses research projects.
Correspondingly, DOD has not funded any new Gulf War illnesses research in
fiscal year 2004, except as reflected in modest supplements to complete
existing projects and a new award pending for research using funding from
a specific appropriation. DOD also did not include Gulf War illnesses
research funding in its budget proposals for fiscal years 2005 and 2006.
DOD officials stated that because the agency is primarily focused on the
needs of the active duty soldier, its interest in funding Gulf War
illnesses research was highest when a large number of Gulf War veterans
remained on active duty after the war-some of whom might develop
unexplained symptoms and syndromes that could affect their active duty
status.6 Since 2000, DOD's focus has shifted from research solely on Gulf
War illnesses to research on medical issues of active duty troops in
current or future military deployments.7 For example, in 2000 VA and DOD
collaborated to develop the Millennium Cohort study, which is a
prospective study evaluating the health of both deployed and nondeployed
military personnel throughout their military careers and after leaving
military service. The study began in October 2000 and was awarded $5.25
million through fiscal year 2002, with another $3 million in funding
estimated for fiscal year 2003.

VA's Coordination of Federal Gulf War Illnesses Research Has Lapsed, and
VA Has Not Determined Whether Key Research Questions Have Been Answered

VA's coordination of federal Gulf War illnesses research has gradually
lapsed. Starting in 1993, VA carried out its responsibility for
coordinating all Gulf War health-related activities, including research,
through interagency committees, which evolved over time to reflect
changing needs and priorities. (See fig. 1.) In 2000, interagency
coordination of Gulf War illnesses research was subsumed under the broader
effort of coordination for research on all hazardous deployments.
Consequently, Gulf War illnesses research was no longer a primary focus.
The most recent interagency research subcommittee, which is under the

6DOD officials also told us that there are about 100,000 Gulf War veterans
currently on active military duty but these veterans generally are in good
health.

7DOD refers to medical research related to current or future military
deployments as its Force Health Protection Research Program. This program
focuses on prevention of illness, reduction of injuries or the severity of
injury, faster evacuation of casualties, and enhancements to general
medical capabilities.

Deployment Health Working Group (DHWG), has not met since August 2003, and
as of April 2004, no additional meetings had been planned.

Additionally, VA has not reassessed the extent to which the collective
findings of completed Gulf War illnesses research projects have addressed
the 21 key research questions developed by the RWG. (See app. II.) The
only assessment of progress in answering these research questions was
published in 2001, when findings from only about half of all funded Gulf
War illnesses research were available. Moreover, the summary did not
identify whether there were gaps in existing Gulf War illnesses research
or promising areas for future research. No reassessment of these research
questions has been undertaken to determine whether they remain valid, even
though about 80 percent of federally funded Gulf War illnesses research
projects now have been completed. In 2000, we reported that without such
an assessment, many underlying questions about causes, course of
development, and treatments for Gulf War illnesses may remain unanswered.8

DOD's Gulf War Investigations Are Complete

As of April 2003, DOD had completed all of its Gulf War health-related
investigations, which are separate from Gulf War illnesses research. DOD
began conducting investigations on Gulf War operations and their
implications for service members' and veterans' health in 1996. Generally,
DOD instituted an investigation after it received a report of a possible
exposure to a chemical or biological agent or some other environmental,
chemical, or biological hazard. From 1996 to 2003, DOD conducted 50
investigations at a cost of about $68 million.

DOD published the 50 investigations in the form of 20 case narratives,9 10
information papers,10 5 closeout reports,11 and 5 environmental exposure

8U.S. General Accounting Office, Gulf War Illnesses: Management Actions
Needed to Answer Basic Research Questions, GAO/NSIAD-00-32 (Washington
D.C.: Jan. 6, 2000).

9Case narratives are interim reports of specific events that took place
during the Gulf War and were updated pending further investigative
efforts.

10Information papers are reports of what is known about military
procedures and equipment used during the Gulf War.

