Operation Desert Storm: Health Concerns of Selected Indiana Persian Gulf
War Veterans (Letter Report, 05/16/95, GAO/HEHS-95-102).

Pursuant to a congressional request, GAO provided information on certain
Persian Gulf War veterans' chronic health problems, focusing on: (1) the
veterans' current military and health status; (2) the health care
services they received after the war; and (3) their opinions on post-war
care.

GAO found that: (1) the veterans surveyed were still concerned about
their health and were dissatisfied with the Department of Veterans
Affairs' (VA) and the Department of Defense's (DOD) services; (2) most
of these veterans were still on active duty and believe their health
problems are linked to their service in the Persian Gulf; (3) less than
half of the separated veterans reported that health problems related to
their Persian Gulf service contributed to their discharges; (4) most of
the veterans reported that their health problems limited their physical
and social activities; (5) almost one-third of the respondents reported
that family members also experienced health problems that were related
to their Gulf service; (6) although over half of these veterans had used
VA or DOD health care services, many veterans received care from sources
other than VA or DOD; and (7) VA and DOD have taken a variety of actions
to address Persian Gulf veterans' concerns by expanding special health
examinations and their outreach efforts.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-95-102
     TITLE:  Operation Desert Storm: Health Concerns of Selected Indiana 
             Persian Gulf War Veterans
      DATE:  05/16/95
   SUBJECT:  Health care services
             Veterans benefits
             Military personnel
             Military hospitals
             Health hazards
             Ground warfare
             Armed forces reserves
             Disease detection or diagnosis
             Health care programs
             Medical examinations
IDENTIFIER:  Indiana
             Persian Gulf War
             Desert Storm
             VA Persian Gulf War Health Registry
             DOD Persian Gulf War Health Surveillance System
             DOD Comprehensive Clinical Evaluation Program
             
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Cover
================================================================ COVER


Report to Congressional Requesters

May 1995

OPERATION DESERT STORM - HEALTH
CONCERNS OF SELECTED INDIANA
PERSIAN GULF WAR VETERANS

GAO/HEHS-95-102

Persian Gulf War Veterans


Abbreviations
=============================================================== ABBREV

  ARCOM - 123rd Army Reserve Command
  CCEP - Comprehensive Clinical Evaluation Program
  DOD - Department of Defense
  VA - Department of Veterans Affairs

Letter
=============================================================== LETTER


B-258098

May 16, 1995

The Honorable Dan Burton
The Honorable Steve Buyer
The Honorable Lee H.  Hamilton
The Honorable John Hostettler
The Honorable Andrew Jacobs, Jr.
The Honorable John T.  Myers
The Honorable Mark E.  Souder
House of Representatives

Many veterans of the Persian Gulf War have expressed concern that
their service in Southwest Asia in some way caused chronic health
problems.  The severity of these problems reported varies; some
veterans report relatively mild symptoms, while others report
debilitating illnesses.  The cause or causes of these problems is
unknown, but many causes have been suggested, including exposure to
chemical or other toxic agents, parasitic infestations, medications
given as a precaution against possible exposure to nerve agents, and
stress.  Persian Gulf veterans' health concerns have received
considerable attention by Congress, federal agencies and the media. 
Both the Department of Veterans Affairs (VA) and the Department of
Defense (DOD) have undertaken research efforts to determine the
extent and causes of these illnesses and have established programs to
provide health examinations to identify and respond to these
veterans' health concerns. 

You asked that we obtain information related to health concerns for
certain Gulf War veterans from the 123rd Army Reserve Command
(ARCOM), headquartered in Indianapolis, Indiana.  Members of the
ARCOM, according to command officials, were among the first to raise
Persian Gulf-related health concerns.  Early in 1992, the Surgeon
General of the Army directed a team from the Walter Reed Army
Institute of Research to examine the 125 ARCOM members who, by that
time, had made their health concerns known to the ARCOM. 

