Gulf War Illnesses: Research, Clinical Monitoring, and Medical
Surveillance (Testimony, 02/05/98, GAO/T-NSIAD-98-88).

GAO discussed two of its recent reports on health care issues of
military personnel deployed for military operations overseas, focusing
on the: (1) adequacy of the mechanisms used by the Department of Defense
(DOD) and the Department of Veterans Affairs (VA) to monitor the
quality, appropriateness, and effectiveness of Gulf War veterans' care
and to follow up on their clinical progress over time; (2) government's
research strategy for studying Gulf War veterans' illnesses and the
methodological problems posed in its studies; (3) consistency of key
officials conclusions with available data on the causes of the Gulf War
veterans' illnesses; and (4) extent to which DOD's efforts for Operation
Joint Endeavor in Bosnia were successful in overcoming the medical
surveillance problems encountered during the Gulf War.

GAO noted that: (1) in it's report on Gulf War veterans' illnesses, GAO
noted that while DOD and VA had provided care to eligible Gulf War
veterans, they had no system for following up on their health to
determine the effectiveness of their care after initial treatment; (2)
also, because of methodological problems and incomplete medical records
on the veterans, research has not come close to providing conclusive
answers on the causes of the illnesses; (3) given the data needed versus
what is available, which is primarily anecdotal, it will be very
difficult, if not impossible, to determine the causes of the illnesses;
(4) the support for some official conclusions regarding stress,
leishmaniasis, and exposure to chemical agents were weak or subject to
other interpretations; and (5) regarding GAO's report on the medical
surveillance of servicemembers deployed in Bosnia, while GAO found that
DOD had improved its capability to monitor and assess the effects of
deployments on servicemembers' health since the Gulf War, certain
problems remained: (a) the database containing deployment information
was inaccurate; (b) not all troops received postdeployment medical
assessments; and (c) many of the medical records GAO reviewed were
incomplete.

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

 REPORTNUM:  T-NSIAD-98-88
     TITLE:  Gulf War Illnesses: Research, Clinical Monitoring, and 
             Medical Surveillance
      DATE:  02/05/98
   SUBJECT:  Armed forces abroad
             Military personnel
             Biological warfare
             Medical examinations
             Disease detection or diagnosis
             Medical research
             Hazardous substances
             Health services administration
             Chemical warfare
             Diseases
IDENTIFIER:  DOD Operation Joint Endeavor
             Bosnia
             Persian Gulf War
             DOD Comprehensive Clinical Evaluation Program
             Gulf War Syndrome
             
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Cover
================================================================ COVER


Before the Committee on Veterans Affairs, House of Representatives

For Release on Delivery
Expected at
1:00 p.m., EDT
Thursday,
February 5, 1998

GULF WAR ILLNESSES - RESEARCH,
CLINICAL MONITORING, AND MEDICAL
SURVEILLANCE

Statement of Donna Heivilin, Director of Planning and Reporting,
National Security and International Affairs Division

GAO/T-NSIAD-98-88

GAO/NSIAD-98-88t

Gulf War Illnesses

(713017)


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

  DOD - x
  NBC - x
  PGVCB - x
  PTSD - x
  VA - x

============================================================ Chapter 0

Mr.  Chairman and Members of the Committee: 

I am pleased to be here today to discuss two recent GAO reports that
responded to congressional mandates\1 regarding health care issues of
military personnel deployed for military operations overseas.  In the
first, we reported on the government's clinical care and medical
research programs relating to illnesses suffered by Gulf War
veterans.\2 For the second, we assessed the medical surveillance\3 of
military personnel in Bosnia.\4 Based on these two reports, I will
discuss four issues: 

  -- the adequacy of the mechanisms used by the Department of Defense
     (DOD) and Veterans Affairs (VA) to monitor the quality,
     appropriateness, and effectiveness of Gulf War veterans' care
     and to follow up on their clinical progress over time;

  -- the government's research strategy for studying Gulf War
     veterans' illnesses and the methodological problems posed in its
     studies;

  -- the consistency of key official conclusions with available data
     on the causes of Gulf War veterans' illnesses; and

  -- the extent to which DOD's efforts for Operation Joint Endeavor
     in Bosnia were successful in overcoming the medical surveillance
     problems encountered during the Gulf War. 