11A closeout report is used to close an investigation. The report is
issued after an investigation has been reviewed and recommendations have
been made to terminate the investigation.

reports.12 Additionally, the RAND Corporation was contracted by the Office
of Special Assistant for Gulf War Illnesses (OSAGWI) to publish 10 reports
reviewing the medical and scientific literature on the known health
effects of substances to which Gulf War veterans may have been exposed.
Some investigations focused on examining possible exposures to chemical
warfare agents or the presence of chemical weapons at specific sites.
Other investigations studied the possible linkage between environmental
hazards (such as contaminated water, equipment used during the Gulf War,
oil well fires, and particulate matter) and illnesses or health effects.

OSAGWI published four annual reports summarizing the results of
investigations. Generally, these reports concluded that there were limited
exposures by troops to some hazards and limited or no short- or long-term
adverse effects expected from these exposures. The last annual report was
published in December 2000.

As of April 2004, federal agencies had funded seven research projects
related to cancer incidence among Gulf War veterans, four of which have
been completed. Published results from the completed and ongoing studies
generally show that rates of cancer among Gulf War veterans were similar
to or lower than the rates among nondeployed veterans or the general
population. However, results of these studies may not be reliable due to
limitations in research related to cancer incidence in Gulf War veterans.
Future research efforts may also be hindered by inadequate federal data on
the health characteristics of Gulf War veterans.

Some Efforts Are Under Way to Monitor Cancer Incidence among Gulf War
Veterans, but Research Limitations May Impede Reliability of Results

12Environmental exposure reports are those that focus on exposure to
potential environmental hazards.

Few Research Projects Related to Cancer Incidence in Gulf War Veterans
Have Been Funded

Of the 240 federally funded research projects on Gulf War illnesses, VA
officials stated that only 7 were related to cancer incidence in Gulf War
veterans-accounting for about 3 percent of the entire research
portfolio.13 Four of the seven research projects have been completed; the
other three are ongoing. Only two of the seven research projects
specifically studied cancer incidence. The remaining five research
projects did not focus on cancer incidence, but instead included cancer as
a component of a broader analysis of mortality, hospitalization, or
general health status of Gulf War veterans. (See table 1 for more details
on these studies.)

13Our review focused only on research related to cancer incidence among
Gulf War veterans; therefore, Gulf War illnesses research projects
studying other aspects of cancer, such as treatments for or causes of
specific cancers, were not reviewed.

    Table 1: Research Related to Cancer Incidence in Gulf War Veterans (GWV)

Description Topic Status Published Selected limitations
Postwar Hospitalization Experience Hospitalization Complete Yesa Sample
was limited to hospitalized GWV

of U.S. Veterans of the Persian Gulf War

in VA, DOD, and some California hospitals. All other GWV were not
included.

2 	Combined Analysis of the VA and General health Complete Yesb DOD Gulf
War Clinical Registries

3 	National Health Survey of Persian General health Complete Yes
(interim)c Gulf Veterans

4 	Gulf War and Vietnam Veterans Cancer incidence Complete No Cancer
Incidence Surveillance

5 	Deployment to the Gulf War and Cancer incidence Ongoing No the
Subsequent Development of Cancer Sample was limited to GWV who
selfenrolled in DOD and VA Gulf War clinical evaluation programs. All
other GWV were not included.

GWV self-reported data may be subject to overreporting of poor health
status. Results were not supported by objective data or documentation.

Due to the long latency period of cancer,e it may have been too early to
study cancer incidence in GWV.

Due to the long latency period of cancer,e it may be too early to study
cancer incidence in GWV.

       Mortality      Mortality  Ongoing Yes         Analysis only included   
Follow-up Study of                    (interim)d  GWV who have             
      Persian Gulf                                      died of cancer. Other 
        Veterans                                             GWV who have not 
                                                       died, but have been    
                                                          diagnosed with      
                                                         cancer, were not     
                                                            included.         
         Longitudinal General                                                 
      Health Study of health                 No      GWV self-reported data   
                 Gulf            Ongoing             may be subject
      War Veterans                                   to overreporting of poor 
                                                     health status.           
                                                        Results may not be    
                                                           supported by       
                                                        objective data or     
                                                          documentation.      