In response to your request, we obtained information on the current
military and health status of these 125 Persian Gulf War veterans,
the health care they have received, and their opinions of that health
care.  Most of this information was obtained through a survey of the
125 ARCOM veterans we conducted in November 1994.  Of the 125, 89
responded.\1 The information reported from the survey cannot be
generalized beyond these respondents to any other Persian Gulf
veterans.  Information on health status and quality of care was not
verified through means such as physical examinations and is based
solely on the perceptions of the respondents.  We also interviewed
officials from the Departments of Defense and Veterans Affairs; the
Walter Reed Army Institute of Research; the VA medical center in
Indianapolis, Indiana; and the ARCOM.  We also reviewed pertinent
policy documents.  We did our work between July 1994 and March 1995
in accordance with generally accepted government auditing standards. 

Appendix I describes the methodology for our survey.  Appendix II is
a copy of the survey showing responses for each question. 


--------------------
\1 After mailing out the survey, we learned that 2 of the 125
reservists had passed away.  Of the remaining 123, 72 percent (89)
responded to our survey. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

Despite DOD and VA efforts to address the concerns of these and other
Persian Gulf veterans, those we surveyed still expressed concerns
about their health and dissatisfaction with services from DOD and VA. 
Most respondents were still in the reserves and almost all reported
that they had health problems they believed were caused by their
service in the Persian Gulf.  Most also reported that these problems
limited their physical and social activities to some extent.  Because
all of the individuals we surveyed had already expressed some concern
about their health, the fact that they reported having health
problems after returning from the Persian Gulf is not surprising. 

Over half of the respondents had taken advantage of medical services,
either the special examinations or other health care, available to
them through VA or DOD.  Many, however, were dissatisfied with the
medical care they received or were unaware of services available. 
DOD and VA have undertaken a variety of efforts to address the
concerns raised by Persian Gulf veterans, including expanding the
health examinations available to them.  Also, in response to recent
legislation, both agencies are expanding outreach efforts to better
ensure that veterans are aware of services available.  Whether these
efforts will satisfy these veterans' concerns remains to be seen. 


   BACKGROUND
------------------------------------------------------------ Letter :2

Between November 1990 and March 1991, 1,200 members of the ARCOM were
sent to the Persian Gulf; most returned between March and August
1991.  The ARCOM's mission was combat service support, and members
were not involved in frontline combat.  In January 1992, officials of
the ARCOM first became aware of members' medical complaints and
symptoms.  In February 1992, one ARCOM member, concerned about these
health complaints, distributed an unofficial questionnaire asking
members if they had health concerns.  In March 1992, the ARCOM
surgeon examined some of the members who were complaining of health
problems. 

By early spring 1992, the ARCOM was aware of 125 members who had
health concerns.  Those concerns included fatigue, joint pain, skin
rashes, and loss of memory.  In response to the Surgeon General's
directive, the Walter Reed team visited the ARCOM headquarters on
April 11 and 12, 1992, to examine the soldiers.  The ARCOM attempted
to schedule appointments for all 125 soldiers; 79 reported for the
examination.  According to ARCOM officials, the remaining 46 were not
examined for a variety of reasons, including scheduling
conflicts--the appointments were made on fairly short notice. 


   MILITARY STATUS
------------------------------------------------------------ Letter :3

Sixty-one of the 89 respondents to our survey reported that they were
still in the military on active duty or in a Selected Reserve or
National Guard unit; 47 were still in the ARCOM.  Of the 28 who
indicated that they were no longer on active duty or in units, 20
reported that they had Persian Gulf-related health problems at the
time they left their units.  Of those, 12 said that these health
problems contributed to some extent to their separation from the
military; 1 of these reported being denied reenlistment because of
weight, and 1 reported being discharged before being eligible for
reenlistment. 

Although the military can discharge a reservist for medical reasons,
an ARCOM official said he was unaware of any members discharged
involuntarily because of health problems that may have been caused by
service in the Persian Gulf.  Additionally, in June 1994, the Under
Secretary of Defense for Personnel and Readiness asked the
Secretaries of the Army, Navy, and Air Force to direct that no
service member with symptoms "associated with Persian Gulf illness"
be discharged unless he or she requests it in writing or he or she
can be medically retired or separated.  In October 1994, the National
Defense Authorization Act for 1995 (P.L.  103-337, Oct.  5, 1994)
provided a presumption that a Persian Gulf veteran who is ill became
ill as a result of service in the Persian Gulf, unless medical
evidence establishes another cause, and specifies that such a
presumption can be used in disability determinations.  DOD officials
explained that passage of this act allowed service members with
illnesses that could not be diagnosed to be medically retired or
separated, with appropriate benefits, because of those illnesses;
without the new presumption, such members could only receive benefits
if a specific diagnosis could be made. 