We are currently working on several related studies requested by
other congressional committees.  For example, we are looking at the
incidence of tumors among Gulf War veterans; the possible presence of
antibodies for synthetic squalene\5 in blood samples of Gulf War
veterans; the processes, methods, and criteria used by the Persian
Gulf Veteran's Coordinating Board (PGVCB),\6 DOD, and VA to approve
or disapprove research protocols; and the extent to which ongoing
research can provide information on what caused Gulf War veterans'
illnesses.  We will be happy to share the results of this work with
you once it is completed. 


--------------------
\1 National Defense Authorization Act for Fiscal Year 1997 (P.L. 
104-201, sec.  744, Sept.  23, 1996). 

\2 Gulf War Illnesses:  Improved Monitoring of Clinical Progress and
Reexamination of Research Emphasis Are Needed (GAO/NSIAD-97-163, June
23, 1997). 

\3 Medical surveillance involves the regular or repeated collection,
analysis, and dissemination of uniform health information. 

\4 Defense Health Care:  Medical Surveillance Improved Since Gulf
War, but Mixed Results in Bosnia (GAO/NSIAD-97-136, May 13, 1997). 

\5 Squalene is an acyclic hydrocarbon that is widely distributed in
nature but is unhealthful to humans in synthetic form. 

\6 The PGVCB, which comprises the Secretaries of Defense, Veterans
Affairs, and Health and Human Services, was charged with coordinating
the federal response to Gulf War veterans' illnesses. 


   RESULTS IN BRIEF
---------------------------------------------------------- Chapter 0:1

I will first summarize our findings on the four issues and then
provide detailed information on them.  In our report on Gulf War
veterans' illnesses, we noted that while DOD and VA had provided care
to eligible Gulf War veterans, they had no system for following up on
their health to determine the effectiveness of their care after
initial treatment.  Also, because of methodological problems and
incomplete medical records on the veterans, research has not come
close to providing conclusive answers on the causes of the illnesses. 
Given the data needed versus what is available, which is primarily
anecdotal, it will be very difficult, if not impossible, to determine
the causes of the illnesses.  Finally, the support for some official
conclusions regarding stress, leishmaniasis (a parasitic infection),
and exposure to chemical agents was weak or subject to other
interpretations. 

Regarding our report on the medical surveillance of servicemembers
deployed in Bosnia, while we found that DOD had improved its
capability to monitor and assess the effects of deployments on
servicemembers' health since the Gulf War, certain problems remained: 
the database containing deployment information was inaccurate, not
all troops received postdeployment medical assessments, and many of
the medical records we reviewed were incomplete. 

After I have provided details on the findings of our reports, I will
discuss our reports' recommendations, the relevant agencies' comments
on them, and our evaluation of those comments. 


   BACKGROUND
---------------------------------------------------------- Chapter 0:2

Before providing you details on the results of our work, let me
briefly provide some background information.  During service
associated with the Gulf War, many of the approximately 700,000
veterans might have been exposed to a variety of potentially
hazardous substances.  These substances include compounds used to
decontaminate equipment and protect it against chemical agents,
pesticides, vaccines, and drugs to protect against chemical warfare
agents (for example, pyridostigmine bromide).  Following the postwar
demolition of Iraqi ammunition facilities, some veterans might also
have been exposed to the nerve agent sarin. 

Over 100,000 of the approximately 700,000 Gulf War veterans have
participated in DOD and VA health examination programs established
between 1992 and 1994.  Of those veterans examined by DOD and VA,
nearly 90 percent have reported a wide array of health complaints and
disabling conditions, including fatigue, muscle and joint pain,
gastrointestinal complaints, headaches, depression, neurologic and
neurocognitive impairments, memory loss, shortness of breath, and
sleep disturbances.  Some of the veterans fear that they are
suffering from chronic disabling conditions because of exposure
during the war to substances with known or suspected health effects. 

