[Senate Hearing 110-314]
[From the U.S. Government Publishing Office]
S. HRG. 110-314
OVERSIGHT HEARING ON RESEARCH AND
TREATMENT FOR GULF WAR ILLNESSES
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HEARING
before the
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
one hundred tenth congress
first session
September 25, 2007
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
DANIEL K. AKAKA, Hawaii, Chairman
JOHN D. ROCKEFELLER IV, West Virginia RICHARD M. BURR, North Carolina, Ranking
PATTY MURRAY, Washington Member
BARACK OBAMA, Illinois LARRY E. CRAIG, Idaho,
BERNARD SANDERS, (I) Vermont ARLEN SPECTER, Pennsylvania
SHERROD BROWN, Ohio JOHNNY ISAKSON, Georgia
JIM WEBB, Virginia LINDSEY O. GRAHAM, South Carolina
KAY BAILEY HUTCHISON, Texas JON TESTER, Montana
JOHN ENSIGN, Nevada
WILLIAM E. BREW, Staff Director
LUPE WISSEL, Republican Staff Director
C O N T E N T S
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SEPTEMBER 25, 2007
SENATOR
Page
Akaka, Hon. Daniel K., U.S. Senator from Hawaii .................... 1
Burr, Hon. Richard, U.S. Senator from North Carolina................ 2
Isakson, Hon. Johnny, U.S. Senator from Georgia..................... 3
Murray, Hon. Patty, U.S. Senator from Washington.................... 4
Sanders, Hon. Bernard, U.S. Senator from Vermont.................... 5
Craig, Hon. Larry E., U.S. Senator from Idaho....................... 7
WITNESSES
Mock, Julie, Gulf War Veteran and President, Veterans of Modern .... 8
Warfare
Prepared statement............................................... 10
Nass, Meryl, M.D., Director of Pulmonary Rehabilitation, Mount Desert
Island Hospital.................................................. 13
Prepared statement............................................... 14
Steele, Lea, Ph.D, Scientific Director, Research Advisory Committee
on Gulf War Veterans' Illnesses, and Senior Health Researcher,
Kansas Health Institute.......................................... 29
Prepared statement............................................... 32
White, Roberta, Ph.D, Professor and Chair, Department of Environmental
Health, Boston University School of Public Health................ 33
Prepared statement............................................... 35
Binns, James, Chairman, Research Advisory Committee on Gulf War
Veterans' Illnesses.............................................. 36
Prepared statement............................................... 37
Kilpatrick, Michael E. M.D., Deputy Director for Force Health
Protection and Readiness Programs, Office of the Assistant Secretary
of Defense for Health Affairs; accompanied by Col. Janet Harris,
Ph.D, RN, Director of Congressionally Directed Medical Research
Programs, Department of the Army................................. 50
Prepared statement............................................... 52
Response to written questions submitted by:
Hon. Daniel K. Akaka.......................................... 54
Hon. Patty Murray............................................. 56
Hon. Bernard Sanders........................................... 57
Kupersmith, Joel, MD, Chief Research and Development Officer, Veterans
Health Administration; accompanied by Timothy O'Leary, MD, Ph.D,
Director of Biomedical Laboratory and Clinical Science Research
and Development Services, Department of Veterans Affairs.......... 61
Prepared statement................................................ 63
Response to written questions submitted by:
Hon. Daniel K. Akaka.......................................... 66
Hon. Patty Murray............................................. 68
Hon. Bernard Sanders.......................................... 70
Attachment.................................................... 73
APPENDIX
Sullivan, Paul, Executive Director, Veterans for Common Sense;
prepared statement................................................ 87
Fahey, Dan, The House Veterans Affairs Committee; prepared statement. 88
OVERSIGHT HEARING ON RESEARCH AND
TREATMENT FOR GULF WAR ILLNESSES
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TUESDAY, SEPTEMBER 25
U.S. SENATE,
COMMITTEE ON VETERANS' AFFAIRS,
Washington, DC.
The Committee met, pursuant to notice, at 9:33 a.m., in room
562, Dirksen Senate Office Building, Hon. Daniel K. Akaka, Chairman
of the Committee, presiding.
Present: Senators Akaka, Murray, Sanders, Craig, Burr, and
Isakson.
OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN,
U.S. SENATOR FROM HAWAII
Chairman AKAKA. This hearing on Research and Treatment for
Gulf War Illnesses will come to order. Good morning, everyone.
Senators Sanders and Murray, asked that the Committee hold
this hearing to focus on recent advances in research on the treatment
of Gulf War illnesses, GWI. I want to commend them for insisting
that we have this hearing. As we look into the background
of this, it certainly is one that we need to hear about.
As Chairman, I must once again question whether DOD is protecting
the health of troops and whether they are adequately monitoring
American servicemembers' health before, during, and after
deployments. This is a legitimate focus for our Committee. Today's
troops are tomorrow's veterans. As servicemembers return from deployments
abroad, many will separate from the military and become
the newest generation of veterans. We need to ensure that
VA has the capability to give these veterans the care they require.
We have this recent study on brain damage and evidence that
suggests there may be an elevated rate of ALS among Gulf War
veterans. Further, the National Academy of Sciences has found
that service in the Gulf places veterans at increased risk for anxiety
disorders, depression, and substance abuse problems.
Unfortunately, as we have heard time and again, the reasons for
these illnesses may never be known because important records
were not kept or were lost. In addition, DOD did not track the location
of individual troops, making it difficult to identify patterns
among those who have fallen ill. In short, DOD was not prepared
to monitor and protect the health of troops during the Gulf War.
For whatever reasons, the health of our own troops was not safeguarded
and many questions may remain forever unanswered. This
raises a basic question for me, and that question is: Are troops now
receiving more than pro forma pre- and post-deployment physical
examinations? The usefulness of these exams is not only critical to
physical health, but for mental health, as well. A grateful Nation
must never forget that the decision to send our young people into
harm's way must always go hand in hand with the knowledge that
it will be our responsibility to care for those who have served.
As I said, this Committee has called this hearing because of the
insistence of some of our Members and we are looking forward to
hearing from you. Let me now call on our Ranking Member, Senator
Burr, for his statement.
STATEMENT OF HON. RICHARD BURR,
U.S. SENATOR FROM NORTH CAROLINA
Senator BURR. Mr. Chairman, thank you and I thank our colleagues
for joining us today.
Mr. Chairman, nearly 16 years ago, after the end of the Gulf
War, questions about the health of those veterans who served in
that conflict still spur passionate responses from tens of thousands
of veterans across the country. This passion was ignited after many
years spent fighting a government who told them it was all in their
heads instead of trying to treat their illness, and that, quite frankly,
was wrong.
What we now know is that as many as 175,000 veterans from the
Gulf War report a whole host of illnesses and health difficulties
that have affected their lives, their careers, and their families.
Over the past 15 years, we have seen evidence of their suffering.
Many of them suffer from fatigue, memory loss, joint pain, and
skin rashes at significantly higher rates than those non-deployed
Gulf War Veterans. We found evidence that suggests that ALS, a
difficult and debilitating disease, seems to afflict veterans of this
conflict at nearly twice the rate we would expect to see. And we
have firsthand accounts of ill parents who are giving birth to ill
children. They believe those illnesses were caused by their service
in the Gulf War. One of those mothers is here with us this morning.
What we still don't know is why all of these people who shared
the common experience of service in the Gulf War are suffering
these problems. Over the past 15 years, our Nation has spent over
$300 million on research, yet we still don't have an answer. While
I am frustrated by the lack of progress, I remain heartened by the
fact that we know more now than we did when we started.
I am also heartened by what I see as an emerging consensus,
and that is whatever the cause of the health problems experienced
by Gulf War veterans, we know one thing: They are real. The best
thing we can do now is to find out how to treat them.
To that end, Mr. Chairman, I would like to see our research efforts
continue to focus heavily on the treatment of our veterans. If
all of our scientific energy cannot provide an answer to why they
are sick, I only hope that at least we can help them manage their
illness.
Mr. Chairman, I look forward to hearing from the first panel
about where we stand in the fight to care for those who fought,
who fought for us in the Gulf War. I hope that we have done some
things right instead of continuing to repeat past mistakes. And I
hope to hear from our second panel, who will focus on what DOD
and VA are doing collectively to provide care and treatment to
brave men and women who fought in the First Gulf War and many
of whom are still fighting today.
However, Mr. Chairman, I have got to say that we are not off
to a good start. Late yesterday afternoon, as I tried to prepare for
today's hearing, I found that our witnesses from DOD and VA had
yet to provide us their testimony. I think the Chairman has heard
me raise this issue before, and I have researched the Committee
rules and the Senate rules as best I can, and there is a requirement
for 48 hours prior to a hearing that the testimony be in the
Committee.
To those individuals who are here to testify today that testimony
was not provided, this will end. I will work with the Chairman, I
will work with my colleagues regardless of the administration to
find a way for witnesses to meet the 48-hour rule. The issues that
we take up today are way too serious for this Subcommittee not to
have ample time to know what the testimonies are and, consequently,
what our questions and our direction should be.
So, Mr. Chairman, I pledge to you and to my colleagues that we
will find a way to resolve what I think is a continual problem of
not providing testimony, regardless of how painful it is, and whether
it is at OMB, whether it is at VA, or whether it is at DOD. I
would suggest to the Chair that in the interim, if, in fact, we can't
find a way to solve this, that we make sure, regardless of how high
up the testimony comes from, that we make sure that those witnesses
are, in fact, the last ones we hear from, and not the protocol
being the first ones that we hear from, that we should require
them to sit here for the duration of the hearing before they have
an opportunity to testify.
Mr. Chairman, again, I want to thank you for holding this important
hearing. I look especially forward to the testimony of the first
panel and I will do my best to read the testimony of the second
panel before they come up. Thank you.
Chairman AKAKA. Thank you very much, Senator Burr.
Using the early bird system here, I am going to call on Senator
Isakson for your testimony, followed by Senator Murray.
STATEMENT OF HON. JOHNNY ISAKSON,
U.S. SENATOR FROM GEORGIA
Senator ISAKSON. Thank you very much, Mr. Chairman. I will be
brief. I want to welcome all of our panelists and thank them for
being here today, particularly on our second panel. Dr. Michael Kilpatrick
testified in Augusta at a field hearing I conducted at the
Augusta VA in August and I appreciate his being here today. That
is what I will address my few points about.
I am extremely concerned about us having the right research and
the right longitudinal information to be sure we can treat our veterans
of the Gulf War and of any conflict with the highest possible
and best quality care, and there have been a number of problems.
There are a few shining stars, though, and that Augusta VA hospital
is one of them that I would like to just point out for a second
as a part of the solution.
At the Augusta Hospital, DOD and Augusta have a seamless
interchange where active duty troops rehabilitating from serious
injuries in the War for Iraqi Freedom actually go to VA and back
again to DOD. It is a seamless handoff of treatment.
Second, the VA is critical to this entire thing because many of
these afflictions, complications, or diseases take place years after
service when these people are in the care of VA and they have that
longitudinal information to match back with DOD.
Every city can't be like Augusta, where you have both a DOD
hospital, being Eisenhower, and a VA hospital, being the Uptown
VA Hospital. However, a number of our major cities in the United
States have both a VA and a DOD hospital, and this is where you
can truly have the coordination and that longitudinal information.
I just want to thank the Chairman for calling this most important
hearing. I thank all of our witnesses for testifying today and
I look forward to hearing their testimony. Thank you, Mr. Chairman.
Chairman AKAKA. Thank you very much, Senator Isakson.
I have another commitment this morning, so at this point I
would like to hand the gavel to Senator Murray and will be reviewing
the transcript later. Members of the Committee will regroup
following the hearing and we will determine what follow-up the
Committee will be taking.
Senator Murray has been a leader in this and also Senator Sanders.
As a result, we have set this hearing and I would like to ask
her to take the gavel at this point and for her to begin with her
statement.
STATEMENT OF HON. PATTY MURRAY,
U.S. SENATOR FROM WASHINGTON
Senator MURRAY [presiding]. Well, thank you very much, Mr.
Chairman, and thank you for holding today's hearing on the latest
research and treatment taking place for our Gulf War veterans' illness.
Let me just say, Senator Burr, I agree with you on the testimony
and look forward to working with you to make sure that the agencies
that we ask to come and testify before us get their material
to us in a timely manner so we can be most effective. So I appreciate
your comments on that.
I do want to recognize our first panel of witnesses who are here
today and who have dedicated so much of their time to fighting for
veterans who are afflicted with Gulf War illness, and I especially
want to thank Julie Mock, who is from my home State of Washington
and is president of the Veterans of Modern Warfare. Despite
her very ill health and the disorders and diseases that her children
struggle with, Julie flew all the way across the country here to
Washington, DC, to testify about Gulf War illness and how it has
affected her and her family. Julie is going to talk to us about the
need for more research, better treatment, and improved access for
Gulf War veterans. She is going to put a face and a story that is
really important to the numbers that we are going to hear about
today and speaks out for many, many others whom I have had the
privilege to know and talk to and who couldn't be here today. Julie,
I want to thank you for that, as well as all of our witnesses.
It has been 16 years since the Gulf War ended, and while for
many Americans the conflict is nothing more than a distant mem-
ory, it remains a source of continuous anguish for thousands of veterans
of that period who now suffer from chronic multi-symptom
illness. This Committee held numerous hearings on Gulf War illness
over the years, beginning in 1993, and those hearings explored
the latest research and probed the possible causes of Gulf War illness.
Since that time, our understanding of medicine has evolved,
technology has improved, and more about that war has been uncovered.
Yet the exact nature and cause of Gulf War illness remains
disputed by many.
What is not disputed is that of the nearly 700,000 U.S.
servicemembers who served in the Gulf War, about 30 percent of
them suffer from chronic multi-symptom illness. Those veterans deserve
to know that everything is being done to identify and connect
all possible exposures to their illnesses. They need to know that
their illnesses will be treated by the VA, and they need to know
that every effort is being made to ensure that what happened to
them will never happen to future generations of warriors.
Today's hearing is an opportunity to discuss the latest research
and treatment options and to question whether current efforts are
sufficient for improving the lives of veterans inflicted with Gulf
War illness or if more needs to be done.
It has been said that those who ignore the past are doomed to
repeat it, and I think it is with those words in mind that we are
holding today's hearings. With more than 160,000 troops currently
stationed in Iraq, we have to ensure that we are studying the lasting
effects of the last time Americans were sent there. We must
never forget the lessons of Vietnam and the horrors of Agent Orange
that those exposures taught us. It is our responsibility to be
proactive about the health and well-being of our men and women
in uniform.
Today, we will have that opportunity to examine a disease and
a group of veterans who are too often overlooked. I look forward to
hearing from all of our witnesses this morning and I thank all of
you for coming forward to address this problem.
We will now hear from Senator Sanders and Senator Craig and
then hear from our witnesses.