Sources: VA, DOD, and published manuscripts.

Note: GAO analysis of VA data, DOD data, and published manuscripts.

aG. C. Gray and others, "The Postwar Hospitalization Experience of U.S.
Veterans of the Persian Gulf War," New England Journal of Medicine, vol.
335, no. 20 (1996), 1505-13, and G. Gray and others, "Are Gulf War
Veterans Suffering War-related Illnesses? Federal and Civilian
Hospitalizations Examined, June 1991 to December 1994," American Journal
of Epidemiology, vol. 151, no. 1 (2000), 63-71.

bU.S. Department of Defense, Combined Analysis of the VA and DOD Gulf War
Clinical Evaluation Programs: A Study of the Clinical Findings from
Systematic Medical Examinations of 100,339 U.S. Gulf War Veterans
(Washington, D.C.: 2002); T. C. Smith and others, "Ten Years and 100,000
Participants Later: Occupational and Other Factors Influencing
Participation in U.S. Gulf War Health Registries," Journal of Occupational
and Environmental Medicine, vol. 44, no. 8 (2002), 758-68; and T. C. Smith
and others, "The Postwar Hospitalization Experience of Gulf War Veterans
Participating in U.S. Health Registries," Journal of Occupational and
Environmental Medicine, vol. 46, no. 4 (2004), 386-97.

cH. K. Kang and others, "Illnesses Among United States Veterans of the
Gulf War: A Population-Based Survey of 30,000 Veterans," Journal of
Occupational and Environmental Medicine, vol. 42, no. 5 (2000), 491-501.

dH. K. Kang and T. A. Bullman, "Mortality among U.S. Veterans of the
Persian Gulf War," New England Journal of Medicine, vol. 335, no. 20
(1996), 1498-504; H. K. Kang and T. A. Bullman, "Mortality Among U.S.
Veterans of the Persian Gulf War: 7-Year Follow-Up," American Journal of
Epidemiology, vol. 154, no. 5 (2001), 399-405; and U.S. Department of
Veterans Affairs, Mortality among U.S. Gulf War Veterans Who Were
Potentially Exposed to Nerve Gas at Khamisiyah, Iraq (Washington, D.C.:
2002).

eSome cancers can take 15 years or more to develop and be detected.

Overall, the four published research projects found that deployed Gulf War
veterans did not have demonstrable differences in cancer-related ailments
compared with nondeployed veterans or the general population. In addition,
one of the published studies found that rates of hospitalization among
Gulf War veterans were similar or lower than among nondeployed veterans,
and another found that cancer-related mortality rates among Gulf War
veterans were similar or lower than in the general population.

Research efforts are continuing for one of the two funded research
projects specifically related to cancer incidence in Gulf War veterans.
Researchers conducted a pilot project, scheduled to end in September 2004,
which matched the cancer registries of six states and the District of
Columbia14 with a database of all Gulf War veterans.15 In order to build
on these efforts, the researchers plan to expand the pilot study to
include additional states with cancer registries to obtain a more refined
estimate of cancer incidence in Gulf War veterans. While this approach
appears promising, the study's principal investigator said further efforts
beyond September 2004 would be limited to working with state cancer
registries that do not charge a fee or do not require on-site use of a
registry.

Research Related to Cancer Incidence in Gulf War Veterans Has Several
Limitations That Could Affect Reliability of Findings

A number of inherent limitations in research related to cancer incidence
in Gulf War veterans could adversely affect the reliability of the
findings from such research. (See table 1.) For example, since some
cancers can take 15 years or more to develop and subsequently be detected,
it may be too early to determine cancer incidence in Gulf War veterans, as
studies 4 and 5 in table 1 were designed to do. Hospitalization studies of
Gulf War veterans are applicable only to those veterans who seek care in
specific hospitals

14The pilot study included cancer registries from California, Florida,
Maryland, New Jersey, Texas, Virginia, and the District of Columbia.