In 1992, VA established a program through which Gulf War veterans
could receive medical examinations and diagnostic services. 
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. 

In 1994, DOD initiated its Comprehensive Clinical Evaluation Program,
through which it used a clinical protocol and provided diagnostic
services similar to those of the VA program. 

In examining the causes of Gulf War veterans' illnesses, the
Presidential Advisory Committee on Gulf War Veterans' Illnesses and
the Institute of Medicine confirmed the need for effective medical
surveillance capabilities.  They found that research efforts to
determine the causes of the veterans' illnesses were hampered by
incomplete data on (1) the names and locations of deployed personnel,
(2) the exposure of personnel to environmental health hazards, (3)
changes in the health status of personnel while deployed, and (4)
immunizations and other health services for personnel while deployed. 

Subsequently, in May 1997, we reviewed the actions DOD had taken
since the Gulf War to improve its medical surveillance capabilities. 
Specifically, we determined what medical surveillance procedures DOD
had used in Operation Joint Endeavor, which was conducted in the
countries of Bosnia-Herzegovina, Croatia, and Hungary, and whether
DOD had corrected the problems that surfaced during the Gulf War. 


   DOD AND VA HAD NO SYSTEMATIC
   APPROACH TO MONITORING GULF WAR
   VETERANS' HEALTH AFTER INITIAL
   EXAMINATION
---------------------------------------------------------- Chapter 0:3

DOD and VA officials claimed that regardless of the cause of Gulf War
veterans' illnesses, the veterans had received appropriate and
effective symptomatic treatment.  Both agencies tried to measure or
ensure the quality of veterans' initial examinations by training
health care specialists and maintaining standards for physicians'
qualifications.  However, these mechanisms did not ensure a given
level of effectiveness for the care provided or help to identify the
most effective treatments.\7

Beyond the initial examination, neither DOD nor VA had mechanisms for
monitoring the quality, appropriateness, or effectiveness of these
veterans' care or clinical progress, and they had no plans to
establish such mechanisms.  VA officials told us that they regarded
monitoring the clinical progress of registry participants as a
separate research project, and officials from DOD's Clinical Care and
Evaluation Program made similar comments. 

We noted that such monitoring was important because (1) undiagnosed
conditions were not uncommon among ill veterans, (2) treatment for
veterans with undiagnosed conditions was based on their symptoms, (3)
veterans with undiagnosed conditions or multiple diagnoses might see
multiple providers, (4) follow-up could provide a better
understanding of the clinical progression of the illnesses over time,
and (5) the success or failure of physicians' treatments of Gulf War
veterans could be identified.  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. 


--------------------
\7 See VA Health Care:  Observations on Medical Care Provided to
Persian Gulf Veterans (GAO/T-HEHS-97-158, June 19, 1997). 


   MOST OF THE FEDERALLY FUNDED
   RESEARCH WAS ONGOING, AND SOME
   HYPOTHESES WERE NOT INITIALLY
   PURSUED
---------------------------------------------------------- Chapter 0:4

Federal research on Gulf War veterans' illnesses and factors that
might have caused their problems was not 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, and much of that responded to legislative requirements or
external reviewers' recommendations.  This 3-year delay complicated
the researchers' tasks and limited the amount of completed research
available.  Of the 91 studies receiving federal funding, over 70 had
not been completed at the time of our review.  The results of some
studies will not be available until after 2000. 

While research on exposure to stress was emphasized in earlier
studies, research on low-level chemical exposure was not pursued
until legislated in 1996.  The failure to fund such research could
not be traced to an absence of proposals.  According to DOD
officials, three recently funded proposals on low-level chemical
exposure had previously been denied funds because, at the time, DOD
did not believe that U.S.  troops had been exposed to chemical
warfare agents. 

We found that additional hypotheses were pursued in the private
sector.  A substantial body of this 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.  For example, animal experiments, studies of
accidental human exposures, and epidemiological studies of humans
offer evidence that low-level exposures to certain organophosphorus
compounds,\8 including sarin nerve agents to which some of our troops
may have been exposed, can cause delayed, chronic neurotoxic effects. 