   CURRENT HEALTH STATUS
------------------------------------------------------------ Letter :4

Most respondents continued to have health problems and reported
having those problems within the 6 months prior to completing our
survey.  The problems indicated by most respondents are similar to
the symptoms reported to the Walter Reed research team.  At least
two-thirds of the respondents reported chronic fatigue, achy joints,
short-term memory loss, headaches, difficulty concentrating,
nervousness or irritability, inability to sleep through the night,
and depression. 

Most respondents reported that these health problems limited their
activities to some extent.  They most frequently cited limitations in
vigorous activities; climbing several flights of stairs; or in
bending, kneeling, or stooping.  They least often cited limitations
in less vigorous types of activities, like walking a block or bathing
and dressing.  Nineteen reported that they were limited to a great
extent in performing one or more types of activity.  However, most
reported that they had worked within the 6 months prior to completing
the survey.  Fifty-three reported that during that time period they
missed no days of work for health reasons, but 9 said they were
unable to work at all during that period. 

Most, but not all, respondents attributed their health problems to
Persian Gulf service.  Eighty-one reported that they were currently
experiencing health problems associated with that service; 76
reported that, overall, their health was worse than shortly before
they went to the Persian Gulf.\2

Sixty-nine respondents said that health problems, which they believed
were caused to some extent by their Persian Gulf service, limited
their physical (56) or social activities (57).  Most of those 69
reported that they had worked within the 6 months prior to completing
the survey.  Thirty-four reported that during that time period they
had missed no days of work for health reasons, but four said they
were unable to work at all. 

Additionally, 23 respondents reported that family members or
individuals they lived with were experiencing health problems the
veteran believed were related to the veteran's Persian Gulf service. 
The veterans reported that these individuals had a wide range of
problems including fatigue, achy joints, irritability, and
depression.  One respondent indicated that he believed his child had
developed cancer as a result of the respondent's service in the
Persian Gulf. 


--------------------
\2 Forty-one described their health as fair or poor; only 14
described their health as very good or better.  Overall, the veterans
who are no longer on active duty or in Reserve or Guard units
reported health problems that are similar to those who are still in
the service. 


   MEDICAL CARE PROVIDED TO
   PERSIAN GULF WAR VETERANS
------------------------------------------------------------ Letter :5

We obtained information about several kinds of medical care that was
available to these Persian Gulf War veterans: 

  stress management training recommended by the Walter Reed team for
     ARCOM members,

  special examinations offered by VA and DOD for Persian Gulf
     veterans to help identify their concerns and ensure appropriate
     treatment, and

  other medical care they may have received in VA and DOD facilities
     as well as care outside these two medical systems. 

Because some veterans told us they were unaware of one or more of
these services, we also discussed with VA and DOD officials efforts
to inform Persian Gulf veterans of the services available to them. 


      FOLLOW-UP TO WALTER REED
      STUDY
---------------------------------------------------------- Letter :5.1

The Walter Reed study team recommended that the ARCOM continue to
provide stress management evaluation and intervention, which the
ARCOM had initiated earlier, to members who had been deployed.\3 In
response to our survey, 33 reported receiving stress management
counseling from the ARCOM.  In total, 45 respondents said that they
had received stress management counseling from DOD, VA, or other
sources. 

ARCOM records indicated that medical personnel from the ARCOM's 55th
Medical (Psychiatric) Detachment, assisted by psychiatrists, offered
stress management training to three ARCOM units in Lafayette and
Scottsburg, Indiana.  These units included approximately 360 of the
1,200 who deployed.  An ARCOM official told us that the ARCOM had
limited resources and offered stress management to these units
because they were the first in which concerns were raised. 

