Gulf War Illnesses: Reexamination of Research Emphasis and Improved
Monitoring of Clinical Progress Needed (Testimony, 06/25/97,
GAO/T-NSIAD-97-191).
Many of the 700,000 Gulf War veterans have complained of mysterious
illnesses since the war's end in 1991. Some believe that their chronic,
disabling conditions are a result of wartime exposure to a host of
potentially hazardous substances, including drugs used to protect
against chemical warfare, fuel in shower water, depleted uranium, and
smoke from oil-well fires. The Pentagon acknowledged last year that some
veterans may have been exposed to the nerve agent sarin following the
postwar demolition of Iraqi ammunition facilities. GAO found that nearly
six years after the end of the Gulf War, little is known about the
causes of illnesses among returning veterans. Neither the Defense
Department nor the Department of Veterans' Affairs has systematically
attempted to determine whether ill Gulf War veterans are any better or
worse today than when they were first examined. Ongoing epidemiological
research should provide descriptive data on veterans' illnesses, but
formidable methodological problems are likely to prevent researchers
from pinpointing the causes of veterans' illnesses. GAO questions the
Pentagon's decision to attribute veterans' symptoms to stress or
parasites while discounting chemical agents as a contributing factor. In
a related testimony (GAO/T-HEHS-97-158, June 19, 1997), GAO discusses
the views of Gulf War veterans on the care they have received from the
Department of Veterans Affairs.
--------------------------- Indexing Terms -----------------------------
REPORTNUM: T-NSIAD-97-191
TITLE: Gulf War Illnesses: Reexamination of Research Emphasis and
Improved Monitoring of Clinical Progress Needed
DATE: 06/25/97
SUBJECT: Armed forces abroad
Medical research
Medical examinations
Chemical warfare
Biological warfare
Health services administration
Hazardous substances
Military personnel
Disease detection or diagnosis
Veterans
IDENTIFIER: Persian Gulf War
VA Persian Gulf War Health Registry
DOD Comprehensive Clinical Evaluation Program
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Cover
================================================================ COVER
Before the Committee on Veterans Affairs, U.S. Senate
For Release on Delivery
Expected at
9:30 a.m., EDT
Wednesday, June 25, 1997
GULF WAR ILLNESSES - REEXAMINATION
OF RESEARCH EMPHASIS AND IMPROVED
MONITORING OF CLINICAL PROGRESS
NEEDED
Statement of Donna Heivilin, Director of Planning and Reporting,
National Security and International Affairs Division
GAO/T-NSIAD-97-191
GAO/NSIAD-97-191T
Gulf War Illnesses
(713010)
Abbreviations
=============================================================== ABBREV
DEET - N,N-diethyl-m-toluamide
DOD - Department of Defense
NBC - nuclear, biological, and chemical
PGVCB - Persian Gulf Veterans Coordinating Boards
PTSD - posttraumatic stress disorder
VA - Veterans Affairs
============================================================ Chapter 0
Mr. Chairman and Members of the Committee:
We are pleased to be here today to discuss the result of our study on
the government's clinical care and medical research programs relating
to illnesses that members of the armed forces might have contracted
as a result of their service in the Persian Gulf War.\1
Our report responds to the mandate of the fiscal year 1997 defense
authorization act. Specifically, we will discuss three issues: (1)
the efforts of the Department of Defense (DOD) and Veterans Affairs'
(VA) to assess the quality of treatment and diagnostic services
provided to Gulf War veterans and their provisions for follow-up of
initial examinations, (2) the government's research strategy to study
the veterans' illnesses and the methodological problems posed in its
studies, and (3) the consistency of key official conclusions with
available data on the causes of the veterans' illnesses.
We will summarize our findings on the three issues we reviewed and
then provide more detail. Regarding the first issue, although
efforts have been made to diagnose veterans' problems and care has
been provided to many eligible veterans, neither DOD nor VA has
systematically attempted to determine whether ill Gulf War veterans
are any better or worse today than when they were first examined.
On the second issue, we found that the majority of the research has
focused on the epidemiological study of the prevalence and cause of
Gulf War illnesses rather than the diagnosis, treatment, and
prevention of them. While this epidemiological research will provide
descriptive data on veterans' illnesses, methodological problems are
likely to prevent researchers from providing precise, accurate, and
conclusive answers regarding the causes of veterans' illnesses.