It was suggested that the ill-defined symptoms experienced by Gulf
War veterans might be due in part to organophosphate-induced delayed
neurotoxicity.  This hypothesis was tested in a privately supported
epidemiological study of Gulf War veterans.\9 The study clarified the
patterns among veterans' symptoms through the use of statistical
factor analyses and demonstrated that vague symptoms of the ill
veterans were associated with brain and nerve damage compatible with
the known chronic effects of exposures to low levels of
organophosphates.  It further linked the veterans' illnesses to
exposure to combinations of chemicals, including nerve agents, 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.  Moreover, exposure to combinations of organophosphates
and related chemicals like pyridostigmine bromide has been shown in
animal studies to be far more likely to cause morbidity and mortality
than any of the chemicals acting alone. 

Aside from the hypotheses being emphasized in the research being
done, we found that the bulk of ongoing federal research on Gulf War
veterans' illnesses was focused on the epidemiological study of the
prevalence and cause of the illnesses.  It is important to note that
to conduct such studies, investigators must adhere to basic,
generally accepted principles. 

First, investigators 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, they must have valid and reliable
methods of collecting and relating data on 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. 

The epidemiological federal research we examined had two
methodological problems:  the lack of a case definition (that is, a
reliable way to identify individuals with a specific disease) and the
absence of accurate exposure 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 on the role of stress in the
veterans' illnesses have been done, basic toxicological questions
regarding the substances to which they were exposed remain
unanswered. 

The ongoing epidemiological research cannot provide precise,
accurate, and conclusive answers regarding the causes of veterans'
illnesses because of these methodological problems as well as the
following: 

  -- Researchers have found it extremely difficult to gather
     information about exposures to such things as oil-well fire
     smoke and insects carrying infection. 

  -- Medical records of the use of pyridostigmine bromide tablets 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 might 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 veterans' illnesses
     have been difficult.  From the outset, the symptoms reported
     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. 


--------------------
\8 Organophosphates are used in many pesticides and chemical warfare
agents, and 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. 

\9 This research, conducted at the University of Texas Southwestern
Medical Center, has been supported in part by funding from the Perot
Foundation. 


   SUPPORT FOR KEY GOVERNMENT
   CONCLUSIONS WAS WEAK OR SUBJECT
   TO ALTERNATIVE INTERPRETATIONS
---------------------------------------------------------- Chapter 0:5

Six years after the war, little was 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.  In January 1997, DOD endorsed the Committee's
conclusions about the likelihood that exposure to 10 commonly cited
chemical agents contributed to the explained and unexplained
illnesses of these veterans.  We found the evidence to support three
of these conclusions to be either weak or subject to alternative
interpretations. 

First, the Committee concluded that stress was likely a contributing
factor to Gulf War veterans' illnesses.  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 stress and
exposure to combat or its aftermath bear little relationship to the
veterans' distress.  The Committee also 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 might be overestimated due to problems in the methods used
to identify it.  Specifically, the studies on PTSD to which the
Committee referred did not exclude 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 might contribute to an
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, the 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.  Such infection could reemerge in cases in which the
patient's immune system becomes deficient.  As the Committee noted,
the infection could 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 noted
that leishmania should be retained as a potential risk factor for
individuals who suffer from immune deficiency. 

Third, the Committee 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 indicated that chemical agents
     were present at Khamisiyah, Iraq, and elsewhere on the
     battlefield.  The magnitude of exposures to chemical agents has
     not been fully resolved.  As we reported in June 1997, 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 investigated a large number of the
     facilities suspected by the U.S.  authorities as being NBC
     related.  Regarding those the Commission had not inspected, we
     determined that each was attacked by coalition aircraft during
     the Gulf War.\10

  -- 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 in ways
     that enhance chronic effects on the brain. 


--------------------
\10 Operation Desert Storm:  Evaluation of the Air Campaign
(GAO/NSIAD-97-134, June 12, 1997), p.  2. 