STATEMENT OF HON. BERNARD SANDERS,
U.S. SENATOR FROM VERMONT
Senator SANDERS. Thank you, Senator Murray, and thank you
for all the work that you have done on this area, as well as Senator
Akaka and many others.
Let me thank many of our panelists, I know Jim Binns and others,
for their persistence on this issue. It would have been easy to
sweep this issue under the rug and forget about it, but many of you
and many who are not here today have continued to fight for recognition
of the importance of this issue and to continue the focus
on the enormous number of people who are suffering from what we
call Gulf War illness.
And I think just the numbers themselves are startling. If you are
talking about in a war where we suffered relatively few fatalities,
to look at something like one in four people who served in the Gulf
coming back with one or another symptom, that is an extraordinarily
high number. It is absolutely imperative that we under-
stand what happened there, both in terms of treating as best we
can those people who have been made ill, but also understanding
the cause of why they have been made ill.
And one of the aspects of this whole issue that has interested me
from day one is that a number of the symptoms that we see from
Gulf War soldiers are symptoms that we see in civil society here
in the United States of people who have never been to the Gulf
War. What is the connection between the two? Whether it is
fibromyalgia, whether it is multiple chemical sensitivity, whether
it is short-term memory loss, whatever it may be, is there a connection
between the two? So if we can get some of the answers here,
not only could we ease the suffering of so many of our soldiers, we
could also learn something that could be applied to the civil society,
as well.
I think it is no secret, as many have already discussed, that
there is a frustration, and I served on the Committee�in fact,
when I was in the House, I don't think there is any issue that I
spent more time on than this issue, and I spent dozens of hours
with Chris Shays of Connecticut, who was then chairing the Subcommittee
on the House Government Reform Committee that dealt
with this issue, hearing with frustration from the Veterans' Administration,
especially from the DOD, from the beginning when they
would come forward and say, ��No, there is no problem. Really,
there is no problem.'' And then finally a few years later, they said,
��Well, yes, there is a problem. It is a psychological problem. It is
just in the heads of these people, and maybe they are malingerers.
We don't know. Maybe they had other problems.'' And then finally
more people came by and they said, ��Well, you know, there really
may be a problem.'' We see this guy who has lost 50 pounds, somebody
else here died, ALS rates are very high. Maybe there is a
problem. And on and on, it was like pulling teeth.
In recent years, however, I think we have been making some
good results in learning a little bit more about it, and I think what
our job is is to make sure that as we appropriate money, and we
are working very hard to appropriate substantially more money to
the research, that we target that money to those scientists who understand
there is a problem and who are serious about finding an
answer to this problem and not just putting it into a bureaucracy
so that we keep hearing, oh, there is nothing there, we haven't
found anything, and so forth and so forth.
New studies just released from a team from Boston University,
VA and the Army have added to the compelling body of recent research
showing that there are serious neurological conditions resulting
from toxic exposures during the war. Ill veterans with five
or more symptoms showed a loss of brain mass in MRI scans of
areas related to memory and learning and also performed significantly
worse on objective learning and memory tests. Veterans exposed
to low levels of nerve gas following the destruction of a major
Iraqi arms depo-in Khamisiyah, Iraq, showed a loss of brain white
matter and poor performance on motor coordination tests equivalent
to aging 20 years.
So we are beginning to make some progress. Madam Chair, I
think we have got to continue focusing on the serious research that
is out there and I certainly look forward to working with you in
that area. Thank you.
Senator MURRAY. Thank you very much.
Senator CRAIG?
STATEMENT OF HON. LARRY E. CRAIG,
U.S. SENATOR FROM IDAHO
Senator CRAIG. Madam Chairman, thank you and I thank the
Committee for this hearing today. I think Senator Sanders has said
it as clearly as can be said. From a failure or unwillingness to recognize,
I think we are now able to move beyond the idea of this
being a single syndrome and recognize that there are a multitude
of problems affecting our soldiers and I hope that is where ongoing
research should be focused.
We have spent a lot of money on this issue and we unfortunately
haven't had great results to date in helping those veterans who, in
fact, suffer and have these kinds of experiences, both psychologically
and physically. I would hope that a clearer direction can
come from this hearing because there is no question that when
well-directed, VA has done some outstanding medical research,
some of the best in the country historically speaking and year after
year we see that hold true. However, it is also true that in the private
sector, we have the kind of research going on now that is critically
important.
We have a phenomenal responsibility to our soldiers, sailors, airmen,
and marines who fought to defend our national interests in
the Gulf, and certainly we are grateful for their service and for
their sacrifice. We must continue to treat these veterans and hopefully
to bring about the kind of research and more importantly the
kind of results that all of us want to see. We need some conclusiveness
to this, some understanding of it beyond the hypothetical.
Quality research that is ongoing can hopefully provide us that.
Again, Madam Chairman, thank you for the hearing today. I am
sure it will add to the body of information that the Senate will
need to be responsive to the needs of our veterans. Thank you all
very much.
Senator MURRAY. Thank you, and we will now hear from our first
panel. Each of you will be given a 5-minute time slot. Any testimony
you don't have time to give us, we will submit for the record.
But I want to again welcome all of you to this morning's panel.
We will first have James Binns. Mr. Binns is the Chairman of
the Research Advisory Committee on Gulf War Veterans' Illnesses.
Next, we will have Julie Mock. As I said, she is President of Veterans
of Modern Warfare and is a veteran of the Gulf War.
Next, we will hear from Dr. Meryl Nass from Mount Desert Island
Hospital in Bar Harbor, Maine. She is the Director of Pulmonary
Rehabilitation and is also a member of the Maine Commission
to Improve the Health and Safety of Members of the National
Guard.
We will then hear from Lea Steele. She is the Scientific Director
of the Research Advisory Committee on Gulf War Veterans' Illnesses.
And finally, we will hear from Dr. Roberta White. She is the
Chair of the Department of Environmental Health at Boston Uni-
versity's School of Public Health and recently published research
on Gulf War illnesses that is of interest to our Committee today.
Again, I thank each of you for being here and your full statements
will appear in the record of the Committee. Mr. Binns, we
will begin with you.
Mr. BINNS. Madam Chairman, I would respectfully request if I
could speak after Dr. Steele and Dr. White, as my testimony is
predicated on theirs.
Senator MURRAY. I will be happy to comply with that, so Julie
Mock, if you would like to begin, then.
STATEMENT OF JULIE MOCK, GULF WAR VETERAN AND
PRESIDENT, VETERANS OF MODERN WARFARE
Ms. MOCK. Thank you for having me here this morning to share
my life with you as a Gulf War veteran. It is an honor to be here
representing my fellow veterans, those who live and those who
have died early deaths as a result, presumably, of their exposures.
I served in the Persian Gulf War with the U.S. Army. I deployed
with the 87th Medical Detachment Dental Services from Germany
and served in theater with the 12th EVAC Hospital. Located
roughly 30 kilometers from both the borders from Kuwait and Iraq,
we were the first forward hospital open for patients. We also provided
dental support for the 301st Military Police Camp EPWs.
During the months of January, February, and March 1991, we
repeatedly experienced the loud alarms of chemical detectors. We
ingested expired PB tablets. We wore masks with expired filters,
inhaled dust and sand in the air that was thick with the black of
burning oil smoke. I experienced respiratory difficulties, my skin
grew hot with red rashes, and I began to suffer from debilitating
headaches. Many of my contemporaries experienced many of the
same or a combination of symptoms.
For a time, my husband, who is also a Persian Gulf War veteran,
and myself were very ready to put the history of our experiences
behind us and move forward with our lives and begin a family. It
was after our children were born in 1995 and 1997 that we could
no longer deny the possible significance of the pre-deployment vaccines
we took before deployment to Saudi Arabia or the possible
chemical environmental exposures we experienced while we were
there.
Nor could we ignore the significant neurological challenges of our
son. As our eldest son's first year passed and his second birthday
approached, it was very clear that Stephen could not speak and he
did not experience sensory events in a typical manner. Our hearts
broke with each new diagnosis. He was severely dyspraxic. Not
only would our son require aggressive speech therapy, but he was
also diagnosed with a dangerous connective tissue disease, sensory
integration disorder, hypotonia, sleep apnea, and learning disabilities,
and eventually with bipolar disorder and Tourette's syndrome.
Stephen, now 12, spent 7 weeks of his young life hospitalized
in order to regulate his very irregular brain.
After a second difficult pregnancy requiring multiple hospitalizations
to stop pre-term labor, we brought our youngest son home
weighing just over four pounds. He, too, has struggled.
Tragically, as the needs of my children grew, my own symptoms
significantly increased. I dismissed the continued physical symptoms
until they began to affect my daily life and the lives and function
of my family. Night sweats, fevers, tremors, joint and muscle
pain, loss of muscle function, hair loss, fatigue, joint nodules, paresthesia,
and memory loss all occurred.
In 2003, I was referred to a neurologist. The lesion on my brain
and the lesions in my spine were proof of my debilitating health
and they provided me a diagnosis of multiple sclerosis. I could no
longer take my children for walks, cook meals, or clean the house.
The burden of our family situation at this time was hopeless and
the stress and grief over our situation was unbearable. We were
forced to move from our two-story home into a one-story rambler.
I began relying on my cane more frequently and began wearing a
stabilizing leg brace. My excruciating headaches necessitated trips
to the emergency room.
All of my efforts and energy were focused on my children. The
developmental and physical needs were significant and their demands
overwhelming. Each child had weekly individual speech
therapy and occupational therapy appointments. Although we have
private health insurance, these rehabilitative therapies are not
paid by insurance companies once a child reaches the age of 7
years. We soon found ourselves with medical expenses totaling
nearly 15 percent of our annual income, after insurance payments.
We are lucky we have private insurance.
We were thankful to find a private school prepared to help our
son learn as only he can, never mind that I must travel 72 miles
daily back and forth to get him to school and home again.
Both boys continue to receive developmental therapies. Stephen
must be taught what most of us take for granted, forming sentences,
self-expression, being able to realize his own hunger or tie
his shoes when his fingers feel tingly. His anguish is devastating
and it breaks my heart.
I have benefited from Solu-Medrol steroid infusions. Lesion activity
has slowed, and my many other symptoms have become much
more manageable. But I am far from a typical healthy 40-year-old
woman. My headaches have forced me to the hospital three times
this year alone, and any time after about 7:30 in the evening, I can
be found with an approximately 60 percent deficit on the right side
of my body. I have little skin bumps that grow and subside, depending
on the severity of my neurological symptoms. On particularly
bad days, my boys try to support me as I walk.
It is clear to my husband and myself that the exposures and vaccines
that we received are more likely than not playing a large
piece in the decline of my health. We have worked very hard to
provide our sons with the best medical care available. More than
one of their providers has taken an interest in our situation and
offered to run a study on Gulf War children.
Most of the parents registered in my Gulf War veterans Yahoo!
web group have stated that their children suffer from many of the
same neurological symptoms as our children, or a combination
thereof. At one time, the group represented nearly 100 children.
My children have the benefit of a unique bond resulting from
their shared struggles. While they share the developmental strug-
gles, they encourage and help each other to a depth that is far beyond
their years. Our lives differ greatly from those of our contemporaries.
Before travel, we must arrange and prepare all of our
medications. We must make certain that hotel rooms will accommodate
their BI-PAPS, the machines that provide them nightly continued
airway pressure, preventing their airway collapse.
My husband has thankfully remained healthy and he continues
to serve in the U.S. Army Reserves. We have often spoken of our
concern for the servicemembers who have taken pre-deployment
vaccines and who are exposed daily to presumed and unknown environmental
contaminants today. We believe that it is vital to the
health of our most recent veterans that you continue to study the
long-term health of Persian Gulf War veterans and our children.
Please learn from what has happened to me, my family, and the
lives, we believe, of at least 300,000 other Persian Gulf War veterans.
The Department of Defense acknowledged our exposures in letters
sent to us in both 1997 and in 2001. There must be accountability
for the health care of our ill veterans. A comprehensive VA
registry must be funded to track Gulf War veterans and their children.
This renewed family registry must be in place to record the
progression of Gulf War veterans as well as the physical and neurological
effects of our children.
The Veterans' Administration must also create an MS registry
for Persian Gulf War veterans. We believe that many of our amalgamated
symptoms are developing into diagnosable illnesses and
diseases, such as brain cancer, ALS, and multiple sclerosis. We believe
that a great many of our veterans who have received MRI diagnostic
readings have been found to have brain and/or spinal lesions.
These findings must be investigated to determine if our veterans
are presenting with a typical or an atypical form of multiple
sclerosis. Dedicated funding must be established to create a systematic
and more standardized approach to diagnosing and treating
the unique illnesses of our Gulf War veterans.
As a cohort, we are becoming increasingly debilitated. We won't
let you forget. We won't let you leave us behind. Please help us and
help our families.
[The prepared statement of Ms. Mock follows:]
PREPARED STATEMENT OF JULIE M. MOCK, PRESIDENT,
VETERANS OF MODERN WARFARE, INC.
My name is Juliana M. Mock, President, Veterans of Modern Warfare, Inc.,
#33107 P.O. Box 96503 Washington, DC 20090-6503. It is an honor to come before
you today and share with you my life as a Persian Gulf War veteran.
I served in the Persian Gulf War with the U.S. Army. I deployed with the 87th
Medical Detachment (Dental Services) from Germany and served in-theater with
the 12th EVAC Hospital.
Our group of 62 was dispatched into Northern Saudi Arabia in mid-December
1990 into an empty grid area that was marked by a dead camel. It is at this
location that we spent our Christmas holiday wringing laundry with blistered
hands just before the onset of a large sandstorm. It is also at this location
that I would hear the first of a succession of chemical alarms.
At the end of December, my 12-person dental team was assigned to the 12th
EVAC Hospital along Tapline Road. Located roughly 30 kilometers from both the
boarders of Iraq and Kuwait, we were the first forward hospital open for
patients. We also provided dental support for the Iraqi EPW's at the 301st
Military Police Camp.
During the months of January, February and March 1991, we repeatedly
experienced the loud alarms of chemical detectors. We ingested expired
pyrostigmine bromide tablets; we wore gas masks with expired filters,
inhaled dust and sand in the air that was thick with the black of burning
oil. I experienced respiratory difficulties, my skin grew hot with red
rashes and I began to suffer from debilitating headaches. Many of my
contemporaries experienced many of the same, or a combination
of these symptoms.
For a time, my husband, also a Persian Gulf War veteran, and myself were
very ready to put the history of our experiences and exposures in the Gulf
far behind us and move forward with our lives and begin a family.
It was after our children were born in 1995 and in 1997 that we could no
longer deny the possible significance of the pre-deployment vaccines we
took before deployment to Saudi Arabia or the possible chemical and
environmental exposures. Nor could we ignore the significant neurological
challenges of our beautiful son. As our eldest son's first year passed and
his second birthday approached, it was very clear that Stephen could not
speak and that he did not experience sensory events in a typical manner.