ARCOM records indicated that on May 16, 1992, personnel from the
medical detachment met with the 417th Quartermaster Company in
Scottsburg, Indiana.  Seventy-five members of the company, which
deployed 126 reservists, and 8 family members participated in the
session.  Also, on June 13 and 14, 1992, medical detachment personnel
met with the 209th Service and Support Company in Lafayette, Indiana. 
About 110 members of that unit, which deployed 171 reservists, and 7
family members attended this session.  In both cases the format of
the meetings included (1) large group discussions with both unit and
family members, (2) small group discussions, and (3) individual
counseling upon request.  Officials also sought help from other
sources outside the ARCOM, such as chaplains.  Officials could not
provide information on participation at a third session they said was
held with the 300th Supply and Support Battalion. 


--------------------
\3 The Walter Reed team made specific recommendations for follow-up
care for a few people, either further tests for parasitic infestation
or psychological evaluation for Post-Traumatic Stress Disorder. 
ARCOM officials said that they made the necessary referrals for the
needed care but that they do not know whether the veterans actually
sought and obtained the care. 


      SPECIAL EXAMINATIONS FOR
      PERSIAN GULF VETERANS
---------------------------------------------------------- Letter :5.2

Many of the veterans who responded to our survey received the special
examinations offered by VA and DOD for Persian Gulf veterans. 
However, some were not aware of these services. 

The Persian Gulf War Veterans' Health Status Act (P.L.  102-585, Nov. 
4, 1992) directed VA to establish a Persian Gulf War Veterans' Health
Registry, and authorized special health examinations for veterans of
the Persian Gulf War.  Any veteran who served during the Persian Gulf
War is eligible for this examination.  VA had begun providing
examinations in September 1992, before enactment of the legislation,
and by January 1995, about 40,000 had been given.  Initial
examinations are given at VA medical centers or clinics by physicians
specifically charged with conducting these examinations.  If after
the initial examination the veteran still has an unexplained illness,
the veteran may be referred to specialists for additional
examinations and, ultimately, to one of three VA Persian Gulf
referral centers.  Forty-six respondents reported receiving the VA
examination; two more had appointments to receive it. 

DOD began giving examinations, called Comprehensive Clinical
Evaluation Program (CCEP) examinations, to Persian Gulf veterans in
June 1994.  The examination protocol has three phases; the second and
third phases are given if additional care or diagnostics are
needed.\4 By the end of 1994 DOD reported that 1,000 examinations had
been completed and another 8,000 were at various stages.  DOD
instructions issued in June 1994 indicated that active duty members,
certain retirees, and reservists who are on active duty seeking an
examination should go to a military medical facility.  Other reserve
members and retirees have the option of seeking an examination at
military facilities or VA medical centers.  All other Persian Gulf
veterans are to seek an examination at VA medical centers.  Fourteen
respondents reported receiving the CCEP examination; 1 had an
appointment to receive it. 

Overall, more than half of the respondents (49) had received the VA
or DOD examination; 11 reported receiving both.  Of the 47
respondents still in the ARCOM, 38 had received the VA or the DOD
examination.  Respondents gave a variety of reasons for not receiving
the examinations.  Relatively few (6 for VA and 4 for DOD) said that
they could not get an appointment at a convenient time or that the
facility was too far away.  Most frequently respondents said that
they were unaware of the examinations.  Of all respondents, 20 were
unaware of the VA examination; most (67) were unaware of the DOD
examination. 


--------------------
\4 In June 1994 VA recommended to medical facilities that if a
diagnosis is not made after the registry examination and other
routine medical evaluations, the CCEP protocol is to be followed. 
This encourages more thorough examination at the local medical
facility, reducing the need for the veteran to travel to one of the
referral centers.  The information letter with this recommendation
noted that the CCEP protocol had been developed for use in VA's
referral centers and had been adapted for use by both VA and DOD. 


      OTHER CARE RECEIVED FROM VA,
      DOD, AND OTHER SOURCES
---------------------------------------------------------- Letter :5.3

Sixty-two respondents reported that they had received medical
care--other than the VA or DOD special examinations--for health
problems they believe were caused by their Persian Gulf service. 
Some received care from more than one source, but more veterans
received care from outside VA and DOD than from VA or DOD facilities. 