Without accurate exposure information, the investment of millions of
dollars in further epidemiological research on the risk factors (or
potential causes) for veterans' illnesses may result in little
return.
Regarding the third issue, support for some official conclusions
regarding stress, leishmaniasis (a parasitic infection), and exposure
to chemical agents was weak or subject to alternative
interpretations.
--------------------
\1 Gulf War Illnesses: Improved Monitoring of Clinical Progress and
Reexamination of Research Emphasis Are Needed (GAO/NSIAD-97-163, June
23, 1997).
BACKGROUND
---------------------------------------------------------- Chapter 0:1
Before turning to the results of our work in detail, let me briefly
provide some background information and discuss the methodology we
used for our study. During their deployment associated with the
Persian Gulf War, many of the approximately 700,000 veterans of the
Gulf War may have been exposed to a variety of potentially hazardous
substances. These substances include compounds used to decontaminate
equipment and protect it against chemical agents, fuel used as a sand
suppressant in and around encampments, fuel oil used to burn human
waste, fuel in shower water, leaded vehicle exhaust used to dry
sleeping bags, depleted uranium, parasites, pesticides, drugs to
protect against chemical warfare agents (such as pyridostigmine
bromide), and smoke from oil well fires. Moreover, DOD acknowledged
in June 1996 that some veterans may have been exposed to the nerve
agent sarin following the postwar demolition of Iraqi ammunition
facilities.
Many of these veterans have complained of a wide array of symptoms
and disabling conditions since the end of the war in 1991. Some fear
that they are suffering from chronic disabling conditions because of
exposure to chemicals, pesticides, and other agents used during the
war with known or suspected health effects. Accordingly, both DOD
and VA established programs through which Gulf War veterans could
receive medical examinations and diagnostic services. From 1992 to
1994, VA participants received a regular physical examination with
basic laboratory tests. In 1994, VA established a standardized
examination to obtain information about exposures and symptoms
related to diseases endemic to the Gulf region and to order specific
tests to detect the "biochemical fingerprints" of certain diseases.
If a diagnosis was not apparent, veterans could receive up to 22
additional tests and additional specialty consultations. In
addition, if the illness defied diagnosis, the veterans could be
referred to one of four VA Persian Gulf referral centers.
DOD initiated its Comprehensive Clinical Evaluation Program in June
1994. It was primarily intended to provide diagnostic services
similar to those of the VA program and employed a similar clinical
protocol. However, the VA program was among the first extensive
efforts to gather data from veterans regarding the nature of their
problems and the types of hazardous agents to which they might have
been exposed.
METHODOLOGY
---------------------------------------------------------- Chapter 0:2
To address our first evaluation question--the extent of DOD's
clinical follow-up and monitoring of treatment and diagnostic
services--we reviewed literature and agency documents and conducted
structured interviews with DOD and VA officials. We asked questions
designed to identify and contrast their methods for monitoring the
quality and outcomes of their treatment and diagnostic programs and
the health of the registered veterans.
The second objective concerns the coherence of the Persian Gulf
Veterans Coordinating Board's (PGVCB) research strategy. To answer
this question, we conducted a systematic review of pertinent
literature and agency documents and reports. We also interviewed
representatives of PGVCB\2 Research Working Group and officials of
VA, DOD, and the Central Intelligence Agency. We surveyed primary
investigators of ongoing epidemiological studies.
Because different methodological standards apply to various types of
research and because the overwhelming majority of federally sponsored
research is categorized as epidemiological, we limited our survey to
those responsible for ongoing epidemiological studies. With the help
of an expert epidemiological consultant, we devised a questionnaire
to assess critical elements of these studies (including the quality
of exposure measurement, specificity of case definition, and steps to
ensure adequate sample size) and to identify specific problems that
the primary investigators may have encountered in implementing their
studies. We interviewed primary investigators for 31 (72 percent) of
the 43 ongoing epidemiological studies identified by PGVCB in the
November 1996 plan. We also reviewed and categorized descriptions of
all 91 projects identified by April 1997, based on their apparent
focus and primary objective. Finally, to review the progress of
major ongoing research efforts, we visited the Walter Reed Army
Institute of Research, the Naval Health Research Center, and two of
VA's Environmental Hazards Research Centers.