15A cancer registry is an information system designed for the collection,
management, and analysis of data on individuals with the diagnosis of a
cancer, which may include data on the occurrence of cancer, the types of
cancer that occur, the cancer's location in the body, the extent of
disease at time of diagnosis, and the kinds of treatment patients receive.

included in the studies; veterans who use other health care systems are
not included. Mortality studies of Gulf War veterans are limited because
only veterans who have died of cancer are captured; other veterans who
have not died, but have been diagnosed with cancer, are not included.
Additionally, some general health studies of Gulf War veterans may use
self-reported data only, which may not be accurate unless validated by
objective physical or laboratory findings. Other research projects, which
have samples that are not representative of all Gulf War veterans, such as
studies 1 and 5 in table 1, may not reliably assess the possibility of
elevated levels of cancer incidence or related ailments in Gulf War
veterans when compared to the general population or nondeployed veterans.

Research related to cancer incidence in Gulf War veterans may also be
hampered by incomplete federal data on the health characteristics of Gulf
War veterans. In 1998, we reported that VA and DOD did not have data
systems providing complete information on the health characteristics of
Gulf War veterans that could be used to accurately estimate cancer
incidence.16 For example, data from medical records and files on
disability claims, treatment, and pensions do not include all Gulf War
veterans. These data do not account for veterans who are separated from
the services and receive non-VA health care or disability benefits.
Furthermore, linking VA and DOD data systems still would not overcome
these shortcomings. VA officials have also stated that existing data
systems, such as medical record or pension systems, are not adequate for
determining cancer incidence and that epidemiological research projects
are needed.

16U.S. General Accounting Office, Gulf War Veterans: Limitations of
Available Data for Accurately Determining the Incidence of Tumors,
GAO/T-NSIAD-98-186 (Washington D.C.: May 14, 1998) and Gulf War Veterans:
Incidence of Tumors Cannot Be Reliably Determined from Available Data,
GAO/NSIAD-98-89 (Washington D.C.: Mar. 3, 1998).

RAC's Efforts to Provide Advice May Be Hindered by VA's Limited
Information Sharing and Collaboration, but Several Changes to Address
These Issues Have Been Proposed

RAC's efforts to provide advice and make recommendations on Gulf War
illnesses research may have been impeded by VA's limited sharing of
information on research initiatives and program planning as well as VA's
limited collaboration with the committee. However, VA and RAC are
exploring ways to improve information sharing, including VA's hiring of a
senior scientist who would both guide the agency's Gulf War illnesses
research and serve as the agency's liaison to provide routine updates to
RAC. VA and RAC are also proposing changes to improve collaboration,
including possible commitments from VA to seek input from RAC when
developing research program announcements. At the time of our review, most
of these proposed changes were in the planning stages.

RAC Officials Cite VA's Poor Information Sharing and Limited Collaboration
as Impediments in Meeting Its Mission

According to RAC officials, VA senior administrators' poor information
sharing and limited collaboration with the committee about Gulf War
illnesses research initiatives and program planning may have hindered
RAC's ability to achieve its mission of providing research advice to the
Secretary of VA. RAC is required by its charter to provide advice and make
recommendations to the Secretary of VA on proposed research studies,
research plans, and research strategies relating to the health
consequences of service during the Gulf War. (See app. III for RAC's
charter.) RAC's chairman and scientific director said that the
recommendations and reports that the advisory committee provides to the
Secretary of VA are based on its review of research projects and published
and unpublished research findings related to Gulf War illnesses.