Our hearts broke with each new diagnosis. He was severely dyspraxic. Not
only would our son require aggressive speech therapy, but he was also
diagnosed with a dangerous connective-tissue disease which causes severe
bruising that must constantly be monitored. He was diagnosed with an
additional skin disorder, sensory-integration disorder, hypotonia, sleep
apnea and learning disabilities and eventually with bipolar disorder and
Tourette's Syndrome. Stephen, now 12, has spent 7 weeks of his young life
hospitalized in efforts to regulate his very irregular brain.
After a second difficult pregnancy requiring multiple hospitalizations to
stop preterm labor, we brought our youngest son home weighing just over four
pounds. Although he was not nearly as challenged as his brother, he has
struggled with auditory processing, sensory integration disorder, hypotonia
and severe sleep apnea.
Tragically, as the needs of my children grew, my own symptoms significantly
increased. I dismissed the continued physical symptoms until they finally
began to affect my daily life and the lives and function of my family: hot
red rashes, daily roving hives, night sweats, fevers, tremors, joint and
muscle pain, loss of muscle function, hair loss, fatigue, joint nodules,
paresthesia and memory loss.
In 2003, I was referred to a neurologist. The lesion on my brain and the
lesions in my spine were found with MRI's and they provided us with proof of
my debilitating health and a diagnosis of Multiple Sclerosis.
I could no longer take my children for walks, cook meals or clean the house.
The burden of our family's situation at this time seemed hopeless and the
stress and grief over our situation was unbearable. We were forced to move
from our two-story home into a one-story rambler. I began relying on my cane
more frequently and began wearing a stabilizing leg brace. My excruciating
headaches necessitated trips to the emergency room.
All of my efforts and energy were focused on my children. Their developmental
and physical needs were significant and their demands overwhelming. Each child
had weekly individual speech therapy and occupational therapy appointments.
Although we have private health insurance, these rehabilitative therapies are
not paid by insurance companies once a child reaches the age of 7 years. We
soon found ourselves with medical expenses totaling nearly 15 percent of our
annual income�after insurance payments.
Our eldest son has seen his specialists on a regular basis: neurologist,
hematologist, rheumatologist, psychiatrist, geneticist, neuropsychologist. We
were thankful to find a private school prepared to help our son learn as only
he can�never mind that I must travel 72 miles daily to get him to school and
home again. And at 12, he is thankful to receive speech therapy at 8 a.m. on
Mondays before we travel to his school. On Tuesdays he receives occupational
therapy and he is learning assistive technology computer programs that will
allow him to more successfully complete his school work and express his
thoughts and ideas. And on Wednesday mornings, both of the boys receive
sensory integration therapy before their school days begin. Stephen must be
taught what most of us take for granted: forming sentences, self-expression,
being able to realize his own hunger or tie his shoes when his fingers feel
``tingly.'' His anguish is devastating and it breaks my heart.
Some days I have help driving the boys to their schools. On the days I do not
have help I return home and rest until I need to leave for the return trip to
fetch them from school. Keeping our household clean is a challenge and we
often must hire help.
I have benefited from Solu-Medrol steroid infusions. Lesion activity has
slowed and my many other symptoms have become more manageable. But I am far
from a typical, healthy 40-year old woman. My headaches have forced me to the
hospital 3 times this year alone and any time after 7:30 p.m. I can be found
with an approximately 60 percent deficit on the right side of my body. I have
little skin bumps that grow and subside, depending on the severity of my
neurological symptoms. On particularly bad days, my boys try to support me
as I walk.
It is clear to my husband and myself that the exposures and vaccines that we
received more likely than not have played a large piece in the decline of my
own health. We have worked very hard to provide our sons with the best medical
care available. More than one of their providers has taken an interest in our
situation, our exposures and the neurological health of our children. More
than one provider has stated that they believe it is plausible for our
circumstances to have played a role in their deficits. And more than one
provider has shown a strong interest in conducting a study focused on the
neurological and physical health of Persian Gulf War veteran children.
We know persons who deployed with us in-theater who have not been healthy
since their deployment and we know that there are many who have deteriorated
slowly over the years and who are now in crisis. Most of the parents
registered in my Gulf War Veterans with children yahoo! web group have stated
that their children suffer from many of the same neurological challenges as
our children. At one time, the group represented nearly 100 children. Parents
reported a pattern of common denominators: severe speech impairments, fine
and gross motor deficits requiring significant developmental intervention,
learning disabilities, and blood and connective tissue disorders. Less common,
although present, were the families reporting hydrocephalus and kidney
disorders.
My children have the benefit of a unique bond resulting from their shared
struggles. While they share their developmental struggles, they encourage
and help each other to a depth that is far beyond their years. Our lives
differ greatly from those of our contemporaries. Before travel, we must
arrange and prepare all their medications. We must make certain that hotel
rooms will accommodate their BI-PAPS the machines that provide them nightly
continued airway pressure preventing airway collapse.
My husband has thankfully remained healthy and he continues to serve in the
U.S. Army Reserves. We have often spoken of our concern for the servicemembers
who have taken pre-deployment vaccines and who are exposed daily to presumed
and unknown environmental contaminants.
We believe that it is vital to the health of our most recent veterans that
you continue to study the long-term health of Persian Gulf War veterans and
our children. Please, learn from what has happened to me, my family and the
lives of at least 300,000 other Persian Gulf War veterans.
The Department of Defense acknowledged our exposures in letters sent in both
1997 and 2001. There must be accountability for the health care of our ill
veterans. A comprehensive VA registry must be funded to track Gulf War
veterans and their children. This renewed family registry must be in place
to record the progression of Gulf War veterans, as well as the physical and
neurological defects of our children.
The Veterans' Administration must also create an MS Registry for Persian Gulf
War veterans. We believe that many of our amalgamated symptoms are developing
into diagnosable illnesses and diseases, such as brain cancer, ALS and
Multiple Sclerosis. We believe that a great many of our veterans who have
received MRI diagnostic readings have been found to have brain and/or spinal
lesions. These findings must be investigated to determine if our veterans are
presenting with a typical or an a-typical form of Multiple Sclerosis.
Dedicated funding must be established to create a systematic and more
standardized approach to diagnosing and treating the unique illnesses of our
veterans.
As a cohort, we are becoming increasingly debilitated. Please help us and
help our families.
Senator MURRAY. Julie, thank you so much for coming and testifying
today. I really appreciate it.
Dr. Nass?
STATEMENT OF MERYL NASS, M.D., MOUNT DESERT ISLAND
HOSPITAL, BAR HARBOR, MAINE
Dr. NASS. Thank you. I practice internal medicine in Maine. I
have a background in anthrax and biological warfare and have
treated patients with multi-symptom illnesses, including Gulf War
syndrome, for the last 8 years.
Gulf War veterans are certainly sick, and it is certain that a
number of hazardous substances to which they were recklessly exposed
caused their illnesses. The chronic neurological and psychological
effects of sarin, pesticides, and solvents were known even
before the 1999 war. We really don't need to keep studying this.
The approach of DOD and VA to these veterans has been callous.
Their illnesses were denied, and when Congress insisted on researching
the illnesses, DOD and VA developed a cynical research
program focused on stress and psychiatric origins for the illnesses.
Only a fraction of the research turned up anything of benefit to the
veterans, and virtually none was geared toward curing them. Yet
there has been no accountability.
DOD and VA created a mantra which they repeated over and
over, ��No unique Gulf War illness,'' which medically has no meaning,
but it effectively minimized the illness and marginalized the
ill.
This booklet, ��A Guide to Gulf War Veterans' Health'' a 3-hour
training course for VA clinicians, not only repeats this mantra but
also claims ��VA has been able to respond to the complexity of veterans'
health problems. Most are readily diagnosed and effective
treatments are available.'' However, the treatments are primarily
psychiatric drugs and cognitive behavioral therapy, despite a paucity
of data to support their effectiveness.
This manual notes on page 19 that the Office of the Special Assistant
to the Deputy Secretary of Defense for Gulf War Illnesses
operated under a three-part mission: (1) Gulf War veterans will receive
appropriate medical care. (2) Two, DOD will do everything
possible to understand and explain Gulf War illnesses. (3) DOD
will put in place all required military doctrine, personnel, medical
policies and procedures to minimize any future problems from exposure
to environmental hazards and chem/bio agents. Yet the
OSAGWI office and subsequent DOD efforts appear to have functioned,
paradoxically, to avoid carrying out any part of this mission.
Physicians have still not been taught this is a real illness, let
alone how to evaluate and care for the patients. The research portfolio
continues to be, for the most part, irrelevant. Of the ten newest
DOD-sponsored studies in this latest 2006 DVA Annual report
to Congress on Gulf War illnesses, only two of the ten are about
a medical treatment, but the treatment is for ALS, malaria, and
Leishmania, which were diagnosed in only a very few veterans. Yet
there remain huge gaps in the completed Gulf War research portfolio.
The effects of infectious diseases acquired overseas, inhaled
depleted uranium, pyridostigmine bromide, and vaccines have barely
been touched.
As far as minimizing future problems from environmental hazards,
has there been a �lessons learned?' Were the chemical alarms
explained? Were there recriminations over aerosolizing sarin on our
troops? Are we now producing depleted uranium without adding in
nuclear reactor waste? Have the recommendations of eight expert
groups to study anthrax vaccine been carried out?
FDA has designated 670 of the 5,500 adverse event reports for
anthrax vaccine filed since 1998 as serious. FDA defines serious as
a death, a life-threatening event, an event requiring a hospitaliza-
tion or a permanent disability. Each of these 670 reports represents
one life. Is anybody investigating them? The GAO (GAO-07-787R)
told the Armed Services Committee in June that 1 to 2 percent of
anthrax-vaccinated individuals ��may experience severe adverse
events which could result in disability or death.''
Deployed troops receive mandatory smallpox vaccine, although
one in 150 recipients will develop heart muscle inflammation as a
result. Some will have permanent damage. Smallpox vaccine probably
contributed to mystery pneumonias and premature cardiac
deaths in soldiers. Where is the risk-benefit analysis for the use of
this vaccine, which was too toxic for a civilian vaccination program?
DOD has a short-term, mission-oriented view. That is its job.
Congress has the responsibility to require DOD to place a much
higher priority on the long-term health of its servicemembers. In
my view, solving the problem will require a new Federal agency to
oversee drug and vaccine safety, since FDA's safety staff have no
regulatory authority and CDC safety studies have received much
criticism. DOD's grants to these agencies may have decreased their
interest in challenging and regulating DOD's use of licensed and
unlicensed drugs and vaccines.
Similarly, there is no excuse for military bases to house some of
the Nation's worst toxic waste dumps. Stronger regulation by
OSHA could improve the training of soldiers in the handling and
disposal of toxic substances.
A new agency to manage the three missions given OSAGWI�research,
treatment, and prevention of future Gulf War-like events�
is a minimum requirement if we are to finally get serious about
Gulf War illnesses. It is a debt we owe our veterans now, 16 years
after the end of the Gulf War. Thank you.
[The prepared statement of Dr. Nass follows:]
PREPARED STATEMENT OF MERYL NASS, M.D., MOUNT DESERT ISLAND HOSPITAL,
BAR HARBOR, MAINE
Thank you very much for your invitation to discuss Gulf War Illnesses and
ideas for improved research and treatment of affected veterans. I practice
general internal
medicine, have a background in bioterrorism, anthrax and vaccine injuries, and
have conducted a clinic for Gulf War (GW) veterans and others with
multi-symptom syndromes (fibromyalgia, chronic fatigue syndrome, multiple
chemical sensitivity) since 1999.
Because so much confusion and controversy has surrounded this illness, I
thought it would be helpful to discuss persisting issues using a question
and answer format, while reviewing recent literature on Gulf War Illnesses.
I hope to clarify what is already known, as well as what needs to be known
in order to provide the best treatment to affected veterans. I will then
discuss my treatment approaches. I use the terms Gulf War Illnesses (GWI)
and Gulf War Syndrome (GWS) interchangeably.
1. WHAT IS GULF WAR SYNDROME?
As early as 1993, Senator Donald Riegle's staff produced a report that said,
``Over 4,000 veterans of the Gulf War suffering from a myriad of illnesses
collectively labeled `Gulf War Syndrome' are reporting symptoms of muscle and
joint pain, memory loss, intestinal and heart problems, fatigue, running
noses, urinary urgency, diarrhea, twitching, rashes and sores.'' 1 In 1998
CDC developed a case definition of the illness, which omits some common
symptoms, but confirms the illness Riegle's staff identified, and provides
clinicians with a reasonable basis for diagnosing veterans and starting
treatment. So there is a long, well-documented history of the reality
of this illness.
-----
1 Staff report to Senator Donald Riegle. Gulf War Syndrome: The case for multiple origin mixed chemical/biotoxin warfare related disorders.
September 9, 1993.
Yet many physicians are unaware of the CDC case definition, and have been
bamboozled by the media into thinking Gulf War Illnesses either do not exist,
are psychosomatic or a result of stress. Surprisingly, this includes
physicians at VA facilities who care for affected patients. This widespread
ignorance is compounded by the VA treatment guidelines (posted on the VA web
site for clinicians), which emphasize the use of psychotropic medications
and cognitive behavioral therapy, although the science to support this is
exceedingly weak. 2
An estimated 200,000 1991 Gulf War veterans (25-30 percent of all deployed
veterans) and some vaccinated, nondeployed Gulf ��era'' veterans suffer from
illnesses related to their service, 3 and have been awarded partial or full
disability benefits by the VA. Although the signs, symptoms and severity of
illness vary considerably between affected veterans, the combination of
symptoms known as ��Gulf War Syndrome'' probably affects most of the 200,000
veterans who are ill.
Their symptoms are not confined to the CDC's defining triad of musculoskeletal
pain, fatigue and cognitive and/or emotional disturbance. 4 Their medical
conditions have been variously described in different studies. For example,
one UK study found that Gulf War veterans were 20 times as likely as other
veterans to complain of mood swings, 20 times as likely to complain of memory
loss and/or lack of concentration, and 5 times as likely to complain of sexual
dysfunction. 5 It is my opinion that the increased mental disorders reported
in GW veterans 6 reflect central nervous system (brain) dysfunction,
manifested in a variety of ways.
Furthermore, some affected veterans have developed anxiety and/or depression
as a result of their loss of function, as well as frustration resulting from
the lack of validation of their illnesses by DOD, VA and civilian health
providers, and failure to receive beneficial treatment. Many veterans have
endured the suspicion of military superiors and colleagues, friends and
family that they are malingering, a result of the mediocre level of much
popular and professional discourse about this illness.
2. CAN WE MAKE MEDICAL SENSE OF THE MULTIPLE SYMPTOMS
THAT OCCUR IN GULF WAR VETERANS?