To address the third objective, we reviewed major conclusions of the
PGVCB and the Presidential Advisory Committee on Gulf War Veterans'
Illnesses to determine the strength of evidence supporting major
conclusions. The purpose of this review was not to critique PGVCB's
or the Presidential Advisory Committee's efforts, per se, but rather
to describe the amount of knowledge about Gulf War illnesses that has
been generated by research 6 years after the war. We reviewed these
conclusions because they are the strongest statements that we have
come across on these matters by any official body. The Presidential
Advisory Committee's report was significant because the panel
included a number of recognized experts who were assisted by a large
staff of scientists and attorneys. In addition, the Committee
conducted an extensive review of the research. Thus, we believed
that evaluating these conclusions would provide important evidence
about how fruitful the federal research has been thus far. We
addressed this objective by reviewing extant scientific literature,
and consulting experts in the fields of epidemiology, toxicology, and
medicine.
Because of the scientific and multidisciplinary nature of this issue,
we ensured that staff conducting the work had appropriate backgrounds
in the field of epidemiology, psychology, environmental health,
toxicology, engineering, weapon design, and program evaluation and
methodology. In addition, we used in-house expertise in chemical and
biological warfare and military health care systems. Also, medical
experts reviewed our work. Moreover, we held extensive discussions
with experts in academia in each of the substantive fields relevant
to this issue. Finally, we talked to a number of the authors of the
studies that we cited in this report to ensure that we correctly
interpreted their findings and had independent experts review our
draft report.
Our work was completed between October 1996 and April 1997 in
accordance with generally accepted government auditing standards.
--------------------
\2 PGVCB, comprised of the Secretaries of Defense, VA, and Health and
Human Services, is charged with coordinating the federal response to
Gulf War veterans' illnesses.
DOD AND VA HAVE NO SYSTEMATIC
APPROACH TO MONITORING GULF WAR
VETERANS' HEALTH AFTER INITIAL
EXAMINATION
---------------------------------------------------------- Chapter 0:3
Over 100,000 of the approximately 700,000 Gulf War veterans have
participated in DOD and VA health examination programs. Of those
veterans examined by DOD and VA, nearly 90 percent have reported a
wide array of health complaints and disabling conditions. The most
commonly reported symptoms in VA and DOD registries include fatigue,
muscle and joint pain, gastrointestinal complaints, headache, skin
rash, depression, neurologic and neurocognitive impairments, memory
loss, shortness of breath, and sleep disturbances.
Officials of both DOD and VA have claimed that regardless of the
cause of veterans' illnesses, veterans are receiving appropriate and
effective symptomatic treatment. Both agencies have tried to measure
or ensure the quality of veterans' initial examinations through such
mechanisms as training and standards for physician qualification.
However, these mechanisms do not ensure a given level of
effectiveness for the care provided or permit identification of the
most effective treatments.\3
We found that neither DOD nor VA has mechanisms for monitoring the
quality, appropriateness, or effectiveness of these veterans care or
clinical progress after their initial examination and has no plans to
establish such mechanisms. VA officials involved in administering
the registry program told us that they regarded monitoring the
clinical progress of registry participants as a separate research
project, and DOD's Clinical Care and Evaluation Program made similar
comments. We believe that such monitoring is important because (1)
undiagnosed conditions are not uncommon among ill veterans, (2)
treatment for veterans with undiagnosed conditions is based on their
symptoms, and (3) veterans with undiagnosed conditions or multiple
diagnoses may see multiple providers. Without follow-up of their
treatment, DOD and VA cannot say whether these ill veterans are any
better or worse today than when they were first examined.
--------------------
\3 See VA Health Care: Observations on Medical Care Provided to
Persian Gulf Veterans (GAO/T-HEHS-97-158, June 19, 1997).
FEDERAL RESEARCH STRATEGY LACKS
A COHERENT APPROACH
---------------------------------------------------------- Chapter 0:4
Federal research on Gulf War veterans' illnesses and factors that
might have caused their problems has not been pursued proactively.
Although these veterans' health problems began surfacing in the early
1990s, the vast majority of research was not initiated until 1994 or
later. Much of this research was associated with legislation or
external reviewers' recommendations. This 3-year delay has
complicated the task facing researchers and has limited the amount of
completed research currently available. Although at least 91 studies
have received federal funding, over 70, or four-fifths, of the
studies are not yet complete, and the results of some studies will
not be available until after 2000.