Although RAC and VA established official channels of communication, VA did
not always provide RAC with important information related to Gulf War
illnesses research initiatives and program planning. In 2002, VA
designated a liaison to work with RAC's liaison in order to facilitate the
transfer of information to the advisory committee about the agency's Gulf
War illnesses research strategies and studies. However, RAC officials
stated that most communication occurred at their request; that is, the VA
liaison and other VA staff were generally responsive to requests, but did
not establish mechanisms to ensure that essential information about
research program announcements or initiatives was automatically provided
to the advisory committee. RAC officials cited the following instances in
which VA did not fully collaborate with the advisory committee or provide
information that RAC considered important:

o  	According to RAC's scientific director, bimonthly teleconferences
between the advisory committee's and VA's liaisons did not result in full
disclosure of relevant ongoing research activities. For example, despite
several months of discussions in which RAC's liaison requested information
about proposed research program announcements for Gulf War illnesses
research, VA's liaison did not inform RAC that VA's Office of Research and
Development was preparing a research program announcement until it was
published in October 2002. Consequently, RAC officials said that they did
not have an opportunity to carry out the committee's responsibility of
providing advice and making recommendations on research strategies and
plans.

o  	RAC officials stated that VA did not notify advisory committee members
that the Longitudinal Health Study of Gulf War Era Veterans-a study
designed to address possible long-term health consequences of service in
the Gulf War-had been developed and that the study's survey was about to
be sent to study participants. RAC officials expressed concern that VA did
not inform the advisory committee about the survey even after the plans
for it were made available for public comment. Although the survey had
been finalized, the study's principal investigator provided additional
time to allow RAC to recommend additional survey question topics and
incorporated RAC's suggested changes into the survey.

o  	In May 2004, VA published its annual report that described the
results, status, and priorities of federally funded Gulf War illnesses
research as of 2002. However, RAC officials said they had not seen a draft
of this report and had not been asked to review or comment on the document
before it was published, even though the advisory committee has a
responsibility to advise the Secretary of VA on the state and direction of
Gulf War illnesses research.

According to RAC officials, there were also instances in which information
relevant to Gulf War illnesses research provided by VA's liaison or other
VA officials was unclear or incomplete. Miscommunication about the purpose
of the October 2002 research program announcement and the details of a
corresponding VA plan to increase funding up to $20 million for research
related to hazardous military deployments, which would include the Gulf
War, led RAC members to believe that VA had committed a large portion of
this $20 million to Gulf War illnesses research for fiscal year 2004.
Moreover, RAC officials did not receive routine reports on Gulf War
illnesses research proposals that had been either received or funded by VA
under the October 2002 research program announcement. RAC officials said
that until VA administrators were asked to brief the advisory committee in
February 2004, advisory committee members were unaware that only one new
Gulf War illnesses research project had received

funding for fiscal year 2004 under this program announcement and that no
other proposals were under review.

Information sharing about these types of issues is common practice among
advisory committees of the National Institutes of Health (NIH), which has
more federal advisory committees than any other executive branch agency.17
A senior official within NIH's Office of Federal Advisory Committee Policy
said that it is standard practice for NIH advisory committees to
participate closely in the development of research program announcements.
For example, some advisory committees' members review preliminary drafts
of announcements, and some discuss program announcements during regular
committee meetings. Furthermore, this official stated that many NIH
institutes require advisory committee approval before issuing research
program announcements. In addition, NIH's advisory committee members are
routinely asked to make recommendations on both research concepts and
priorities for research projects, and are kept up-to-date about the course
of ongoing research projects. This official also stated that NIH advisory
committee members often review draft reports summarizing research findings
or research progress prior to their publication.

Additionally, RAC officials stated that VA's staffing choices for the
liaison position and more recent VA staff turnover have hindered the
development of working relationships and information flow. RAC officials
stated that the initial VA liaison-a senior official in one of VA's four
research services-was not very knowledgeable about current Gulf War
illnesses research developments. In early 2003, VA's Chief Research and
Development Officer (CRADO),18 whom RAC officials said was knowledgeable
about Gulf War illnesses issues, began to serve as the VA liaison to RAC.
(See fig. 6 for organizational chart.) However, this individual left VA in
December 2003, and according to RAC officials, further communication with
the advisory committee was delegated to lower-level VA staff. After the
advisory committee's February 2004

17NIH is the largest funder of medical research in the United States and
maintains more than 140 chartered advisory committees. NIH has four types
of advisory committees-for the purposes of this report, we refer to
practices of two committee types: program advisory committees and national
advisory councils.