According to Gronseth, ``Although an objective marker to GWS would be useful
for studies, the absence of such a marker does not make the syndrome any less
legitimate. . . The real debate surrounding medically unexplained conditions
is not whether or not they exist, but defining their cause.'' 7
Many patients with GWS meet criteria for other medically unexplained
conditions, also known as multi-symptom syndromes, such as chronic fatigue
syndrome, 8 fibromyalgia, and multiple chemical sensitivity. 9 These
conditions are poorly understood, but have a very similar pattern of symptoms
and findings as GWS. Some underlying mechanisms have been shown to be the
same as well. 10
An important VA study in which 1000 deployed 1991 Gulf War and 1,000 nondeployed
Gulf era veterans were carefully examined 10 years after the Gulf War,
found that deployed veterans were 2.3 times as likely to have fibromyalgia, and 40.6
------
2 Donta ST, Clauw DJ, Engel CC Jr. et. al. Cognitive behavioral therapy and
aerobic exercise for Gulf War veterans' illnesses: a randomized controlled
trial. JAMA. 2003 Mar 19;289(11):1396-404.
3 Steele L. Prevalence and patterns of Gulf War illness in Kansas veterans:
association of symptoms with characteristics of person, place, and time of
military service. Am J Epidemiol. 2000 Nov 15;152(10):992-1002.
4 Fukuda, K. et. al. Chronic Multi-symptom Illness Affecting Air Force
Veterans of the Gulf War. JAMA 1998; 280: 981-988. `` . . . a case was
defined as having 1 or more chronic symptoms (more than 6 months) from 2 of
the following categories: fatigue; mood and cognition; and musculoskeletal.''
5 Simmons R, Maconochie N, Doyle P. Self-reported ill health in male UK Gulf
War veterans: a retrospective cohort study. BMC Public Health. 2004 Jul
13;4:27.
6 Toomey R, Kang HK, Karlinsky J et. al. Mental health of US Gulf War
veterans 10 years after the war. Br J Psychiatry 2007; 190: 385-93.
7 Gronseth GS. Gulf war syndrome: a toxic exposure? A systematic review.
Neurol Clin. 2005 May;23(2):523-40.
8 Thomas HV, Stimpson NJ, Weightman AL et. al. Systematic review of
multi-symptom conditions in Gulf War veterans. Psychol Med 2006; 36: 735-47.
9 Ibid.
10 Baraniuk JN, Casado B, Maibach HA. Chronic Fatigue Syndrome--related
proteome in human cerebrospinal fluid. BMC Neurol. 2005 Dec 1;5:22.
times as likely to have chronic fatigue syndrome as nondeployed era veterans,
11 confirming a relationship between these conditions and GWS.
3. DOES THE CDC CASE DEFINITION IDENTIFY ALL DEPLOYMENT-RELATED ILLNESSES IN
GULF WAR VETERANS?
No. We know ALS (amyotrophic lateral sclerosis or Lou Gehrig's disease) occurs
twice as often in GW vets as in the civilian population, but it also occurs
50 percent more often in soldiers in general. 12 The military exposures
leading to these increased ALS rates are unknown.
Possible reasons ALS has been studied more carefully in GW veterans than other
illnesses, are that (a) veterans develop the illness at a younger age than the
civilian population, 13 (b) Congressional testimony by affected, now deceased
Gulf War veteran Michael Donnelly in 1997 gave the illness visibility, 14 and
(c) ALS only affects a small number of people.
Chronic diarrhea is another illness commonly seen in GW veterans, but it is
not included in the CDC's case definition. GW veterans have developed a
variety of other medical illnesses. What we still don't know is whether there
are, for instance, more heart attacks in deployed GW veterans than there would
have been, had they not deployed. The research is contradictory on whether
various illnesses occur more often in Gulf War veterans, although several
studies list a large number of symptoms that are seen more commonly in GW
veterans.
4. WHY DON'T WE KNOW WHETHER DEPLOYED VETERANS HAVE MORE ILLNESSES (LIKE
HEART ATTACKS) THAN THEY WOULD HAVE OTHERWISE?
The results of research depend on the methods used to investigate the research
question. Epidemiological research is limited to evaluating a statistical
relationship between an exposure and an illness. But statistically
significant relationships occur for many reasons other than cause and effect.
Thus, statistics alone cannot prove cause and effect. Only when all other
factors that can bias the result have been taken into account, will the
results be reliable. Here is one example of why some Gulf War research results
may be contradictory:
As Steele 15 showed, many nondeployed Gulf ``era'' veterans were given
vaccinations in preparation for deployment, and these vaccinated ``era''
veterans reported multi-symptom illness at 3 times the rate of unvaccinated,
nondeployed ``era'' veterans.
According to the military's Defense Medical Surveillance System (DMSS) raw
data, soldiers vaccinated with anthrax vaccine have heart attacks at a greater
rate than prior to vaccination. 16 Thus, if deployed veterans are compared to
a nondeployed group, of whom many received deployment vaccines, determining
whether deployed veterans have more heart attacks than expected is confounded
(made unreliable) by the nondeployed group's vaccinations.
Military and VA health databases have not been made available to independent
researchers to study.
5. HAS THE HEALTH OF GULF WAR VETERANS IMPROVED OVER TIME?
Veterans who developed this syndrome have, for the most part, remained ill. 17
Ten years later, one study found that 29 percent of deployed veterans had
chronic, multi-symptom illness. 18
------
11 Eisen SA, Kang HK, Murphy FM et. al. Gulf War veterans' health: medical
evaluation of a US cohort. Ann Intern Med 2005; 142: 122.
12 Weisskopf MG, O'Reilly EJ, McCullough ML et. al. Prospective study of
military service and mortality from ALS. Neurology 2005;64(1):32-7.
13 Haley RW. Excess incidence of ALS in young Gulf War veterans. Neurology.
2003 Sep 23;61(6):750-6.
14 http://members.aol.com/vetcenter1/donnelly.htm.
15 Steele L. Prevalence and patterns of Gulf War illness in Kansas veterans:
association of symptoms with characteristics of person, place, and time of
military service. Am J Epidemiol. 2000 Nov 15;152(10):992-1002.
16Data DOD shared with the Institute of Medicine in 2001:
http://merylnass.googlepages.com/AMSAtitlepage.pdf;
http://merylnass.googlepages.com/
17 Ozakincy G, Hallman WK and Kipen HM. Persistence of symptoms in veterans
of the First AMSAHeartattackdata.pdf Gulf War: 5-year follow-up. Environ
Health Perspectives 2006; 114: 1553-7.
18 Blanchard MS, Eisen SA, Alpern R et. al. Chronic multisymptom illness
complex in Gulf War 1 veterans 10 years later. Am J Epidemiol 2006; 164:
708-9.
6. DO GW VETERANS DIE AT A HIGHER RATE?
Three studies have demonstrated that GW veterans had an approximately 50
percent greater risk of accidental deaths, particularly from motor vehicle
accidents. Although this has been attributed to elevated risk-taking behavior
in deployed GW soldiers by some, others (including myself) suspect it is at
least partly related to the cognitive problems faced by GW veterans,
particularly their difficulties with attention and concentration.
One study found that testicular cancer rates were increased in Persian Gulf
War veterans. 19 This is usually a curable cancer that occurs in young males,
so would not be expected to increase overall mortality rates significantly.
Other statistical studies have shown no more deaths and no more birth defects
in offspring of GW soldiers than in comparable groups. However, was the
control group truly comparable? Deployed troops are known to be much healthier
than a group of age and sex-matched civilians, and this is commonly termed the
``Healthy Warrior'' effect. But they may also be healthier than the Gulf
``era'' troops who were not deployed, although ``era'' troops usually form the
comparison group.
Steele showed that in Kansas veterans, the rate of multi-symptom illness
varied by deployment location. 20 Since different units had very varied
exposures during their deployments, high rates of birth defects and/or deaths
in certain units are possible. Yet the types of large epidemiological studies
that have been performed have usually obscured possible localized effects of
service in the Gulf.
7. SELF REPORTS
The validity of studies of GW veterans' health and exposures has been
criticized on the basis that the exposure and illness data are reported by
veterans, and not obtained from more reliable sources, such as military or VA
databases. Some measures of current health could be obtained from those
databases, but the data would be incomplete. Exposure data have not been a
part of the available record for most veterans. Exposure data that have been
supplied by DOD have been unreliable (in terms of the Khamisiyah plume
modeling, according to GAO 21) or the data contradicted the self-reports (as
in immunization data supplied by DOD to VA, following presentation of a VA
study that linked anthrax vaccinations to subsequent ill health 22), or the
data are missing or classified. The number, names and locations of all sites
at which chemical warfare agents were exploded remain unknown to the public.
Are self-reports valid? two recent studies indicate that GW veterans give
reliable answers to questions. 23 A study that compared GW veterans with Gulf
era veterans' performance on neuropsychological examinations found that only 1
percent of GW veterans provided ``noncredible'' exams versus 4 percent of era
veterans. 24 Therefore, self-reports by GW veterans can safely be judged
credible.
8. WHY HAS THE REALITY OF GULF WAR SYNDROME
BEEN SO CONTENTIOUS?
Perhaps remarks by Alabama Congressman Glen Browder in a 1993 House
Armed Services Oversight and Investigations Subcommittee meeting shed some
light on this:
-------
19 Levine PH, Young HA, Simmens SJ et. al. Is testicular cancer related to
Gulf War deployment? Evidence from a pilot population-based study of Gulf War
veterans and cancer registries. Mil Med 2005: 170: 149-53.
20 Steele L. Op. cit.
21 GAO-04-821T. June 1, 2004: ``The modeling assumptions . . .were inaccurate
because they were uncertain, incomplete and nonvalidated.'' ``DOD and VA's
conclusions about no association between exposure to CW agents and rates of
hospitalization and mortality . . .cannot be adequately supported because of
study weaknesses.''
22 Mahan CM, Kang HK, Dalager NA. Anthrax vaccination and self-reported
symptoms, functional status, and medical conditions in the National Health
Survey of Gulf War Era Veterans and Their Families. Ann Epidemiol. 2004
Feb;14(2):81-8.
23 Kelsall HL, Sim MR, Forbes AB et. al. Symptoms and medical conditions in
Australian veterans of the 1991 Gulf War: relation to immunisations and other
Gulf War exposures. Occup Environ Med. 2005 Mar;62(3):142-3. ``More than 10
years after the 1991 Gulf War, Australian veterans self-report all symptoms
and some medical conditions more commonly than the comparison group. Further
analysis of the severity of symptoms and likelihood of the diagnosis of
medical conditions suggested that these findings are not due to over-reporting
or to participation bias.''
24 Barrash J, Denburg NL, Moser DJ et. al. Credibility of neuropsychological
performances of Persian Gulf War veterans and military control subjects
participating in clinical epidemiological research. Mil Med 2007; 172:
697-707.
``I have asked a lot of questions about why the Pentagon continues to
stonewall these Gulf War veterans, or why are they so resistant to full and
open examination of this problem. I don't have any conclusive answers but I
can speculate.
First, it may be pride. To acknowledge these mystery casualties may blemish
our Persian Gulf victory. Or, such an acknowledgement may be a terrifying
admission that the United States did not and perhaps cannot protect
our military men and women against chemical and biological warfare.
But I personally suspect that dealing openly and fully with these mystery
ailments, and therefore the dirty little secret, will require the Pentagon to
make budgetary and programmatic adjustments that it does not want to
make.'' 25
Military doctrine calls for continuing use of anthrax and smallpox vaccines,
multiple simultaneous vaccinations, pyridostigmine bromide tablets for
prophylaxis of nerve gas exposure and depleted uranium munitions and armor.
Thus, military studies that concluded these exposures were safe should come as
no surprise. Yet evidence of their adverse effects on health is abundant.
The American Type Culture Collection (ATCC) supplied various microbial
cultures to Iraq, in shipments approved by the Department of Commerce, during
a period in which the United States assisted Iraq in its war with Iran. This
may have influenced why infections due to Brucella melitensis, one of the
bacteria provided to Iraq, were not investigated. Vollum 26 strain anthrax
(which had been weaponized by the US military before the Biological Weapons
Convention came into force in 1975) was provided to Iraq by ATCC. Knowing a
U.S. corporation provided Iraq virulent anthrax (not a strain used to make
vaccines) may have influenced the defense department's decision to vaccinate
troops against anthrax. Similarly, the ATCC provided Clostridium botulinum to
Iraq; some soldiers were later vaccinated for potential exposure to botulinum
toxins.
Admitting that soldiers became ill as a consequence of what the US gave Iraq
may be politically unacceptable, undermining the likelihood that credible
scientific studies of these exposures, funded by the government, would be
performed.
According to the House Committee on Government Reform and Oversight in 1997,
``VA medical policy may have been biased against findings of chemical exposure
by relying on DOD assertions and unproven theories of toxic causation.
VA continues today to maintain that chronic symptoms in Gulf War veterans
cannot be attributed to toxic exposures unless acute symptoms first
appear at the time of exposure.'' 27
Yet the requirement for acute symptoms to occur in order to be harmed by
chemical weapons (organophosphates) is scientifically insupportable.
Investigating certain GW exposures has been a career killer. While some
researchers were amply rewarded for finding stress/psychological causes for
Gulf War Illnesses, other researchers were punished for exploring politically
unacceptable causes:
Jim Moss, Ph.D. on pyridostigmine potentiation research: ``Middle
and upper level management at USDA promised me I would be blackballed if I
did not stop the research, or if I ever disclosed my research to anybody
(this was before I appeared before the Senate VA Committee). My biggest
regret from my 1994 Senate VA Committee testimony has been that I did not
tell the Committee about the threats.'' 28 29
Charles Gutierrez, M.S., found microorganisms resembling Brucella
melitensis in stools of dozens of Gulf War veterans in Tennessee, but had his
studies halted: ``In the years following the Persian Gulf War, extensive
clinical studies on samples from Persian Gulf War veterans were performed at
the James Quillen VA in Moun-
-----
25 Use of chemical weapons in Desert Storm. Hearing before the Oversight and
Investigations subcommittee of the Committee on Armed Services, House of
Representatives. 103d Congress, 1st session. November 18, 1993.
26 Identified by Geoffrey Holland, who investigated the provenance of the
ATCC anthrax strains supplied to Iraq.
http:www.abc.net.au/worldtoday/content/2005/s1434633.htm.
27 House Committee on Government Reform and Oversight. Gulf War Veterans'
Illnesses: VA, DOD continue to resist strong evidence linking toxic causes
to chronic health effects. November 7, 1997. House Report 105-388. 105th
Congress, 1st Session.
28 Personal communication, September 17, 2007.
29 Chaney LA, Rockhold RW, Mozingo JR, Hume AS, Moss JI. Potentiation of
pyridostigmine bromide toxicity in mice by selected adrenergic agents and
caffeine. Vet Hum Toxicol. 1997 Aug;39(4):214-9.