Public Law 103-210 (Dec.  20, 1993) authorized VA to provide health
care services on a priority basis to Persian Gulf veterans if VA (1)
determines that they may have been exposed to toxins or environmental
hazards while serving in the Persian Gulf and (2) does not determine
that the veterans' health problems were caused by factors other than
that possible exposure.  Before this legislation, these veterans were
not eligible for care in VA hospitals without reimbursement unless VA
had determined that their health problems were service connected or
they met other eligibility requirements such as income criteria. 
Those on active duty are eligible for care for all health problems in
DOD facilities; and those still in the reserves are eligible for
health care at DOD facilities only for health-related problems that
occurred, or were aggravated, while on active duty.  Those no longer
in the military are eligible for care from VA but not from DOD. 

Of the 62 who reported receiving care for health problems they
believed to be related to Persian Gulf service, 47 got care in the
civilian sector (20 got care only from the civilian sector), and 42
got care from VA (33) or DOD (24).  Whatever the source, most
veterans received care as an outpatient. 

Most reported getting less than half of the care they believe they
need for their Persian Gulf-related health problems.  Sixty-three
veterans reported that they need care for these health problems, but
fewer than half of these (29) were under a physician's care at the
time of our survey. 

Thirty-six reported that they were not receiving care from VA but
would like to; 44 reported that they were not receiving care from DOD
but would like to.  The reason most often cited for not receiving
care was that they were not aware they were eligible for it--14 did
not know they were eligible for VA care; 29 did not know they were
eligible for DOD care.\5

Relatively few (7 for VA and 6 for DOD) reported that they had not
received care because the facilities were too far away or they could
not get an appointment at a convenient time. 


--------------------
\5 While all Persian Gulf veterans are eligible for care in VA
facilities for problems possibly related to exposure to toxins or
environmental hazards during Persian Gulf service (and not found to
have other causes), not all are eligible for DOD care.  Most of those
who said they did not know they were eligible for DOD care, in fact,
may not be.  For example, most reservists not on active duty and
those no longer associated with the military are not eligible for DOD
care beyond the CCEP examination. 


      VA AND DOD OUTREACH EFFORTS
---------------------------------------------------------- Letter :5.4

Both VA and DOD have undertaken outreach efforts to publicize the
examinations and other services available to Persian Gulf veterans. 
Some efforts began before our survey, and others are planned or began
after our survey was conducted in response to recent legislation and
concerns we raised during our study. 


         VA OUTREACH
-------------------------------------------------------- Letter :5.4.1

VA headquarters outreach has been done primarily through veterans
service organizations; a computer bulletin board; public service
announcements; and published literature, chiefly the Persian Gulf
Review.  VA officials told us that this newsletter is sent to all
veterans who have received the VA exam, to veterans service
organizations, and to veterans who ask to be on the mailing list; it
is also being placed in waiting rooms in VA medical centers. 
However, officials said that local efforts are more important in
informing veterans of the examinations and care available.  Officials
at the Indianapolis VA medical center told us that the center's
Persian Gulf Coordinator had visited every National Guard and Reserve
unit in Indiana to describe medical care available to Persian Gulf
veterans and pass out literature.  He also arranged for public
service announcements, was interviewed on local radio and television,
and conducted a variety of other local outreach activities.\6 Also,
in January 1993 the ARCOM Command Executive Officer sent a memorandum
to ARCOM unit heads requiring them to notify unit members that the VA
examination was available. 

The Veterans' Benefits Improvements Act (P.L.  103-446, Nov.  2,
1994) requires that VA implement a program to inform veterans and
their families of the medical care and other benefits that may be
provided by VA and DOD arising from service in the Persian Gulf War,
as well as the results of research related to Persian Gulf illnesses. 
This program is to communicate information through a toll-free
telephone number and a semiannual newsletter to all those on the
Persian Gulf War Health Registry.  The registry was authorized in
November 1992 by the Persian Gulf War Veterans Health Status Act,
which specified five groups who were to be included:  Persian Gulf
veterans who (1) had requested the VA examination, (2) had applied
for medical service in VA medical facilities, (3) had filed a claim
for compensation for a disability that might be related to Persian
Gulf service, (4) had died and are survived by a claimant for VA
dependency and indemnity compensation, or (5) had received the DOD
special examination and asked to be included in the VA registry.\7