We found that some hypotheses received early emphasis, while some
hypotheses were not initially pursued. While research on exposure to
stress received early emphasis, research on low-level chemical
exposure was not pursued until legislated in 1996. The failure to
fund such research cannot be traced to an absence of
investigator-initiated submissions. According to DOD officials,
three recently funded proposals on low-level chemical exposure had
previously been denied funds. We found that additional hypotheses
were pursued in the private sector. A substantial body of research
suggests that low-level exposure to chemical warfare agents or
chemically related compounds, such as certain pesticides, is
associated with delayed or long-term health effects.
Regarding delayed health effects of organophosphates, the chemical
family used in many pesticides and chemical warfare agents, there is
evidence from animal experiments, studies of accidental human
exposures, and epidemiological studies of humans that low-level
exposures to certain organophosphorus compounds, including sarin
nerve agents to which some of our troops may have been exposed, can
cause delayed, chronic neurotoxic effects.\4
It has been suggested that the ill-defined symptoms experienced by
Gulf War veterans may be due in part to organophosphate-induced
delayed neurotoxicity.\5 This hypothesis was tested in a privately
supported epidemiological study of Gulf War veterans.\6 In addition
to clarifying the patterns among veterans' symptoms by use of
statistical factor analysis, this study demonstrated that vague
symptoms of the ill veterans are associated with objective brain and
nerve damage compatible with the known chronic effects of exposures
to low levels of organophosphates.\7 It further linked the veterans'
illnesses to exposure to combinations of chemicals, including nerve
agents, pesticides in flea collars, N,N-diethyl-m-toluamide (DEET) in
highly concentrated insect repellents, and pyridostigmine bromide
tablets.
Toxicological research indicates that pyridostigmine bromide, which
Gulf War veterans took to protect themselves against the immediate,
life-threatening effects of nerve agents, may alter the metabolism of
organophosphates in ways that activate their delayed, chronic effects
on the brain.\8 Moreover, exposure to combinations of
organophosphates and related chemicals like pyridostigmine or DEET
has been shown in animal studies to be far more likely to cause
morbidity and mortality than any of the chemicals acting alone.\9
We found that the bulk of ongoing federal research on Gulf War
veterans' illnesses focuses on the epidemiological study of the
prevalence and cause of the illnesses. It is important to note that
in order to conduct such studies, investigators must follow a few
basic, generally accepted principles.
First, they must specify diagnostic criteria to (1) reliably
determine who has the disease or condition being studied and who does
not and (2) select appropriate controls (people who do not have the
disease or condition).
Second, the investigators must have valid and reliable methods of
collecting data on the past exposure(s) of those in the study to
possible factors that may have caused the symptoms. The need for
accurate, dose-specific exposure information is particularly critical
when low-level or intermittent exposure to drugs, chemicals, or air
pollutants is possible. It is important not only to assess the
presence or absence of exposure but also to characterize the
intensity and duration of exposure.
We found that the ongoing epidemiological federal research suffered
from two methodological problems: a lack of a case definition, and
absence of accurate exposures data. Without valid and reliable data
on exposures and the multiplicity of agents to which the veterans
were exposed, researchers will likely continue to find it difficult
to detect relatively subtle effects and to eliminate alternative
explanations for Gulf War veterans' illnesses. Prevalence data can
be useful, but it requires careful interpretation in the absence of
better information on the factors to which veterans were exposed.
While multiple federally funded studies of the role of stress in the
veterans' illnesses have been done, basic toxicological questions
regarding the substances to which they were exposed remain
unanswered.
We found that federal researchers studying Gulf War illnesses have
faced several methodological challenges and encountered significant
problems in linking exposures or potential causes to observed
illnesses or symptoms. For example:
-- Researchers have found it extremely difficult to gather
information about exposures to such things as oil well fire
smoke and insects carrying infection.
-- DOD has acknowledged that records of the use of pyridostigmine
bromide and vaccinations to protect against chemical/biological
warfare exposures were inadequate.
-- Gulf War veterans were typically exposed to a wide array of
agents, making it difficult to isolate and characterize the
effects of individual agents or to study their combined effects.
-- Most of the epidemiological studies on Gulf War veterans'
illnesses have relied only on self-reports for measuring most of
the agents to which veterans may have been exposed.
-- The information gathered from Gulf War veterans years after the
war may be inaccurate or biased. There is often no
straightforward way to test the validity of self-reported
exposure information, making it impossible to separate bias in
recalled information from actual differences in the frequency of
exposures. As a result, findings from these studies may be
spurious or equivocal.