30 Personal communication, September 17, 2007.
tain Home, Tennessee. This work was not adequately pursued by the VA, and was
instead ordered stopped. The findings in these patients need to be addressed,
as they may fill in gaps in the existing body of GW illness research.'' 30
Garth Nicolson, Ph.D., on mycoplasma studies: `` I was told by the
President of my institution (the Univ. of Texas M.D. Anderson Cancer Center)
to stop my GWI research or face disciplinary action. I refused to stop my
research, and my professional career, academic position (and any possible
future academic position) were destroyed by character assignation and outright
lies about my research activities. This occurred even though our work was
published in peer-reviewed academic journals. This was described in our book
Project Day Lily (www.projectdaylily.com).'' 31 32 33.
9. HOW IS IT THAT FEDERAL PUBLIC HEALTH ``WATCHDOG'' AGENCIES AND OVERSIGHT
MECHANISMS FAILED TO PREVENT THE PUBLIC HEALTH DISASTER OF GWS?
Federal agencies that could have weighed in on the safety of drugs
and vaccines given to soldiers in the Gulf have become politicized, and their
decision-making processes are opaque. The regulation of toxic substances is
fragmented, overseen by a variety of agencies. Recent FDA decisions, and the
agency's structure, suggest safety has a low priority.
FDA permitted use of unlicensed drugs and vaccines, and use of
licensed products for unproven purposes, during the Gulf War and later
FDA repeatedly approved anthrax vaccine use for bioterrorism
preparedness in the absence of required human data demonstrating
effectiveness, and despite ample evidence of safety concerns
Astonishingly, FDA drug and vaccine safety experts have no
regulatory authority 34
FDA ``safety experts work largely in isolation, with limited
resources and outdated technology.'' 35
``The FDA has bungled its effort to build a new system for
detecting the side effects of medicines after they go on the market,
delaying its implementation by at least 4 years, according to a report
commissioned by the agency itself . . . the FDA has wasted an estimated $25
million on its efforts.'' 36
CDC continues to misinform recipients of anthrax vaccine with an
official Vaccine Information Statement affirming vaccine safety that is in
conflict with the vaccine's FDA-approved package insert, 37 and what CDC
officials told GAO about adverse events following vaccination. The GAO,
citing CDC and Vaccine Healthcare Center officials as sources, reported that
1-2 percent of anthrax-vaccinated individuals ``may experience severe adverse
events, which could result in disability or death,'' in June 2007. 38
CDC conducted a trial of anthrax vaccine in 1,564 people beginning
in 2002 and provided an interim report on the study to FDA. Yet CDC has
released no information to the public about the trial findings, despite filing
over 100 adverse event reports on trial subjects to the Vaccine Adverse Event
Reporting System.
These Federal agencies know that injured military servicemembers are
prevented by the Feres Doctrine 39 from seeking a remedy for their injuries
through the legal system.
There are no viable legal remedies to hold military or government
personnel accountable for deliberate cover-ups resulting in denial of
healthcare and disability benefits mandated by Federal law.
30 Personal communication, September 17, 2007.
31 Personal communication, September 17, 2007.
32 Nicolson GL, Nasralla MY, Haier J, Pomfret J. High frequency of systemic
mycoplasmal infections in Gulf War veterans and civilians with Amyotrophic
Lateral Sclerosis (ALS). J Clin Neurosci. 2002 Sep;9(5):525-9.
33 Nicolson GL and Nicolson NL. Diagnosis and treatment of mycoplasmal
infections in persian gulf war llness illness-cfids patients. Journal of
Occupational Medicine, Immunology and Toxicology 5: 69-78, 1996.
34 Smith SW. Sidelining safety--the FDA's inadequate response to the IOM.
NEJM September 6, 2007. 960-3.
35 Ibid.
36 Mathews AW. Report blasts FDA's system to track drugs. Consultant says
mission is hobbled by missteps; agency disputes claims. Wall Street Journal.
March 3, 2007.
37 http://www.fda.gov/OHRMS/DOCKETS/98fr/05n-0040-bkg0001.pdf.
38 GAO-07-787R. Military Health: DOD's Vaccine Healthcare Centers Network.
June 29, 2007. Web address: http://www.gao.gov/cgi-bin/getrpt?GAO-07-787R.
39 http://usmilitary.about.com/library/milinfo/blferes.htm.
9. WHAT GULF WAR EXPOSURES DID SOLDIERS FACE, AND WHAT DO WE KNOW ABOUT
THE INJURIES THEY MAY CAUSE?
(a) Depleted uranium (DU)
DU is comprised of uranium that has had 40 percent of its radioactive isotope,
uranium-235, extracted. However, the DU used by the United States military
also contains ``recycled'' nuclear reactor waste, including small amounts of
highly radioactive plutonium-239, neptunium-237, technicium-99, americium etc.
40 41
Both munitions and armor may be made from DU. When a DU munition strikes
an object, or when DU armor is struck, it ignites and up to 50 percent of its
mass can aerosolize into minute particles that may be inhaled and will
contaminate the area for the foreseeable future. Inhaled DU may have prolonged
retention in the lungs, accumulates in specific brain regions (in rat
experiments) 42 and settles in bone. Inhaled DU led to behavioral effects in
animals. 43 It is excreted by the kidneys. Its toxicity is both chemical and
radiological.
The only veterans who have been studied longitudinally for DU exposure
comprise a small group with embedded DU shrapnel. They have shown limited
findings of genotoxicity and are otherwise well, 44 but have a ``relatively
low uranium burden compared to historical uranium-exposed controls.'' 45
However, other veterans with inhalation exposures are probably at greater
risk of DU toxicity. One study found that reported exposure to DU doubled the
risk of dying from disease. 46 (Reported pesticide exposure in this study
doubled the likelihood of accidental death.)
Consider that the recycled nuclear materials added to DU may not be evenly
dispersed. If so, there are likely some veterans with greater exposure to
highly radioactive materials, who are at increased risk of cancers, immune and
reproductive effects. Recent evidence also points to uranium as an endocrine
disruptor. 47
If we review the health of workers in uranium processing plants, we can obtain
clues about what to expect in DU-exposed veterans. Uranium workers have had
elevated rates of cancers, especially kidney and respiratory tract cancers.
They also had elevated levels of chronic kidney disease.
The Energy Employee Occupational Illness Compensation Program Act of 2000
(P.L. 106-398) established a ``special cohort'' of workers employed at three
Department of Energy uranium gaseous diffusion plants and Alaska's nuclear
test site: because of the absence of exposure records, and the presence of
ultra hazardous workplace exposures, the burden of proof has been shifted to
the government for ill workers at these facilities. 48 The combination of an
ultra hazardous workplace and absent exposure records 49 mirrors the plight of
Gulf War veterans, and suggests to us that burden of proof requirements could
be changed for veterans who suffer from illnesses characteristic of their
toxic exposures.
``Personal medical records of veterans, including sick call records, are
inadequate or missing. Documents which could help verify possible exposures
and military unit locations remain in DOD files. Most of the military NBC
logs, which are records of toxic warfare agent detections, are missing or
destroyed . . .''
(b) Sarin
Sarin is an organophosphate ``nerve'' agent or anticholinesterase, which
leads to excessive accumulation of the neurotransmitter acetylcholine at
nerve synapses. It
-----
40 http://www.nato.int/du/docu/d010118b.htm.
41 Alvarez R. The legacy of depleted uranium in the United States. Institute
for Policy Studies monograph. June 2003.
42 Fitsanakis VA, Erickson KM, Garcia SJ et al. Brain accumulation of depleted
uranium in rats following 3- or 6-month treatment with implanted depleted
uranium pellets. Biol Trace Elem Res 2006; 111: 185-97.
43 Monleau M, Bussy C, Lestaevel P et al. Bioaccumulation and behavioural
effects of depleted uranium in rats exposed to repeated inhalations. Neurosci
Lett. 2005 Dec 16;390(1):31-6.
44 McDiarmid MA, Engelhardt SM, Oliver M et al. Health surveillance of Gulf
War 1 veterans exposed to depleted uranium: updating the cohort. Health Phys
2007; 93: 60-73. sults of Gulf War 1 veterans exposed to depleted uranium.
Int Arch Occup Envir Health 2006;
45 McDiarmid MA, Engelhardt SM, Oliver M et al. Biological monitoring and
surveillance re- 79:11-21.
46 MacFarlane GJ, Hotopf M, Maconochie N et al. Long-term mortality amongst
Gulf War veterans: is there a relationship with experiences during deployment
and subsequent morbidity? Int J Epidemiol 2005; 34: 1403-8.
47 Raymond-Whish S, Mayer LP, O'Neal T et al. Drinking water with uranium
below US EPA water standard causes estrogen receptor-dependent responses in
female mice. Envir Health Perspectives 2007; online September 14, 2007.
48 Alvarez R. Op. cit.
49 Committee on Government Reform and Oversight. Gulf War Veterans' Illnesses:
VA, DOD continue to resist strong evidence linking toxic causes to chronic
health effects. Second Report. November 7, 1997. 105th Congress, 1st session.
Page 61.
is in the same family as pesticides such as parathion and malathion. A recent
study found a significant association between levels of estimated
sarin/cyclosarin exposure and reduced white matter in the brain. 50 The same
researchers also found that ``Sarin and cyclosarin exposure was associated
with less proficient neurobehavioral functioning on tasks involving fine
psychomotor dexterity and visuospatial abilities 4-5 years after exposure.'' 51
According to the Congressional Office of Technology Assessment (OTA) in 1990:
``Of particular concern are the delayed neurotoxic effects of some of the
organophosphorous (organophosphate) insecticides. Some of these compounds
cause degeneration of nerve processes in the limbs, leading to
changes in sensation, muscular weakness and lack of coordination. Because
of this property, the EPA requires that organophoshorous insecticides undergo
special testing for delayed neurotoxicity.'' 52
Thus despite claims by DOD that lack of acute sarin toxicity precluded later
disease, it was common knowledge at the time of the 1991 Gulf War that delayed
adverse effects do occur from exposure to this class of compounds.
Furthermore, a VA study of mortality in 100,000 veterans said to be exposed to
sarin at Khamisiyah found a statistically significant doubling of deaths from
brain cancer in the exposed group, compared to unexposed Gulf War veterans, as
well as a limited dose-response relationship. 53
According to a popular toxicology textbook, anticholinesterases may cause
``drowsiness, lethargy, fatigue, mental confusion, inability to concentrate,
headache, pressure in head, generalized weakness.'' 54
(c) Other pesticides
Carbamate pesticides were used in the Gulf and also cause acetylcholine
accumulation. They would augment the adverse effects of sarin and
organophosphate insecticides. Organochlorine and pyrethrin insecticides have
different mechanisms of action, but are also toxic to the peripheral and
central nervous system, so their adverse effects might compound those of the
acetylcholinesterases. Some pesticides have adverse immunotoxic effects as
well. 55 A recent review by NIH's National Institute of Environmental Health
Sciences researchers discussed the state of knowledge of pesticide toxicity,
and suggested that general malaise associated with mild cognitive dysfunction
may be a sensitive marker for pesticide neurotoxicity. 56
(d) Organic Solvents
These include jet and vehicle fuels, some cleaning agents and other industrial
chemicals. According to the Office of Technology Assessment:
``Acute exposure to organic solvents can affect an individual's manual
dexterity, response speed, coordination and balance. Chronic exposure of
workers may lead to reduced function of the peripheral nerves and such adverse
neurobehavioral effects as fatigue, irritability, loss of memory, sustained
changes in personality or mood, and decreased ability to learn and
concentrate.'' 57
Therefore, sarin nerve gas, organophosphate and other pesticides, and solvents
have the potential to induce the neurological and neurobehavioral effects seen
in Gulf War veterans. This was known prior to the first Gulf War.
(e) Endemic diseases and/or biological weapons exposures
It remains unknown whether troops faced any biological attacks. Exposure to
novel microorganisms has never been ruled out. The role of infections endemic
to
------
50 Heaton KJ, Palumbo CL, Proctor SP et al. Quantitative magnetic resonance
brain imaging in US veterans of the 1991 Gulf War potentially exposed to sarin
and cyclosarin. Neurotoxicology 2007 28:761-9.
51 Proctor SP, Heaton KJ, Heeren T et al. Effects of sarin and cyclosarin
exposure during the 1991 Gulf War on neurobehavioral functioning in US army
veterans. Neurotoxicology 2006; 27: 931-9.
52 Congressional Office of Technology Assessment. Neurotoxicity: Identifying
and controlling poisons of the nervous system. April 1990. OTA-BA-436. Page
50.
53 Bullman TA, Mahan CM, Kang HK et al. Mortality in US Army Gulf War veterans
exposed to 1991 Khamisiyah chemical munitions destruction. Am J Public Health
2005; 95:1382-8.
54 Klaassen CD. Cassarett and Doull's Toxicology. 5th edition, 1996. McGraw
Hill, N.Y. p.657.
55 Congressional Office of Technology Assessment. Identifying and controlling
immunotoxic substances. Neurotoxicity: Identifying and controlling poisons of
the nervous system. April 1990. OTA-BA-436. Government Printing Office. 1991.
56 Kamel F and Hoppin JA. Association of pesticide exposure with neurologic
function and disease. Environ Health Perspect. 2004 Jun;112(9):950-8.
57 Congressional Office of Technology Assessment. 1990. Op. cit. page 30.
the middle east in Gulf War Illnesses is also unknown. The following three
microorganisms probably infected some Gulf War veterans, but other
microorganisms may also contribute to GWI.
Leishmaniasis, due to a parasite spread by the sandfly, is endemic
in Iraq, but the visceral form of the disease is difficult to diagnose. Until
better diagnostics are available, it is certain that cases will be missed. It
can take months or even years to develop symptoms, and leishmaniasis may
develop into a chronic, debilitating illness.
Brucella melitensis is both endemic to Iraq and a potential
biological warfare agent. It can cause a slowly developing, fatiguing illness
with a variety of possible signs and symptoms, especially joint pain and
fever. It is difficult to diagnose because standard tests usually miss it,
so unless it is considered in the differential diagnosis and special tests
ordered, it will be overlooked.
Mycoplasmas have been linked to chronic multi-symptom illnesses. 58
They are widely distributed, and the known spectrum of clinical illness they
cause continues to expand. 59 A significant percentage of GW veterans have
antibodies to mycoplasma.
(f) Contaminated water
Possible contaminants include endemic or deliberately added microorganisms and
petroleum products. Soldiers reported that some storage tanks supplying
drinking water were also used for vehicle fuels, and the water contained fuel
residues.
(g) Smoke from oil well fires
Little reliable data on the contents and concentrations of materials
comprising the oil well fire smoke is available. 60 Toxic inhalants could have
been burned deliberately by retreating Iraqi troops.
(h) Pyridostigmine bromide (unlicensed use) a.k.a. PB, NAPPS
Also increases acetylcholine at nerve synapses; will augment the adverse
effects of sarin, organophosphate and carbamate insecticides. Multiple studies
have linked PB use to later illness in GW troops. 61
(i) Other unlicensed drugs approved for use in the Gulf theater 62
Centoxin (J5 monoclonal antibody), purchased by the military, prior
to licensure of the drug, to treat sepsis in Gulf War veterans. Found later to
increase mortality rates in treated patients. 63 64 Never licensed.