VA is continuing publication of the Persian Gulf Review.  However, at
the time of our study, VA did not have in one place a registry with
the names of all the required veterans in the five groups--although
officials indicated they had access to the names in all five groups. 
The newsletter was being sent to veterans who had received the VA
special examination, but not to members of the other groups the law
required to be included in the registry.  After we discussed these
issues with VA officials, they indicated that they were taking steps
to consolidate the registry list and to mail the newsletter and other
information to an expanded number of veterans.  This could have
substantial impact.  For example, while only about 40,000 veterans
had received the VA special examination, and therefore were receiving
information from VA, VA indicated that another 110,000 Persian Gulf
veterans had received inpatient or outpatient care from VA.  VA
officials told us that they expected to have a complete registry and
to mail required information to all on the registry by the end of May
1995. 

VA also instituted the toll-free telephone information service,
required by the Veterans' Benefits Improvement Act, in February 1995. 
Officials reported that about 29,000 veterans had called the number
in the first month of operation.  They believed that this indicated
the outreach mechanism was having a substantial impact. 


--------------------
\6 After we discussed the results of our survey with the Persian Gulf
Coordinator at the Indianapolis VA medical center, he agreed to
contact those respondents who told us they were unaware of services,
to explain their eligibility for the special medical examinations and
other medical care available from VA and DOD. 

\7 The act also required VA, from time to time, to provide veterans
on the registry with information concerning significant developments
in research on the health consequences of military service in the
Persian Gulf. 


         DOD OUTREACH
-------------------------------------------------------- Letter :5.4.2

DOD has also taken steps to publicize services available to Persian
Gulf veterans.  For example, in May 1994 DOD sent a memorandum to
Persian Gulf veterans notifying them that they were eligible for an
examination and how to arrange for one.  DOD sent the memorandum by
mail to retirees and those who had left the military.  DOD officials
stated that they went to considerable lengths to find up-to-date
mailing addresses for these people, including purchasing addresses
from a private credit reporting firm.  DOD also sent the memorandum
to the services for distribution through command channels to active
duty and reserve members.  However, during our review, DOD officials
determined that the services had sent the memorandum to active duty
units but not to reserve units, instead relying on public
communication channels to inform reservists.  Officials of the ARCOM
told us that they had not received information about the CCEP from
Reserve headquarters.  DOD officials indicated that it is often
difficult for them to reach members of reserve units because the
units are so dispersed nationally. 

Additionally, in June 1994 DOD initiated a toll-free number for
Persian Gulf veterans.  Callers to this hotline receive information
about the special examinations and other medical care available from
VA and DOD and are referred to medical facilities to receive the VA
or DOD examination, if they so desire.  However, in April 1995 an
ARCOM official told us he was unaware of either the DOD or VA hot
line. 

In October 1994 the National Defense Authorization Act for 1995
required that DOD establish an outreach program for those in the
military who served in the Persian Gulf.  Among other things, DOD is
to inform them of (1) illnesses that might be associated with Persian
Gulf service, (2) counseling and medical care available to them from
DOD and VA, and (3) procedures for being put on the VA registry or
another registry, the Persian Gulf War Health Surveillance System,
managed by DOD.\8 DOD officials emphasized that, in addition to the
memorandums and the telephone hot line discussed, they are continuing
extensive contacts with media and with veteran and military
organizations.  They noted that the toll-free number was receiving
about 400 calls per week, indicating, they believed, that outreach
efforts are effective. 

In commenting on a draft of this report, DOD officials outlined other
outreach activities they are planning.  These include the following: 

  DOD plans to publish research findings in both scientific and
     medical journals and general media.  Specific publication
     methods have not yet been decided.  Agency officials do not
     expect research findings to be available until early 1996. 

  Another toll-free telephone number will be established to answer
     questions and provide information to veterans about their
     individual circumstances, such as unit locations and possible
     exposures. 