   SUCCESS IN IMPROVING MEDICAL
   SURVEILLANCE WAS MIXED FOR
   SERVICEMEMBERS DEPLOYED TO
   BOSNIA
---------------------------------------------------------- Chapter 0:6

In 1994, DOD began developing a directive and implementing
instruction to address the problems experienced in the medical
surveillance of Gulf War veterans.  Although DOD had not issued this
guidance when Operation Joint Endeavor began, it did develop a
comprehensive medical surveillance plan in January 1996 for the
Bosnia deployment.  The plan included establishing a system to
identify which servicemembers deployed to the theater, assessing
environmental health threats, monitoring diseases and nonbattle
injuries, and conducting postdeployment medical assessments. 

In examining medical surveillance in Bosnia in late 1996 and early
1997, we found many remaining problems, despite DOD's attempts to
implement its plan.  These problems are as follows: 

  -- First, DOD had not developed a system for accurately tracking
     the movement of individual servicemembers in units within the
     theater.  Such a system is important for accurately identifying
     exposures of servicemembers to health hazards where they are
     located. 

  -- Second, predeployment blood samples were not available for many
     servicemembers who deployed to Bosnia, and of the blood samples
     that were available in the repository for servicemembers who
     deployed, many were quite old. 

  -- Third, many Army personnel did not receive required
     postdeployment medical assessments.  Moreover, when the
     assessments were done, they were done much later than required. 

  -- Fourth, the centralized database for monitoring the extent to
     which required medical assessments were done was incomplete for
     the 618 servicemembers whose medical records we reviewed.  More
     specifically, it omitted 12 percent of the in-theater medical
     assessments and 52 percent of the home unit medical assessments. 

  -- Finally, many of the medical records that we reviewed were
     incomplete regarding in-theater postdeployment medical
     assessments done, servicemembers' visits to battalion aid
     stations for medical treatment during deployment, and
     documentation of personnel being vaccinated against tick-borne
     encephalitis (a health threat in the theater). 


   METHODOLOGY
---------------------------------------------------------- Chapter 0:7

To address our first objective--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. 

To examine PGVCB's research strategy, we conducted a systematic
review of pertinent literature and agency documents and reports.  We
also interviewed representatives from PGVCB's Research Working Group
and officials from 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 might 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 them.  The
purpose of this review was not to critique the efforts of PGVCB or
the Presidential Advisory Committee but rather to describe the amount
of knowledge about Gulf War illnesses that had been generated by
research
6 years after the war.  We reviewed these conclusions because they
were the strongest statements that we had found on these matters by
any official body.  The Presidential Advisory Committee's report was
significant because the panel included a number of recognized experts
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
had been.  We addressed this objective by reviewing extant scientific
literature and by 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, weapons 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 our report to ensure that we correctly
interpreted their findings and had independent experts review our
draft report. 

Finally, regarding our fourth objective, we interviewed key agency
officials, examined relevant information from the DOD Deployment
Surveillance Team's database, and reviewed the medical records of
active duty servicemembers in selected Army units in Germany who were
deployed to Operation Joint Endeavor. 

Our work was completed between October 1996 and April 1997 in
accordance with generally accepted government auditing standards. 

Appendix I contains a bibliography of research material referred to
in our testimony. 


   RECOMMENDATIONS TO THE
   SECRETARIES OF DEFENSE AND
   VETERANS AFFAIRS
---------------------------------------------------------- Chapter 0:8

Because of the numbers of veterans who have experienced illnesses
that might 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. 

While DOD agreed with the thrust of our recommendations, VA believed
they "reflected a lack of understanding of clinical research,
epidemiology, and toxicology." The Presidential Advisory Committee
disagreed with our findings, particularly that the support for some
of its conclusions was weak.  Despite these disagreements with our
report, none of the comments we received provided evidence to
challenge our principal findings and conclusions. 

In response to our recommendation regarding the treatment of Gulf War
veterans, in December 1997, DOD and VA asked the Institute of
Medicine to establish a committee to assess the appropriate
methodology for monitoring the health outcomes and treatment efficacy
for Gulf War veterans.  On February 2, 1998, PGVCB informed us that
it had initiated a joint program with DOD to conduct multicenter
treatment trials for fibromyalgia and chronic fatigue syndrome in
Gulf War veterans.  It is anticipated that such a protocol will begin
in late 1998 or early 1999. 