Ribavirin, purchased by the military for use in unspecified viral
illnesses. Yet when used later as an experimental treatment for SARS,
Ribavirin produced anemia, bradycardia and hypomagnesemia, increasing
mortality. 65 Other researchers later noted, ``Ribavirin should not be used
empirically for the treatment of viral syndromes of unknown etiology.'' 66
Ribavirin also causes immunotoxicity. 67 Its adverse reactions include fatigue
and depression, which may persist after the drug is stopped.
-------
58 Nasralla M, Haier J, Nicolson GL. Multiple mycoplasmal infections detected
in blood of patients with chronic fatigue syndrome and/or fibromyalgia
syndrome. Eur J Clin Microbiol Infect Dis. 1999; 18(12):859-65.
59 Baseman JB, Tully JG. Mycoplasmas: sophisticated, reemerging, and burdened
by their notoriety. Emerg Infect Dis. 1997 Jan-Mar; 3(1):21-32.
60 Committee on Government Reform and Oversight. Gulf War Veterans' Illnesses:
VA, DOD continue to resist strong evidence linking toxic causes to chronic
health effects. Second Report. November 7, 1997. 105th Congress, 1st session.
Page 67.
61 Schumm, W.R., Reppert, E.J., Jurich AP et al. Pyridostigmine bromide and
the long-term subjective health status of a sample of over 700 male Reserve
Component Gulf War era veterans. Psychological Reports 2002; 90: 707-721.
62 Rettig R. Military use of drugs not yet approved by the FDA for CW/BW
defense. RAND Monograph on Lessons from the Gulf War. 1999.
63 Shulman R. Current drug treatment of sepsis. Hospital Pharmacist 2002;
9:97-101.
64 Quezado ZM, Natanson C, Alling DW et al. A controlled trial of HA-1A in a
canine model
65 Chiou HE, Liu CL, Buttrey MJ et al. Adverse effects of ribavirin and
outcome in severe
66 Muller MP, Dresser L, Raboud J et al. Adverse events associated with
high-dose ribavirin: of gram-negative septic shock. JAMA 1993; 269: 2221-7.
acute respiratory syndrome in two medical centers. Chest 2005; 128:263-72.
evidence from the Toronto outbreak of severe acute respiratory syndrome.
Pharmacotherapy 2007; 27: 494-503.
67 Office of Technology Assessment. Identifying and controlling immunotoxic
substances. April 1991. OTA-BP-BA-75.
(j) Electromagnetic fields
Electromagnetic weapons, including high power microwaves, 68 were used to
disrupt and destroy Iraqi electronic systems. Generation of electromagnetic
fields may have been used for other effects, and for communication. Whether
electromagnetic fields contributed to illness is unknown, as are the types and
magnitudes of the exposures. However, the European Union's European
Environment Agency has just called for immediate action to reduce exposure to
microwaves, following an international scientific review, which concluded that
safety limits set for the radiation are ``thousands of times too lenient.'' 69
(k) Vaccines
Botulinum toxoid vaccine, manufactured by Michigan Department of
Public Health, meant to immunize against botulinum toxins. The toxins block
neurotransmission, as does the toxoid. Never licensed. Very little known about
safety or efficacy.
Anthrax vaccine, licensed with inadequate data. Concentration
increased 100 times due to manufacturing changes at the time of the Gulf War.
Identified as a risk factor for Gulf War illnesses by multiple studies. 70 71
72 73 74 The vaccine's package insert lists the CDC definition of Gulf War
Syndrome as a reported adverse event following anthrax vaccine. Many of the
over 5,000 reports to the Vaccine Adverse Event Reporting System of FDA-CDC
for anthrax vaccine indicate chronic illnesses whose symptoms resemble GWS. I
have treated many soldiers who became ill following anthrax vaccine given
since the 1991 Gulf War, and the majority experience cognitive impairment,
generalized pain and fatigue, among other symptoms, meeting the CDC's case
definition for GWS. See my testimony to the House Veterans Affairs Health
Subcommittee for additional information. 75
Multiple vaccines given together within a short time period. Are
multiple simultaneous vaccinations dangerous? Although the question has been
discussed by the Institute of Medicine, the Armed Forces Epidemiology Board
and the British Ministry of Defense, they provide no conclusive answer.
Studies of multiple vaccinations associated with Gulf War Illnesses have shown
a positive, dose-response relationship, suggesting they did contribute to GWI.
76 77 Soldiers engaged in Operation Iraqi Freedom have also reported Gulf War
Illness-like disease following multiple vaccinations, with both acute and
chronic effects. 78
British military policy now separates anthrax and smallpox vaccinations from
other vaccinations by at least 5 days .79
10. WHAT CAN WE CONCLUDE ABOUT THE EXPOSURES?
(a) Several of the exposures can individually produce the symptoms GW veterans
are experiencing. Injuries from these substances can affect cognition,
emotion, motor and sensory function. These include sarin, pesticides,
solvents, anthrax vaccine and some chronic infections, at a minimum.
-----
68 http://www.globalsecurity.org/military/systems/munitions/hpm.htm.
69 Lean G. EU calls for urgent action on wi-fi radiation. New Zealand Herald.
September 16, 2007.
http://www.nzherald.co.nz/section/2/story.cfm?c--id=2&objectid=10463870.
70 Unwin C, Blatchley N, Coker W, Ferry S, Hotopf M, Hull L, et al. Health of
UK servicemen who served in Persian Gulf War. Lancet. 1999 Jan 16;
353(9148):169-78.
71 Goss-Gilroy. Study of Canadian Gulf War Veterans: NR-98.050. Study
contracted by the Canadian Department of National Defense, released June 29,
1998 and published on its web site, accessed between 1999 and 2001 but no
longer at the previous URL:
http://www.dnd.ca/menu/press/Reports/Health/health--study--eng--1.htm.
72 Schumm WR, Reppert EJ, Jurich AP et al. Self-reported changes in subjective
health and anthrax vaccination as reported by over 900 Persian Gulf War era
veterans. Psychol Rep. 2002 Apr;90(2):639-53.
73 Boyd KC, Hallman WK, Wartenberg D, Fiedler N, Brewer NT, Kipen HM. Reported
exposures, stressors, and life events among Gulf War Registry veterans. J
Occup Environ Med. 2003 Dec;45(12):1247-56.
74 Wolfe J, Proctor SP, Erickson DJ, Hu H. Risk factors for multisymptom
illness in US Army veterans of the Gulf War. J Occup Environ Med. 2002
Mar;44(3):271-81.
75 http://merylnass.googlepages.com/writtentestimony7-26-07.doc.
76 Kelsall HL, Sim MR, Forbes AB et al. Symptoms and medical conditions in
Australian veterans of the 1991 Gulf War: relation to immunisations and other
Gulf War exposures. Occup Environ Med. 2004 Dec;61(12):1006-13.
77 Cherry N, Creed F, Silman A, et al. Health and exposures of United Kingdom
Gulf war veterans. Part II: The relation of health to exposure. Occup Environ
Med. 2001 May;58(5):299-306.
78 http://www.bmj.com/cgi/content/full/326/7401/1234a. Dyer O. Ministry of
Defence accused of contravening inoculation guidelines. BMJ 2003;326:1234.
79 Ibid.
(b) Combined exposures to certain toxic substances (and simultaneous exercise)
greatly magnify the potential for adverse reactions:
Somani et al. Exercise plus Pyridostigmine Bromide amplified
oxidative injury in skeletal muscle of mice. 80
Abou-Donia et al. ``These results suggest that exposure to real-life
doses of malathion, DEET and permethrin, alone or in combination, produce no
overt signs of toxicity but induce significant neurobehavioral deficits and
neuronal degeneration in brain.'' 81
McCain et al. ``A significant increase in lethality occurred when PB,
permethrin and DEET were given concurrently, when compared to expected
additive values.'' 82
Haley RW et al. ``Some Gulf War veterans may have delayed, chronic
neurotoxic syndromes from wartime exposure to combinations of chemicals that
inhibit butyrylcholinesterase and neuropathy target esterase.'' 83
(c) Multiple simultaneous vaccinations increased the risk of GWS.
(d) For some other exposures, there is very little available information on
toxicity.
(e) Depleted uranium likely contributed to chronic illnesses (and deaths in
soldiers tasked to clean up DU). 84
(f) Illnesses resulting from infections, electromagnetic fields, smoke, drugs
and possibly other exposures have not been ruled out in GW veterans.
11. WHAT IS KNOWN ABOUT UNDERLYING PATHOLOGY IN GWS?
(a) Autonomic nervous system function has been shown to be altered in Gulf War
veterans in multiple studies, as has hypothalamic pituitary adrenal function.
85
(b) Altered immune function reflects another aspect of this disorder for many
veterans. 86
(c) One's genes affect the speed of processing of toxic substances and later
manifestation of toxic effects. 87
(d) Gulf War soldiers encountered an unprecedented mix of noxious substances,
which are known to cause neurological, immunologic and other adverse effects.
Gulf War Illness research even suggests a dose-response relationship between
some exposures and symptoms. 88
A very reasonable hypothesis is that those who became ill reached a
tipping point, where their body's ability to safely process the toxic
materials they took in was exceeded. Chronic illness may have resulted from
tissue damage (such as permanent loss of neurons) and/or persisting metabolic
abnormalities, which have yet to be defined, but are suspected to include
impaired oxidative phosphorylation 89 90
-----
80 Jagannathan R, Husain K and Somani SM. Interaction of pyridostigmine and
physical stress on antioxidant defense system in skeletal muscle of mice. J
App; Toxicol 2001; 21: 341-8.
81 Del-Rahman A, Dechkovskaia AM, Goldstein LB et al. Neurological deficits
induced by malathion, DEET and permethrin, alone or in combination in adult
rats. J Toxicology and Environmental Health 2004; 67: 331-356.
82 McCain WC, Mark RL, Johnson JS et al. Acute oral toxicity study of
pyridostigmine bromide, permethrin, and DEET in the laboratory rat. J
Toxicology and Environmental Health 1997; 50: 113-124.
83 Self-reported exposure to neurotoxic chemical combinations in the Gulf War.
A cross-sectional epidemiologic study. Haley RW, Kurt TL. JAMA. 1997 Jan
15;277(3):231-7.
84 Doug Rokke, PhD. Personal communication September 18, 2007.
85 Clauw D, Groner G, Whalen K. Hypothalamic pituitary adrenal function in
veterans with unexplained illness, compared to fibromyalgia subjects and
controls. Presented at the Conference on Illnesses among Gulf War veterans: A
decade of scientific research. January 24-26, 2001. Alexandria, VA.
86 Zhang Q, Zhou XD, Denny T et al. Changes in immune parameters seen in Gulf
War veterans but not in civilians with chronic fatigue syndrome. Clin Diagn
Lab Immunol. 1999 Jan;6(1):6-13.
87 Haley RW, Billecke S, La Du BN. Association of low PON1 type Q (type A)
arylesterase activity with neurologic symptom complexes in Gulf War veterans.
Toxicol Appl Pharmacol. 1999 Jun 15;157(3):227-33.
88 Kelsall HL, Sim MR, Forbes AB et al. Symptoms and medical conditions in
Australian veterans of the 1991 Gulf War: relation to immunisations and other
Gulf War exposures. Occup Environ Med. 2005 Mar;62(3):142-3. ``Increased
symptom reporting was associated with several exposures, including having
more than 10 immunisations, pyridostigmine bromide tablets, antibiological
warfare tablets, pesticides, insect repellents, reportedly being in a chemical
weapons area, and stressful military service experiences in a strong
dose-response relation.''
89 Rose MR, Sharief MK, Priddin J et al. Evaluation of neuromuscular symptoms
in UK Gulf War veterans: a controlled study. Neurology. 2004 Nov 9;63(9):
1681-7.
90 Wong R, Lopaschuk G, Zhu G et al. Skeletal muscle metabolism in the chronic
fatigue syndrome. In vivo assessment by 31P nuclear magnetic resonance
spectroscopy. Chest. 1992 Dec;102(6):1716-22.
and/or other fundamental changes in body chemistry that can affect multiple
organ systems.
12. WHY HAVE WE NO EFFECTIVE TREATMENT STRATEGIES
16 YEARS AFTER THE END OF THE WAR?
VA Treatment Trials 91 92
The original two VA treatment trials were exorbitantly expensive, particularly
given the number of subjects and cost of the interventions. Failure to conduct
additional treatment studies was rationalized by these trials' high cost.
The mycoplasma/doxycycline trial was a ``failed study'' in that
positive results seen at 3 and 6 months did not carry over to 9 and 12-month
follow-up, possibly due to a high dropout rate. 93 Yet it was not repeated
with a larger number of veterans to reach a definitive conclusion regarding
the benefit of antibiotic treatment.
The cognitive behavioral therapy/exercise trial showed extremely
modest gains and a high dropout rate; these treatments are known to be of
little value in patients with chronic fatigue syndrome, and exercise can make
them worse; yet cognitive behavioral therapy and exercise are primary
treatments recommended for GW veterans, who have a high rate of chronic
fatigue syndrome.
We do not need to continue to examine whether the noxious exposures already
studied can cause GWI. They can, and they did. And we should have expected it.
Some people were genetically more susceptible; some people received more or
larger exposures. The result is that many veterans became chronically ill.
The manner in which DOD and VA pursued GW research was flawed for a variety
of reasons.
A significant amount of research focused on stress or psychiatric
causes of illness.
Certain exposures were studiously avoided as objects of study.
Methodologies chosen were sometimes inadequate to answer the
questions posed.
Exposure data provided by DOD to researchers was not necessarily
accurate.
Funded studies were not selected on the basis of whether they would
lead to a treatment, or to a policy change to protect future soldiers.
Instead, some might suspect the research was designed to avoid uncovering
negative information regarding use of DU, pyridostigmine bromide and anthrax
vaccine.
This review of some GWI research shows that completed research projects have:
confirmed the symptoms of the illnesses;
identified specific neurological deficits in affected veterans and
some of their anatomic/physiologic correlates;
provided partial information on rates of different GW-associated
illnesses; and
furthered our knowledge of the adverse effects caused by some noxious
GW exposures, alone and in combination.
13. WHERE SHOULD THE RESEARCH GO FROM HERE? HOW CAN WE MELD OUR RESEARCH
GOALS WITH THE NEED TO DEVELOP EFFECTIVE TREATMENT STRATEGIES?
Infections (where a treatment payoff could be very large)
Perform conclusive research to determine if GW veterans have
untreated chronic infections. Utilize all modalities including microscopy,
specialized cultures, serology, PCR, etc. Develop new diagnostics when needed,
such as for visceral leishmaniasis.
Also seek novel infections (biological agents), using above
techniques, genetic techniques, monoclonal antibodies, etc.
Perform empiric antibiotic trials in veterans who test positive,
including a repeat trial of antibiotics for veterans with positive mycoplasma
forensic PCR (the test used to screen veterans for the earlier trial).