  DOD plans to develop information to send directly to reserve units
     to inform reservists about available health services, such as
     the CCEP and hot line. 


--------------------
\8 This act also required DOD to provide information on all
individuals who were registered in DOD's registry to VA for inclusion
in the VA registry.  DOD provided this information to VA in April
1995. 


   SATISFACTION WITH CARE RECEIVED
------------------------------------------------------------ Letter :6

Of those who received care through VA and DOD, most were dissatisfied
with it.  Many of the veterans were dissatisfied with the special
examinations they were given.  Of the 46 who had received the VA
examination, 28 were dissatisfied with it.  Likewise, 7 of the 14 who
had received the DOD examination were dissatisfied with it.  Most
respondents were also dissatisfied with the other care they received
from VA and DOD medical facilities.  Of the 33 who had received other
care from VA, 22 were dissatisfied; 13 of 24 were dissatisfied with
the other care from DOD.  In contrast, more veterans were satisfied
than dissatisfied with care received outside VA and DOD.  Of the 47
who had received care outside DOD and VA, 7 reported being
dissatisfied. 

The following table compares veterans' satisfaction with selected
aspects of care in VA and DOD, and outside VA and DOD. 



                           Table 1
           
             Veterans' Satisfaction With Selected
                       Aspects of Care


                                          VA     DOD   Other
Aspect of care                        (n=33)  (n=24)  (n=47)
------------------------------------  ------  ------  ------
Ability to diagnose problem               26      21      21
Outcome of care received; how much        26      20      22
 it helped
Attention providers gave to what          23      16       6
 respondent said
------------------------------------------------------------
VA officials told us that dissatisfaction with care does not
necessarily mean that the care was of poor quality.  They noted, for
example, that if these individuals believed they were sick and were
not improved or cured, they might be dissatisfied, even if the
medical provider had done all that was possible to diagnose and treat
the problem.  They also noted that satisfaction with physicians'
ability to diagnose problems should not be viewed as an indication of
the accuracy of the diagnosis.  These officials suggested that the
initial assessment by the Walter Reed team--that many of the health
problems were caused by stress--was not accepted by many of the
veterans examined, and that this initial assessment may also have
colored veterans' overall satisfaction with both DOD and VA health
care.  Additionally, many of these veterans might have received care
in 1992 or 1993, before DOD began the CCEP examination and before VA
expanded the protocol for the examination provided at local medical
facilities. 


   SUMMARY
------------------------------------------------------------ Letter :7

Most of the respondents, all of whom had expressed concerns about
their health in 1992, reported that they continued to have health
problems they believed were related to service in the Persian Gulf. 
Over half had taken advantage of medical services, either the special
examinations or other health care, available to them through DOD and
VA.  However, despite VA and DOD efforts to provide health
examinations and care to these veterans and to inform them of these
services, many respondents were either unaware of services or
dissatisfied with them.  Whether changes made in outreach and
services will alleviate the concerns these veterans reported to us is
unknown. 


   AGENCY COMMENTS
------------------------------------------------------------ Letter :8

In a letter dated April 17, 1995, commenting on a draft of this
report, the Secretary of Veterans Affairs expressed concern that
readers would misinterpret the report findings.  (See app.  III.) He
was concerned that readers would generalize the findings about this
small group of Persian Gulf veterans to all Persian Gulf veterans and
that the readers would consider these veterans' perceptions of care
as conclusive evidence about care received.  As stated in the report,
we agree that the responses of the 89 veterans cannot be generalized
to any larger population and that the information on health status
and health care received was based on veterans' memories and
perceptions. 

DOD officials, including the Deputy Assistant Secretary of Defense
for Clinical Services, provided comments on the draft in an April 18,
1995, meeting.  The officials said that they generally concurred with
the information in the report, but expressed concern similar to that
expressed by the Secretary of Veterans Affairs about the possibility
that readers would generalize our findings beyond the 89 respondents. 
The officials also outlined additional outreach efforts that were
being planned; we incorporated that information into the report. 


---------------------------------------------------------- Letter :8.1

We are sending copies of this report to interested congressional
committees, the Secretaries of Defense and Veterans Affairs, and
other interested parties. 