-- Classifying the symptoms and identifying illnesses of Gulf War
veterans have been difficult. From the outset, symptoms
reported by veterans have been varied and difficult to classify
into one or more distinct illnesses. Moreover, several
different diagnoses might provide plausible explanations for
some of the specific health complaints. It has thus been
difficult to develop a case definition (that is, a reliable way
to identify individuals with a specific disease), which is a
criterion for doing effective epidemiological research.
In summary, the ongoing epidemiological research will not be able to
provide precise, accurate, and conclusive answers regarding the
causes of veterans' illnesses because of these formidable
methodological problems.
--------------------
\4 Sarin has been used as a chemical warfare agent since World War
II, most recently during the Iran-Iraq war, and by terrorists in
Japan.
\5 R. W. Haley et al., "Preliminary Findings of Studies on the Gulf
War Syndrome," Presentations to the Intergovernmental Coordinating
Board for the Gulf War Illness and the Staff of the Presidential
Advisory Committee on Gulf War Veterans' Illnesses" (Sept. 16,
1995); R. W. Haley, "Organophosphate-Induced Delayed
Neurotoxicity," Internal Medicine Grand Rounds, University of Texas
Southwestern Medical Center, Dallas, Texas (Oct. 10, 1996); and G.
A. Jamal et al., "The Gulf War Syndrome: Is There Evidence of
Dysfunction in the Nervous System?" Journal of Neurology,
Neurosurgery, and Psychiatry, Vol. 60 (1996), pp. 449-451.
\6 This research, conducted at the University of Texas Southwestern
Medical Center, has been supported in part by funding from the Perot
Foundation.
\7 R. W. Haley et al., "Is There a Gulf War Syndrome? Searching
for Syndromes by Factor Analysis of Symptoms," Journal of American
Medical Association, vol. 277 (1997), pp. 215-222; R. W. Haley et
al., "Evaluation of Neurologic Function in Gulf War Veterans: A
Blinded Case-Control Study," Journal of American Medical Association,
vol. 277 (1997), pp. 223-230; and R. W. Haley et al.,
"Self-reported Exposure to Neurotoxic Chemical Combinations in the
Gulf War: A Cross-sectional Epidemiologic Study," Journal of
American Medical Association, vol. 277 (1997), pp. 231-237.
\8 C. N. Pope and S. Padilla, "Potentiation of Organophosphorus
Delayed Neurotoxicity," Journal of Toxicology and Environmental
Health, vol. 31 (1990), pp. 261-273.
\9 M. B. Abou-Donia et al., "Increased Neurotoxicity Following
Concurrent Exposure to Pyridostigmine Bromide, DEET, and
Chlorpyrifos," Fundamentals of Applied Toxicology, vol. 34 (1996),
pp. 201-222 and M. B. Abou-Donia et al., "Neurotoxicity Resulting
From Coexposure to Pyridostigmine Bromide, DEET, and Permethrin,"
Journal of Toxicology and Environmental Health, vol. 48 (1996), pp.
35-56.
SUPPORT FOR KEY GOVERNMENT
CONCLUSIONS IS WEAK OR SUBJECT
TO ALTERNATIVE INTERPRETATIONS
---------------------------------------------------------- Chapter 0:5
Six years after the war, little is conclusively known about the
causes of Gulf War veterans' illnesses. In the absence of official
conclusions from DOD and VA, we examined conclusions drawn in
December 1996 by the Presidential Advisory Committee on Gulf War
Veterans' Illnesses. This Committee was established by the President
to review the administration's activities regarding Gulf War
veterans' illnesses. In January 1997, DOD endorsed the Committee's
conclusions about the likelihood that exposure to 10 commonly cited
agents contributed to the explained and unexplained illnesses of
these veterans. We found that the evidence to support three of these
conclusions is either weak or subject to alternative interpretations.
First, the Committee concluded that "stress is likely to be an
important contributing factor to the broad range of illnesses
currently being reported by Gulf War veterans." While stress can
induce physical illness, the link between stress and these veterans'
physical symptoms has not been firmly established. For example, a
large-scale, federally funded study concluded that "for those
veterans who deployed to the Gulf War and currently report physical
symptoms, neither stress nor exposure to combat or its aftermath bear
much relationship to their distress."\10 The Committee has stated
that "epidemiological studies to assess the effects of stress
invariably have found higher rates of posttraumatic stress disorder
(PTSD) in Gulf War veterans than among individuals in nondeployed
units or in the general U.S. population of the same age."