Value for money
A large number of small, inexpensive pilot studies should be funded
instead of a few large, mainly epidemiologic studies; later give larger grants
to those projects that show the most promise in terms of treatment strategies.
-----
91 Donta ST, Clauw DJ, Engel CC Jr et al. Cognitive behavioral therapy and
aerobic exercise for Gulf War veterans' illnesses: a randomized controlled
trial. JAMA. 2003 Mar 19;289(11):1396-404.
92 Donta ST, Engel CC Jr, Collins JF et al. Benefits and harms of doxycycline
treatment for Gulf War veterans' illnesses: a randomized, double-blind,
placebo-controlled trial. Ann Intern Med. 2004 Jul 20;141(2):85-94.
93 Personal communication with Sam Donta, MD, the Principal Investigator.
Make the grant application process inclusive. Encourage clinicians
who have been caring for GW veterans to participate. Reduce the complexity,
time and cost needed to complete grant applications. Don't restrict VA
research grants to VA employees,
as has been the case: open the process to the best scientists and proposals.
Note the low cost, excellent methodology, analysis and results of
Lea Steele's Kansas veterans study, 94 compared to numerous federally funded
studies that cost at least ten times more and yielded much less information.
Use her strategies as a model for other studies: passion for the subject,
careful use of funds, thoughtful design and analysis.
The selection process for grants must be transparent, which has not
previously been the case.
Promising areas--basic research
The underlying causes of all the multi-symptom syndromes remain unknown. It
is very probable that the molecular and cellular origin of these syndromes
will be the same, although they are likely triggered by a variety of noxious
exposures combined with genetic susceptibility. Because together these
syndromes affect an estimated 6 million Americans, research identifying their
underlying causes will pay enormous dividends, and should point the way to
more effective treatment and prevention strategies.
Gene expression studies have the potential to identify fundamental
physiological processes that have been altered. 95 96 97 Genetic and proteomic
studies of both predisposing gene patterns and protein differences between
affected and unaffected veterans have already shown promise in pilot studies,
98, 99 and should be continued.
Abnormal ion channel function may provide a conceptual and
physiologic bridge between fatigue, neuropathies and motor neuron disorders
like ALS, providing clues to why different disorders develop after similar
exposures. 100, 101 It may also help explain episodic alterations in mental
status, arrhythmias and epileptic seizures in veterans. Maintaining ion
gradients across membranes requires a lot of cellular energy. This can
potentially be improved with supplements that improve intracellular
adenosine triphosphate (ATP) production and oral electrolytes.
Specific studies that could reap valuable rewards
Detailed study of individual families, in which family members have
developed illnesses similar to the ill veteran. An exhaustive search for
microorganisms should be undertaken. Search for DU that may have been present
on items that returned home with the veteran. Seek other toxics in the home
as appropriate to illnesses. Investigate gene expression in these families.
Study illnesses and mortality in selected units that have reported
high death rates; try to recapture their locations, job descriptions and
exposures when deployed.
Collect several hundred very ill GW veterans and perform exhaustive
investigations on them, followed by treatment trials.
Investigate those hypotheses for which researchers were threatened
or forced to end their studies. Investigate the electromagnetic field
strengths and frequencies of all weapons, communications devices and other
equipment that may have been used in the war, and try to determine which
areas or units were exposed and estimate the magnitude of exposure.
-----
94 Steele L. Prevalence and patterns of Gulf War illness in Kansas veterans:
association of symptoms with characteristics of person, place, and time of
military service. Am J Epidemiol. 2000 Nov 15;152(10):992-1002.
95 Cameron B, Galbraith S, Zhang Y, Davenport T, Vollmer-Conna U, Wakefield D,
Hickie I, Dunsmuir W, Whistler T, Vernon S, Reeves WC, Lloyd AR. Dubbo
Infection Outcomes Study. Gene expression correlates of postinfective fatigue
syndrome after infectious mononucleosis. J Infect Dis. 2007 Jul 1;196(1):
56-66.
96 Fang H, Xie Q, Boneva R, Fostel J, Perkins R, Tong W. Gene expression
profile exploration of a large dataset on chronic fatigue syndrome.
Pharmacogenomics 2006 Apr;7(3):429-40.
97 Whistler T, Jones JF, Unger ER et al. Exercise responsive genes measured in
peripheral blood of women with chronic fatigue syndrome and matched control
subjects. BMC Physiol. 2005
98 Baraniuk JN, Casado B, Maibach H et al. A chronic fatigue syndrome-related
proteome in
99 Vladutiu GD and Natelson BH. Association of medically unexplained fatigue
with ACE in-
100 Kuwabara S, Misawa S. Axonal ionic pathophysiology in human peripheral
neuropathy and
101 Chaudhuri A, Watson WS, Pearn J, Behan PO. The symptoms of chronic fatigue
syndrome Mar 24;5(1):5. human cerebrospinal fluid. BMC Neurol 2005; December
1: 5:22. sertion/deletion polymorphisms in Gulf War veterans. Muscle Nerve
2004; 30: 38-43. motor neuron disease. Curr Neurovasc Res. 2004 Oct;1(4):
373-9. are related to abnormal ion channel function. Med Hypotheses. 2000
Jan;54(1):59-63.
The choice of control groups in research is critical to a meaningful
outcome: compare GW veterans with controls who did not receive deployment
vaccines and had demonstrated equivalent health status. Review all research
projects with independent experts prior to funding, to minimize confounding
and bias.
Eight expert committees have made recommendations on the research
studies needed for anthrax vaccine since 1999. 102 Their recommendations are
excellent, and should be followed.
Eight hundred Israeli soldiers received U.S. anthrax vaccine or a
similar Israeli anthrax vaccine several years ago, and dozens have reported
chronic illnesses they believe are related to their vaccinations. 103
Information from this trial should be obtained, along with follow-up
examinations to document what illnesses, if any, have developed and rates of
illnesses.
A clinical trial of various strategies to remove toxic substances
would be extremely useful. Do antioxidants, vitamins, saunas, or other
strategies safely remove toxins after an exposure and lead to better health?
Obtain relevant information from existing government databases
The Army Medical Surveillance Activity has performed many analyses
of its raw data (the Defense Medical Surveillance System) on the health status
of soldiers and GW veterans. These studies were not published, nor are they
easily available. A researcher 104 who filed Freedom of Information Act
requests to learn what was studied, shared 66 pages with approximately 40
study titles listed per page with me. I have filed a Freedom of Information
Act Request for the contents of 60 of these studies that pertain to the health
of Gulf War veterans; my request is pending. Any serious study of Gulf War
veteran health needs to make use of this material and the available military
and VA databases. The Institute of Medicine noted that, ``Analysis of DMSS
data should be the primary approach for investigation of possible AVA (anthrax
vaccine adsorbed)-related health effects of medical significance.'' 105
This should be true of other potential health impacts, in addition to anthrax
vaccine.
VA and military databases, used correctly, can tell us which other
illnesses can be linked to the Gulf deployment, and the strength of the
association, so that appropriate presumptions can be made about the illnesses'
cause; disability decisions can then be made based on presumption.
Independent researchers who gain access to this data to study GWI,
and determine what other illnesses may be linked with the 1991 Gulf War
deployment, should not be subject to the military chain of command nor be VA
employees.
We can learn more about the health risks of toxic GW exposures by
gaining access to data held by Federal agencies. This includes obtaining
information about anthrax vaccine adverse effects from FDA. What in-house
studies or reviews have been done of anthrax vaccine? How has FDA evaluated
the 5,600 adverse event reports, particularly the 670 it judged serious? What
assessment was done of the 44 reported deaths associated with anthrax vaccine?
How is the vaccine tested for safety? (I filed several FOIAs with FDA for this
information since 2001. So far, 99 percent of what I requested was redacted,
and much has never been provided in any form. Yet the material should not have
been withheld according to FDA guidelines (21 CFR 20.61 and 21 CFR 601.51.)
EPA and NIEHS have information about pesticide, heavy metal and
solvent health risks. DOE has information on the makeup and production of
depleted uranium. These sources of information should be explored for their
potential to shed more light on the specifics of the illnesses causes by these
materials.
Anthrax vaccine trials: NIH has data on human trials of failed
anthrax vaccines and CDC has data on its own clinical trial of 1,564 subjects
who received anthrax vaccine since 2002. What adverse events occurred in these
carefully studied groups? What is the current health of the subjects? Late
follow-up could be done on these subjects to evaluate for longer-term adverse
events.
Multiple vaccines: Currently deploying soldiers are receiving
multiple simultaneous vaccinations and should be studied.
The military vaccine healthcare centers have data on over 2,000
soldiers who have become ill after anthrax vaccines. As well as documenting
the illnesses in great detail, the centers have tried a variety of treatment
regimens. Information on
-----
102 http://merylnass.googlepages.com/Selectedfindings.doc.
103 http://www.haaretz.com/hasen/spages/863699.html.
104 Michael Ravnitzky.
105 IOM Committee to Review the CDC Anthrax Vaccine Safety and Efficacy
Program. An Assessment of the CDC Anthrax Vaccine Safety and Efficacy Research
Program. 2003.
the illnesses and the effectiveness of the treatments is extremely relevant
to GW veterans.
14. MY MEDICAL APPROACH TO TREATMENT
GWS is one of medicine's poor stepchildren for many reasons. Patients with
memory and concentration problems require a lot more time and understanding
from both physicians and clinic staff, compared to other patients. They miss
appointments, lose prescriptions, forget the instructions you gave them. They
have an average of eight different problems to address at each visit. They
often have emotional issues. They are at high risk of family breakdown and
economic collapse. Standard medications don't alleviate their symptoms.
Providers may not understand their illnesses nor the context in which they
seek care. They may be suspected as having secondary gain (desiring a
disability pension) as the driver for medical visits. Yet sometimes almost the
only thing the physician can do for the GWI patient is to aid the disability
process by keeping detailed notes.
This syndrome is not described in textbooks. Journal articles may list the
symptoms, but fail to guide clinicians with information on effective
treatments. If the clinician reads the GWI literature, she may come away
confused as to whether there really is a medical illness, and whether she
should transfer the patient to the psychiatric clinic.
There are no standard medical treatments for the chronic effects of exposure
to pesticides, solvents, toxic materials in inhaled smoke, etc. A few doctors
have experimented with various detoxification strategies, 106 107 and some
alternative doctors use these treatments frequently, but they are not proven
to be effective and are not eligible for third party reimbursement.
Medicine is a business. Third party payers use similar visit codes to
reimburse physicians. Treating 4 patients in an hour pays much better than
treating one. The maximal visit code pays for a 40 minute visit. Additional
time spent with the patient will not be reimbursed. Extra time spent by office
staff is not reimbursed. I am fortunate that as a salaried physician, my
employer, Mount Desert Island Hospital, allows me to conduct a specialty
clinic as a community service, even though I could bring in considerably more
fees treating patients with standard illnesses during brief visits. Patients
often travel long distances to see these doctors, who are few and far between.
Thus they need long visits. Few GW veterans can afford to pay out of pocket
for medical care, which is how most doctors who treat multi-symptom syndromes
expect payment, because of the limitations placed on reimbursement
by insurers. Frankly, until the financial disincentive is changed, I doubt
that treatment of GW veterans will improve greatly.
What do I actually do with patients? First, patients complete detailed
questionnaires prior to their visit to help me determine which aspects of the
illnesses are present in their case. Because I am familiar with the features
of the multisymptom syndromes, I know what to look for, ask about, and can
direct treatment to these aspects of the illness. For example:
Are they sensitive to odors (especially diesel exhaust), fluorescent
lights or foods?
What happens when exposed to these things?
Do they have intermittent episodes of confusion?
Do they balance their own checkbook?
How is their driving?
How is their GI tract function?
How do they sleep? Has their partner noticed pauses in breathing?
Do they have chronic pain? Where? What exacerbates or relieves it?
What kind of activity can they perform? For how long? What makes them
stop?
Do they have rashes?
How is their breathing?
How is their libido and sexual function?
Is there mold, or are there other substances at home or elsewhere
that increase symptoms?
If they have developed multiple chemical sensitivity (which seems to be present
in about 40 percent of GWS patients), I help them identify the odors that provoke
symptoms so they can avoid them. I prescribe elimination diets to identify foods that
-----
106 Krop J. Chemical sensitivity after intoxication at work with solvents:
response to sauna therapy. J Altern Complement Med. 1998 Spring;4(1):77-86.
107 Kilburn KH, Warsaw RH, Shields MG. Neurobehavioral dysfunction in firemen
exposed to polycholorinated biphenyls (PCBs): possible improvement after
detoxification. Arch Environ Health. 1989 Nov-Dec;44(6):345-50.
trigger symptoms. I order tests to rule out other causes of symptoms, such as
muscle diseases, standard autoimmune conditions, thyroid disease, anemia, etc.
I may order sleep studies. Some patients may get a muscle biopsy or other
specialized tests. Stools are cultured and endoscopy performed when indicated.
I then address treatment for each symptom individually, since we cannot
currently address underlying causes. However, I additionally try to optimize
patients' overall metabolic function with diet, vitamins and supplements
designed to increase cellular energy and provide substrates for important
intracellular molecules such as NADH, glutathione, ATP. Antioxidants may also
be helpful. Most veterans cannot afford this treatment, however. Vitamins and
supplements are not covered by insurance, although they are usually much
cheaper than prescription medications.
Hopefully, clinical trials will demonstrate whether these approaches improve
health, and if so, perhaps the VA will make vitamins and supplements available
to GW veterans.
I treat the sleep disorder, diarrhea, pain, low hormone levels, or whatever
other symptoms are present. I try one treatment after another, since there are
many adverse reactions to medications, and it is often difficult to predict
which medicines are likely to be effective. Usually, you can improve sleep
considerably, but energy only a little. You can improve pain. The diarrhea can
resolve, though it may return later. Sometimes sex hormones improve sexual
function, but often they do not. Thyroid hormone may provide a modest energy
boost. Autonomic dysfunction may be treated with increased salt and water
intake, drugs and/or hormones to raise blood pressure, and electrolytes. If
you are very lucky, cognition may improve.
The doctor-patient relationship, and lifestyle coaching, may be equally as
important as medications. Patients need to know you are their partner, not a
representative of a system they fear is pitted against them. I warn them that
marital difficulties should be expected. I prefer their partners to attend
visits, and am happy to answer partners' questions. Treating psychological
problems may be helpful, but veterans are sensitive that such treatment is a
denial they have physical illness. I explain that they have real medical
illness, and may give them an article or book on GWS that describes the
resulting psychological and physical symptoms, to help them understand their
disorder. I may refer to other therapists. I suggest that people
with limited mental and physical energy reserve their most challenging tasks
for when they feel most rested. I may advise them not to drive alone.
With this treatment, I estimate a veterans's overall function can improve
30-40 percent and sometimes more. But it is a piecemeal, palliative,
symptom-based approach that does not provide a cure. It also requires highly
intensive care. A list of many of the treatments I employ was provided to the
VA Research Advisory Committee and listed on my web site at:
http://www.anthraxvaccine. org/gulfwartreatment.htm.