18The CRADO is responsible for oversight of research programs within the
four VA research services: the Biomedical Laboratory Research and
Development Service, the Clinical Science Research and Development
Service, the Health Services Research and Development Service, and the
Rehabilitation Research and Development Service.

meeting, the acting CRADO (appointed in December 2003) and the deputy
CRADO began to communicate regularly with the advisory committee. However,
the acting CRADO has additional management responsibilities that can limit
the amount of time available to coordinate with RAC. Specifically, in
early April 2004, this official was named to temporarily head VA's health
care system-the Veterans Health Administration.19 For this reason, the
deputy CRADO more often has acted as a point of contact for the committee.

Figure 6: Organizational Relationships between VA and RAC, as of April
2004

Advice and

The same VA official was serving in each position as of April 2004.

Source: VA.

19The Veterans Health Administration is the nation's largest integrated
health care system, employing more than 180,000 health care professionals
and operating more than 1,300 health care facilities. In addition to its
medical care mission, the veterans health care system is the nation's
largest provider of graduate medical education and a major contributor to
medical and scientific research.

VA and RAC Are Exploring Methods to Improve Information Sharing and
Collaboration

In recognition of RAC's concerns, VA is proposing several actions to
improve information sharing, including VA's hiring of a senior scientist
to guide its Gulf War illnesses research and improving formal channels of
communication. In addition, VA and RAC are exploring methods to improve
collaboration. These would include possible commitments from VA to seek
input from RAC when developing research program announcements and to
include RAC members in a portion of the selection process for funding Gulf
War illnesses research projects. As of April 2004, most of the proposed
changes were in the planning stages.

Since the February 2004 RAC meeting, VA and RAC officials said they have
had multiple meetings and phone conversations and have corresponded via
e-mail in an attempt to improve communication and collaboration. VA
officials said they have already instituted efforts to hire a senior
scientist to guide the agency's Gulf War illnesses research efforts. The
official assigned to this position will be the RAC liaison and coordinator
of VA's research on Gulf War illnesses and health issues related to other
hazardous deployments. According to VA officials, this official will be
required to formally contact RAC officials weekly, with informal
communications on an as needed basis. In addition, this official will be
responsible for providing periodic information on the latest publications
or projects related to Gulf War illnesses research.

To facilitate collaboration with RAC, VA has proposed involving RAC
members in developing VA program announcements designed to solicit
research proposals, both specifically for Gulf War illnesses and related
areas of interest, such as general research into unexplained illnesses.
RAC officials stated that throughout March and April 2004, VA and RAC
officials had been jointly developing a new research program announcement
for Gulf War illnesses. In addition, VA has proposed that RAC will be able
to recommend scientists for inclusion in the scientific merit review
panels. VA also plans to involve RAC in reviews of project relevancy to
Gulf War illnesses research goals and priorities after the research
projects undergo scientific merit review. This could facilitate RAC's
ability to provide recommendations to the CRADO on the projects that it
has judged to be relevant to the Gulf War illnesses research plan.

Conclusions

While more than 80 percent of federally funded Gulf War illnesses research
projects have been completed, little effort has been made to assess
progress in answering the 21 key research questions or to identify the
direction of future research in this area. Additionally, in light of
decreasing federal funds and expanding federal research priorities,
research specific to Gulf War illnesses is waning. Without a comprehensive
reassessment of Gulf War illnesses research, underlying questions about
the unexplained illnesses suffered by Gulf War veterans may remain
unanswered.

Since RAC's establishment in January 2002, its efforts to provide the
Secretary of VA with advice and recommendations may have been hampered by
incomplete disclosure of VA's Gulf War illnesses research activities. By
limiting information sharing with RAC, VA has not fully realized the
assistance that the scientists and veterans' advocates who serve on RAC
could provide in developing effective policies and guidance for Gulf War
illnesses research. VA and RAC are exploring new approaches to improve
information sharing and collaboration. If these approaches are
implemented, RAC's ability to play a pivotal role in helping VA reassess
the direction of Gulf War illnesses research may be enhanced. However,
most of these changes had not been formalized at the time of our review.