In response to our recommendation on research programs, as of January
1998, according to the research working group of PGVCB, 23 studies
had been added to the research portfolio, including research on the
toxicology of low-level exposures to neurotoxins such as
pyridostigmine bromide, insecticides, and chemical warfare nerve
agents, with an emphasis on interactions among them. 

In our report on the deployment and medical records for
servicemembers deployed to Bosnia, we recommended that the Secretary
of Defense direct the Assistant Secretary of Defense for Health
Affairs, along with the military services, the Joint Chiefs of Staff,
and the Unified Commands, as appropriate, to

  -- expeditiously complete and implement a DOD-wide policy on
     medical surveillance for all major deployments of U.S.  forces,
     using lessons learned during Operation Joint Endeavor and the
     Gulf War;

  -- develop procedures to ensure that medical surveillance policies
     are implemented, to include emphasizing (a) the need for unit
     commanders to ensure that all servicemembers receive required
     medical assessments in a timely manner and (b) the need for
     medical personnel to maintain complete and accurate medical
     records; and

  -- develop procedures for providing accurate and complete medical
     assessment information to the centralized database. 

In response to our recommendation, DOD established a new policy and
implementing guidance in August 1997 and has emphasized to field
commanders the importance of the system.  The guidance mandated
medical surveillance of servicemembers before, during, and after
military deployments and specified procedures for conducting such
surveillance. 

It is important to note that GAO has not evaluated DOD's, VA's, and
the PGVCB's proposed plans regarding the treatment and research for
Gulf War veterans' illnesses.  Also, while we have reviewed DOD's new
medical surveillance guidance, we have not evaluated the
implementation of it.  Nonetheless, we believe that if the guidance
is properly implemented, DOD's medical surveillance system would be
greatly enhanced. 

A number of other actions--particularly legislative actions--have
taken place to help ailing Gulf War veterans.  In a law sponsored by
this Committee (P.L.  105-114, sec.  209, Nov.  21, 1997), the
Secretary of Veterans Affairs is required to set up a program, by
July 1, 1998, to test new approaches to treating those veterans
suffering from undiagnosed illnesses and disabilities.  Also, recent
defense authorization legislation (P.L.  105-85, Nov.  18, 1997),
requires DOD and VA to (1) prepare a plan, by March 1, 1998, for
providing appropriate health care to Gulf War veterans and (2)
establish a program of clinical trials at multiple sites to assess
the effectiveness of protocols for treating the veterans. 

In addition to the legislation, on October 31, 1997, the Presidential
Advisory Committee issued a special report in which it noted that (1)
VA should move quickly to incorporate Gulf War veterans into its case
management system and (2) DOD should place a higher priority on
medical surveillance to ensure that the health data problems that
occurred during the Gulf War do not recur in future military
operations. 


-------------------------------------------------------- Chapter 0:8.1

Mr.  Chairman, that concludes my prepared remarks.  I will be happy
to answer any questions you or members of the Committee may have. 


BIBLIOGRAPHY
=========================================================== Appendix 1

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. 

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. 

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," September 16,
1995. 

R.  W.  Haley, "Organophosphate-Induced Delayed Neurotoxicity,"
Internal Medicine Grand Rounds, University of Texas Southwestern
Medical Center, Dallas, Texas, October 10, 1996. 

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. 

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. 

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. 

Presidential Advisory Committee on Gulf War Veterans' Illnesses,
Final Report (Washington, D.C.:  GPO, 1996). 

Presidential Advisory Committee on Gulf War Veterans' Illnesses,
Special Report (Washington, D.C.:  GPO, 1997). 

C.  N.  Pope and S.  Padilla, "Potentiation of Organophosphorus
Delayed Neurotoxicity," Journal of Toxicology and Environmental
Health, vol.  31 (1990), pp.  261-273. 

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. 


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