This work was done under the supervision of Ruth Ann Heck, Assistant
Director.  Other major contributors were William Stanco, Edward
Murphy, and Clarita Mrena.  Please call me on (202) 512-7101 or Ms. 
Heck on (202) 512-7007 if you have any questions. 

David P.  Baine
Director, Federal Health Care
 Delivery Issues


SURVEY SCOPE AND METHODOLOGY
=========================================================== Appendix I


   SURVEY POPULATION
--------------------------------------------------------- Appendix I:1

Much of the information contained in this report is based on a survey
we conducted with 125 of the 1,200 reservists from the 123rd Army
Reserve Command (ARCOM) who were deployed to the Persian Gulf during
Operation Desert Storm.  These 125 reservists were scheduled to be
evaluated in 1992 by the Walter Reed Army Institute of Research in
response to concerns about their health that they expressed just
after returning from the Persian Gulf. 


   DATA COLLECTION
--------------------------------------------------------- Appendix I:2

To collect the data, we designed a mail questionnaire that included
questions regarding the reservists' current military status; health
status; participation in special VA and DOD examinations; other
health care received from VA, DOD, and other providers; opinions
about the quality of the care received; and satisfaction with that
care.  To determine reservists' current health status, we included a
list of possible health problems.  This list was adapted from items
on a medical questionnaire developed by the Epidemiology Consultant
Service within the Walter Reed Army Institute of Research and
administered to those reservists from the ARCOM who were evaluated by
the Institute in April 1992.  The contents of the questionnaire were
discussed with VA and DOD officials.  The questionnaire itself was
pretested with several members of the ARCOM.  On the basis of these
discussions and the pretests, the questionnaire was revised
accordingly. 

To develop the mailing list for the veterans in our survey, we used
databases maintained by the ARCOM, DOD's Office of Reserve Affairs,
the VA medical center in Indianapolis, and VA's central information
system.  The questionnaire was first mailed to the reservists on
October 28, 1994.  Those who did not respond to the initial mailing
were sent a second questionnaire.  Subsequent to mailing out the
questionnaire, we learned that 2 of the 125 reservists had passed
away--one prior to the start of our survey, the other shortly after
our first mailing.  Eighty-nine of the remaining 123 reservists (72
percent) completed and returned our questionnaire.  The information
obtained through this survey pertains to only these 89 respondents
and cannot be generalized to any other population. 

Data from surveys such as ours rely on respondents' memories. 
Because of the extensive resources that would be involved, we did not
conduct examinations or review medical files to verify the health
status these veterans reported.  As a limited check on the accuracy
of the responses provided, we compared information available in VA
and DOD automated records to respondents' answers about

  their current military status,

  whether they had received the special examinations offered by VA
     and DOD, and

  whether they had received inpatient or outpatient care in VA
     facilities. 

It was not feasible to compare responses regarding care received from
DOD health facilities to DOD data because DOD medical records for the
reservists are not centrally located.  Taking into account that VA
and DOD records did not always cover the same time periods addressed
in our questionnaire, those survey responses we could compare with
existing data are generally consistent with VA and DOD records. 


   NONRESPONSE ANALYSIS
--------------------------------------------------------- Appendix I:3

We also used automated information from these VA and DOD records to
compare those who responded to our survey with those who did not. 

Nonrespondents and respondents were similar in many ways.  About the
same proportion of each group

  were still in the military at the time of our survey,

  were examined by the Walter Reed Army Institute of Research team in
     1992, and

  had received outpatient care from VA since returning from the
     Persian Gulf. 

In other ways, however, respondents and nonrespondents were
different.  Over one-third of the respondents received VA's special
Persian Gulf examination, as opposed to about one-fifth of the
nonrespondents.  Also, a few of the respondents were admitted to a VA
medical facility from fiscal years 1991 to 1993, but none of the
nonrespondents was admitted during that time. 




(See figure in printed edition.)APPENDIX II
SUMMARY OF QUESTIONNAIRE RESPONSES
=========================================================== Appendix I



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(See figure in printed edition.)APPENDIX III
COMMENTS FROM THE SECRETARY OF
VETERANS AFFAIRS
=========================================================== Appendix I



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