Recommendations for 	With respect to the federal Gulf War illnesses
research efforts, we recommend that the Secretary of Veterans Affairs take
the following

Executive Action action:

o  	conduct a reassessment of the Gulf War illnesses research strategy to
determine whether the 21 key research questions have been answered,
whether they remain relevant, and whether there are promising areas for
future research.

To facilitate RAC's ability to provide advice on Gulf War illnesses
research, we recommend that the Secretary of Veterans Affairs take the
following additional two actions:

o  	ensure that a liaison who is knowledgeable about Gulf War illnesses
research is appointed to routinely share information with RAC and

o  	ensure that VA's research offices collaborate with RAC on Gulf War
illnesses research program development activities.

Agency Comments
and Our Evaluation

We provided a draft of this report for comment to VA and DOD. In
commenting on this draft, VA agreed with the report's conclusions and
concurred with the report's recommendations. VA said that it has begun a
preliminary assessment of the federal Gulf War illnesses research
strategy, including an evaluation of the 21 key research questions, to
ensure the research strategy's continued validity and to identify
promising areas for future research. The agency also noted that it has
undertaken various steps, such as coordinating its most recent request for
Gulf War research applications with RAC, in order to better collaborate
with the advisory committee. VA's written comments are in appendix IV.

DOD informed us that it had no substantive comments on the draft report.
Both VA and DOD provided technical comments, which we incorporated where
appropriate.

We are sending copies of this report to the Secretary of VA, the Secretary
of Defense, and the Secretary of HHS. We will also provide copies to
others upon request. In addition, the report will be available at no
charge
on GAO's Web site at http://www.gao.gov.

If you or your staff have any questions about this report, please call me
at
(202) 512-7119 or Bonnie Anderson at (404) 679-1900. Karen Doran, John
Oh, Danielle Organek, and Roseanne Price also made key contributions to
this report.

Sincerely yours,

Janet Heinrich
Director, Health Care-Public Health Issues

                       Appendix I: Scope and Methodology

To describe the status of research and investigations on Gulf War
illnesses, we reviewed reports to congressional committees outlining
annually awarded and completed research projects and research funding. We
summarized data from the Department of Veterans Affairs' (VA) annual
reports to congressional committees, including numbers of funded research
projects and total funding by federal agency, in order to determine the
status of completed research. We interviewed VA's then-Assistant Chief
Research and Development Officer (CRADO) and the Department of Defense's
(DOD) Deputy Director of the Deployment Health Support Directorate (DHSD)
regarding the agencies' current and future Gulf War illnesses research and
investigation plans. We also interviewed CRADO and DHSD staff and senior
managers with DOD's medical research offices, including Defense Research
and Engineering and the Army's Medical Research and Materiel Command. We
reviewed other relevant documents, including interagency coordinating
council meeting minutes, federal laws, presidential directives, and VA-
and DOD-published documents on Gulf War illnesses research and DOD
investigations.

To describe efforts made by VA and DOD to monitor cancer incidence among
Gulf War veterans, we interviewed VA's then-Assistant CRADO, a VA senior
research manager, and VA researchers, along with DOD's Deputy Director of
DHSD. We reviewed annual reports to congressional committees describing
federally funded Gulf War illnesses research, published articles from
peer-reviewed journals reporting research findings, and other agency
documents describing research projects.

To evaluate the VA's Research Advisory Committee on Gulf War Veterans'
Illnesses (RAC) efforts to provide advice on Gulf War illnesses research,
we interviewed RAC's Chairman and Scientific Director, attended the most
recent RAC meeting in February 2004, and reviewed RAC reports and
recommendations to the Secretary of VA. We also interviewed officials with
the National Institutes of Health's (NIH) Office of Federal Advisory
Committee Policy and officials within an NIH advisory committee to
identify common practices related to information sharing and collaboration
between NIH and its advisory committees. To determine VA's efforts to
improve information sharing and collaboration with RAC, we interviewed
VA's deputy CRADO and CRADO staff.