Our review indicated that the prevalence of PTSD among Gulf War
veterans may be overestimated due to problems in the methods used to
identify it. Specifically, the studies on PTSD to which the
Committee refers have not excluded other conditions, such as
neurological disorders that produce symptoms similar to PTSD and can
also elevate scores on key measures of PTSD. Also, the use of broad
and heterogenous groups of diagnoses (e.g., "psychological
conditions"--ranging from tension headache to major depression) in
data from DOD's clinical program may contribute to overestimation of
the extent of serious psychological illnesses among Gulf War
veterans.
Second, the Committee concluded that "it is unlikely that infectious
diseases endemic to the Gulf region are responsible for long-term
health effects in Gulf War veterans, except in a small known number
of individuals." Similarly, PGVCB concluded that because of the small
number of reported cases, "the likelihood of leishmania tropica as an
important risk factor for widely reported illness has diminished."
While this is the case for observed symptomatic infection with the
parasite, the prevalence of asymptomatic infection is unknown, and
such infection may reemerge in cases in which the patient's immune
system becomes deficient. As the Committee noted, the infection may
remain dormant up to 20 years. Because of this long latency, the
infected population is hidden, and because even classic forms of
leishmaniasis are difficult to recognize, we believe that leishmania
should be retained as a potential risk factor for individuals who
suffer from immune deficiency.
Third, the Committee also concluded that it is unlikely that the
health effects reported by many Gulf War veterans were the result of
(1) biological or chemical warfare agents, (2) depleted uranium, (3)
oil well fire smoke, (4) pesticides, (5) petroleum products, and (6)
pyridostigmine bromide or vaccines. However, our review of the
Committee's conclusions indicated the following:
-- While the government found no evidence that biological weapons
were deployed during the Gulf War, the United States lacked the
capability to promptly detect biological agents, and the effects
of one agent, aflatoxin, would not be observed for many years.
-- Evidence from various sources indicates that chemical agents
were present at Khamisiyah, Iraq, and elsewhere on the
battlefield. The magnitude of the exposure to chemical agents
has not been fully resolved. As we recently reported, 16 of 21
sites categorized by Gulf War planners as nuclear, biological,
and chemical (NBC) facilities were destroyed. However, the
United Nations Special Commission found after the war that not
all the possible NBC targets had been identified by U.S.
planners. The Commission has investigated a large number of the
facilities suspected by the U.S. authorities as being NBC
related. Regarding those the Commission has not yet inspected,
we determined that each was attacked by coalition aircraft
during the Gulf War. One of these sites is located within the
Kuwait theater of operation in close proximity to the border,
where coalition ground forces were located.\11
-- Exposure to certain pesticides can induce a delayed neurological
condition without causing immediate symptoms.
-- Available research indicates that exposure to pyridostigmine
bromide can alter the metabolism of organophosphates (the
chemical family of some pesticides that were used in the Gulf
War, as well as certain chemical warfare agents) in ways that
enhance chronic effects on the brain.
--------------------
\10 R. H. Stretch et al., "Physical Health Symptomatology of Gulf
War-era Service Personnel From the States of Pennsylvania and Hawaii,
Military Medicine, vol. 160 (1995), pp. 131-136.
\11 Operation Desert Storm: Evaluation of the Air Campaign
(GAO/NSIAD-97-134, June 12, 1997), p. 2.
RECOMMENDATIONS TO DOD AND VA
---------------------------------------------------------- Chapter 0:6
Because of the numbers of Gulf War veterans who continue to
experience illnesses that may be related to their service during the
Gulf War, we recommended in our report that the Secretary of Defense,
with the Secretary of Veterans Affairs, (1) set up a plan for
monitoring the clinical progress of Gulf War veterans to help promote
effective treatment and better direct the research agenda and (2)
give greater priority to research on effective treatment for ill
veterans and on low-level exposures to chemicals and their
interactive effects and less priority to further epidemiological
studies.
We also recommended that the Secretaries of Defense and Veterans
Affairs refine the current approaches of the clinical and research
programs for diagnosing posttraumatic stress disorder consistent with
suggestions recently made by the Institute of Medicine. The
Institute noted the need for improved documentation of screening
procedures and patient histories (including occupational and
environmental exposures) and the importance of ruling out alternative
causes of impairment.
Mr. Chairman, that concludes our prepared remarks. We will be happy
to answer any questions you may have.
*** End of document. ***