Appendix II: Key Gulf War Illnesses Research Questions

From 1995 through 1996, the Research Working Group (RWG) of the
interagency Persian Gulf Veterans' Coordinating Board identified 19 major
research questions related to illnesses in Gulf War veterans. RWG later
added 2 more questions to create a set of 21 key research questions to
serve as a guide for federal research on Gulf War illnesses. (See table
3.)

Appendix II: Key Gulf War Illnesses Research Questions

         Table 2: Twenty-one Key Gulf War Illnesses Research Questions

Research
question number Key research questions

What is the prevalence of symptoms/illnesses in the Persian Gulf veterans
population? How does this prevalence compare to that in an appropriate
control group?

What was the overall exposure of troops to Leishmania tropica?

What were the exposure concentrations to various petroleum products, and
their combustion products, in typical usage during the Persian Gulf
conflict?

What was the extent of exposure to specific occupational/environmental
hazards known to be common in the Persian Gulf veterans' experience? Was
this exposure different from that of an appropriate control group?

What were the potential exposures of troops to organophosphate nerve agent
and/or sulfur mustard as a result of allied bombing at Muhammadiyat and Al
Muthannna, or the demolition of a weapons bunker at Khamisiyah?

What was the extent of exposure to chemical agent, other than at
Khamisiyah, Iraq, in the Persian Gulf as a function of space and time?

    What was the prevalence of pyridostigmine bromide use among Persian Gulf
                                    troops?a

What was the prevalence of various psychophysiological stressors among
Persian Gulf veterans? Is the prevalence different from that of an
appropriate comparison population?

Are Persian Gulf veterans more likely than an appropriate comparison group
to experience nonspecific symptoms and symptom complexes?

Do Persian Gulf veterans have a greater prevalence of altered immune
function or host defense when compared with an appropriate control group?

Is there a greater prevalence of birth defects in the offspring of Persian
Gulf veterans than in an appropriate control population?

Have Persian Gulf veterans experienced lower reproductive success than an
appropriate control population?

Is the prevalence of sexual dysfunction greater among Persian Gulf
veterans than among an appropriate comparison population?

Do Persian Gulf veterans report more pulmonary symptoms or diagnoses than
persons in appropriate control populations?

Do Persian Gulf veterans have a smaller baseline lung function in
comparison to an appropriate control group? Do Persian Gulf veterans have
a greater degree of nonspecific airway reactivity in comparison to an
appropriate control group?

Is there a greater prevalence of organic neuropsychological and
neurological deficits in Persian Gulf veterans compared to appropriate
control populations?

17 	Can short-term, low-level exposures to pyridostigmine bromide, the
insect repellent DEET, and the insecticide permethrin, alone or in
combination, cause short-term and/or long-term neurological effects?

18 	Do Persian Gulf veterans have a significantly higher prevalence of
psychological symptoms and/or diagnoses than do members of an appropriate
control group?

19 What is the prevalence of leishmaniasis and other infectious diseases
in the Persian Gulf veteran population?

20 	Do Persian Gulf veterans have a greater risk of developing cancers of
any type when compared with an appropriate control population?

21 	Are Persian Gulf veterans experiencing a mortality rate that is
greater than that of an appropriate control population? Are specific
causes of death related to service in the Persian Gulf?

Source: VA.

Appendix II: Key Gulf War Illnesses Research Questions

aPyridostigmine bromide is a drug that was supplied to troops for use as a
pretreatment for potential exposure to nerve agents.

Appendix III: Charter for VA's Research Advisory Committee on Gulf War Veterans'
Illnesses

Appendix III: Charter for VA's Research Advisory Committee on Gulf War
Veterans' Illnesses

Appendix III: Charter for VA's Research Advisory Committee on Gulf War
Veterans' Illnesses

Source: RAC.

Appendix IV: Comments from the Department of Veterans Affairs

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