I greatly appreciate this opportunity to share my knowledge and opinions with
the Committee.
I would also like to express my appreciation to Walter Schumm, Ph.D., Garth
Nicolson, Ph.D., and affected Gulf War veterans Doug Rokke, Ph.D., Joyce
Riley, R.N. and Kirt Love for sharing materials on GWS that were used in this
presentation. My deepest thanks also to Lt. Col. John Richardson, retired Air
Force GW veteran (still healthy), who has worked tirelessly to improve the
condition of his fellow GW veterans and anthrax vaccine-injured soldiers.
Senator MURRAY. Thank you very much, Dr. Nass.
Dr. Steele?
STATEMENT OF LEA STEELE, PH.D., SCIENTIFIC DIRECTOR,
RESEARCH ADVISORY COMMITTEE ON GULF WAR
VETERANS' ILLNESSES, AND ASSOCIATE PROFESSOR,
KANSAS STATE UNIVERSITY
Dr. STEELE. Good morning. I am Dr. Lea Steele. I am an epidemiologist
and have conducted research on the health of Gulf War
veterans for the past 10 years. I am now privileged to serve as Scientific
Director of the Research Advisory Committee on Gulf War
Veterans' Illnesses. This Federal advisory body of distinguished scientists
and veterans was mandated by Congress to review the scientific
research on the health of Gulf War Veterans. Our members
include Dr. Roberta White, who will be speaking later, other distin-
guished and leading experts, a former president of the American
Association for the Advancement of Science, and the head of CDC's
Neurotoxicology Laboratory. Our Committee chair, Mr. Jim Binns,
will also be testifying.
Our Committee has now reviewed the extensive amount of scientific
research on the health of Gulf War veterans. We will be releasing
a major report on Gulf War illness in the next several
months, but my purpose today is to share with you some of the
highlights of what the Committee has learned in the course of our
scientific work.
First, I think it is important to distinguish between Gulf War illness
and other conditions connected to the Gulf War. By Gulf War
illness, we mean the complex of symptoms that you have heard
about that affect Gulf War veterans at high rates but are not explained
by standard medical diagnoses or medical tests. Veterans
with Gulf War illness typically have some combination of severe
headaches, memory and cognitive problems, persistent pain
throughout the body, and profound fatigue. Other difficult problems
include GI symptoms. We know veterans who have had diarrhea
for 16 years. Respiratory problems are also common, as well as unusual
skin lesions.
This condition we refer to as Gulf War illness, then, is distinct
from other diagnosed conditions that are associated with service in
the Gulf War. Among these other diagnosed conditions are ALS, or
Lou Gehrig's disease, which a large VA study has found affects
twice as many Gulf War veterans as other veterans of that period.
Brain cancer is also now a Gulf War health issue.
You may be familiar with the chemical weapons incident near
Khamisiyah, Iraq in March 1991. The Pentagon has estimated that
as many as 100,000 U.S. troops were potentially exposed to lowlevel
nerve agents when a large weapons depot containing sarin
and cyclosarin was destroyed. Recent studies have identified diverse
neurological problems in relation to that incident, including
that veterans downwind from the demolitions have died from brain
cancer at twice the rate of veterans in other areas of theater.
There may also be other problems with other diagnosed diseases,
but studies are lacking. Our Committee has recommended studies
to assess rates of multiple sclerosis, Parkinson's disease, and other
conditions in Gulf War veterans. All of these issues are important,
but in truth, far fewer Gulf War veterans have ALS or brain cancer
than the very large number with Gulf War illness, so I will focus
now on what we have learned from the many, many scientific studies
of this condition. Here are just some of the highlights.
First, I just want to underscore the point that Gulf War illness
is real and it affects a large number of veterans. You may have
heard in media stories or from government agencies that there is
no Gulf War illness or no ``unique Gulf War syndrome.'' That is just
not true.
There is unquestionably a condition that resulted from the 1991
Gulf War, documented in study after study of Gulf War veterans
very consistently from around the United States. No studies have
found otherwise. The ``no unique syndrome'' comment means different
things to different people and is more of a semantic point
about what does or does not constitute a unique syndrome. Our
Committee has not considered it particularly important if this condition
is called a unique syndrome. The point is that a lot of veterans
are sick with a condition caused by their service in the Gulf
War.
How many are sick? Well, as you have heard earlier today, studies
find that between 25 and 30 percent of Gulf War veterans have
this condition in relation to their service in the war. So that means
that Gulf War illness affects between 175,000 and 200,000 of the
700,000 Americans who served in the Gulf War.
Next, Gulf War illness was not caused by psychological stress.
The most comprehensive and well-analyzed studies have found no
connection between Gulf War illness and serving in combat. In fact,
psychiatric conditions like PTSD are much lower in Gulf War veterans
than veterans of other wars, and this stands to reason since
unlike current deployments severe trauma was relatively uncommon
in the 1991 Gulf War. A decisive victory was achieved after
6 weeks of air strikes and a ground war that lasted just 4 days.
Most troops did not see combat and were never in areas where battles
took place.
So what did cause Gulf War illness? Many different Gulf War exposures
have been suggested. These include the smoke from over
600 burning Kuwaiti oil wells, multiple vaccines, depleted uranium
munitions, and chemical weapons. The most consistent evidence
implicates a group of chemicals that can have toxic effects on the
brain. These chemicals include the little white pills called
pyridostigmine bromide that were given to troops to protect them
from the effects of nerve agents. Also, excessive use of pesticides
and low levels of nerve gas in theater. Some of these neurotoxic
chemicals have a similar type of action. They affect a single brain
chemical, the neurotransmitter acetylcholine. Studies also show
that these brain toxins can act synergistically. Combined exposures
are worse than any single exposure by itself.
And last but certainly not least, effective treatments for Gulf
War illness are urgently needed. Studies show that few veterans--
and there have now been four longitudinal studies--few veterans
with Gulf War illness have recovered or even substantially improved
over time. As a result, many Gulf War veterans have been
sick for as long as 16 years. Effective treatments for Gulf War illness
have not been found. Very few have even been studied. Our
Committee continues to give highest priority to research that leads
to effective treatments for Gulf War illness.
So in short, Gulf War illness is real, it is serious, and it is still
widespread in veterans of the 1991 Gulf War. It is not the result
of psychological stress and it is not the same thing that happens
after every war. Scientific progress has certainly been made in understanding
the big picture questions about Gulf War illness. The
Research Advisory Committee believes that remaining questions
can and must be addressed, particularly identification of treatments.
Thank you.
[The prepared statement of Dr. Steele follows:]
PREPARED STATEMENT OF LEA STEELE, PH.D., SCIENTIFIC DIRECTOR, RESEARCH
ADVISORY COMMITTEE ON GULF WAR VETERANS' ILLNESSES; ASSOCIATE PROFESSOR,
KANSAS STATE UNIVERSITY
Good morning and thank you for inviting me today. I'm Dr. Lea Steele, an
epidemiologist and associate professor at Kansas State University. I have
conducted research on the health of Gulf War veterans for the past 10 years
and am privileged to serve as Scientific Director of the Research Advisory
Committee on Gulf War Veterans' Illnesses. This public advisory body of
distinguished scientists and veterans was mandated by Congress and charged
with reviewing scientific research on the health of Gulf War Veterans. Our
members include Dr. White, who will be testifying today, other leading
experts, a former president of the American Academy for the Advancement of
Science, and the head of CDC's Molecular Neurotoxicology Laboratory. The
Committee Chair, Mr. Jim Binns, will also be testifying today.
The Committee has now reviewed and assessed the extensive amount of scientific
research and government investigations on the Gulf War and the health of Gulf
War veterans. We will release a major report on Gulf War illness in the next
several months. My purpose today is to share with you some highlights of what
the Committee has learned in the course of our scientific work.
First, I want to distinguish between the condition known as Gulf War illness
and other health issues related to the 1991 Gulf War. By Gulf War illness I am
referring to the multi-symptom condition that affects Gulf War veterans at
high rates, but is not explained by standard diagnoses or medical tests.
Veterans with Gulf War illness typically experience some combination of severe
headaches, memory and concentration problems, persistent pain throughout the
body, and profound fatigue. Other difficult symptoms include gastrointestinal
problems--we know veterans who have had diarrhea for 16 years. Respiratory
problems are also common, and unusual skin lesions and rashes. Gulf War
illness is real, it was not caused by stress, it is not the same thing that
happens after every war, and it is widespread among Gulf War veterans.
There are also other health issues related to Gulf War service. These include
ALS, or Lou Gehrig's Disease, which a large VA study has shown affects twice
as many Gulf War veterans as other veterans of that period. Brain cancer has
also become a Gulf War health issue. You may be familiar with a well-known
incident near Khamisiyah, Iraq, in March 1991. The Pentagon has estimated that
about 100,000 U.S. military personnel were potentially exposed to low-level
nerve agents with the destruction of a large weapons depot that contained
sarin and cyclosarin. Recent studies have identified diverse neurological
problems in relation to that incident, including findings that veterans
downwind from the demolitions have died from brain cancer at twice the rate of
veterans in other areas of theater.
There may also be problems with other diagnosed diseases, but studies are
lacking. The Research Advisory Committee has recommended studies to assess
conditions such as multiple sclerosis, Parkinson's disease, and cancer in Gulf
War veterans. All of these issues are important, but far fewer Gulf War
veterans have ALS or brain cancer than the very large number affected by Gulf
War illness. So I will focus now on what we have learned from the many
scientific studies on this condition. Here are some of the highlights:
Gulf War illness is real and affects a large number of veterans. You
might have heard in media stories or from government agencies that there is no
Gulf War illness or no ``unique Gulf War syndrome.'' There is unquestionably a
condition that resulted from service in the 1991 Gulf War, documented in
epidemiologic studies of Gulf War veterans from around the U.S. and some
allied countries. No studies have found otherwise. The ``no unique syndrome''
comment refers more to a semantic point about what does or does not constitute
a ``unique syndrome.'' Our Committee has never considered it particularly
important whether the condition is or is not called a unique syndrome. The
point is that a lot of veterans are sick with a condition
caused by their service in the Gulf War.
How many are sick? Studies consistently find that 25-30 percent of Gulf War
veterans have this condition, in relation to their service in the war. This
includes VA's most recent large follow-up study. That means that Gulf War
illness affects between 175,000 and 200,000 of the 700,000 Americans who
served in the Gulf War.
Gulf War illness was not caused by psychological stress. The most
comprehensive and well-analyzed studies have found no connection between Gulf
War illness and serving in combat. In fact, rates of psychiatric conditions
like PTSD are considerably lower in Gulf War veterans than veterans of other
wars. This stands to reason since, unlike current deployments, severe trauma
was relatively uncommon in the 1991 Gulf War. A decisive victory was achieved
after 6 weeks of intensive air strikes and a ground war that lasted just 4
days. Most troops did not see combat and were never in areas where battles
took place.
Research studies consistently identify links between Gulf War illness
and neurotoxic chemicals. Many different Gulf War exposures have been
suggested as causes of Gulf War illness. These include the smoke from over 600
burning Kuwaiti oil wells, multiple vaccines, depleted uranium munitions, and
low-dose exposure to chemical weapons.
The most consistent and extensive evidence implicates chemicals that can have
toxic effects on the brain. These chemicals include pills (pyridostigmine
bromide, or PB) that were given to protect troops from effects of nerve
agents, excessive use of pesticides, and low levels of nerve gas in theater.
Many of these chemicals have a similar type of action; they affect levels of a
particular brain chemical, the neurotransmitter acetylcholine. Studies also
show that these brain toxins can act synergistically, that is, combined
exposures are worse than any single exposure by itself.
A link between Gulf War illness and neurotoxic chemicals is also compatible
with what we know from studies of biological abnormalities in Gulf War
veterans. Diverse studies have identified abnormalities in the brain and the
autonomic nervous systems of sick Gulf War veterans, using different types of
sophisticated brain scans and other testing methods.
Effective treatments for Gulf War illness are urgently needed.
Studies show that few veterans with Gulf War illness have recovered or even
substantially improved over time. As a result, many Gulf War veterans have
been sick for as long as 16 years. Effective treatments for Gulf War illness
have not been found--very few have even been studied. The Research Advisory
Committee continues to give highest priority to research that leads to
effective treatments for sick Gulf War veterans.
In short, Gulf War illness is real, it is serious, and it is still widespread
among veterans of the 1991 Gulf War. It is not the result of psychological
stress and is not the same thing that happens after every war. Progress has
been made in understanding ``big picture'' questions about Gulf War illness.
The Research Advisory Committee believes that remaining questions can and must
be addressed. It is our obligation, not only to assist 1991 Gulf War veterans
who are still sick as a result of their wartime service, but also to ensure
that similar problems do not affect future American troops deployed to war.
Senator MURRAY. Thank you, Dr. Steele.
Dr. White?
STATEMENT OF ROBERTA WHITE, PH.D, PROFESSOR AND
CHAIR, DEPARTMENT OF ENVIRONMENTAL HEALTH,
BOSTON UNIVERSITY SCHOOL OF PUBLIC HEALTH
Dr. WHITE. Thank you, Senator Murray, and thank you for inviting
me to describe research on Gulf War illnesses here this morning.
In your written testimony, you have a description of my credentials
and research funding history, so I won't go over that. But
briefly, I have been studying Gulf War illnesses since 1993 and was
research director of one of the three initial VA-funded centers on
Gulf War illness. Shortly after the Gulf War, VA's Central Office
contacted the VA Boston Health Care System about the fact that
Gulf War veterans were returning with unusual symptoms. They
asked some of us to look into the problem.
Our approach was to examine all of the possible factors that we
could think of that might explain the appearance of unexplained
illnesses in Gulf War veterans. Our major study population was a
group of about 3,000 veterans who had been surveyed when they
returned from the war through Fort Devens, Massachusetts. We
studied health symptoms, Post Traumatic Stress Disorder, milder
experiences of stress related to deployment, psychiatric disorders,
and hazardous exposures experienced by Gulf War veterans.
One of our findings was that veterans who reported pesticide and
chemical warfare agent exposure performed worse on objective
tests of intellectual skills and had higher mood complaints than
veterans who did not report these exposures. This suggested that
these Gulf War exposures were associated with changes in brain
function. Since we had the data on Post Traumatic Stress Disorder,
stress levels, psychiatric disorders, and purposeful failure of tests
for our study group, we were able to rule out these factors as explaining
the findings on the behavioral test measures. This led us
to believe that environmental exposures in the Gulf might explain
some of the problems that veterans were experiencing.
We wanted to study the question of brain changes more directly,
so we began using newly available brain imaging techniques. These
techniques allow quantification of the sizes of brain structures. We
also wanted to utilize new data that provided estimates of actual
exposures in the theater.
For two studies, we used data from DOD that modeled the
amount of sarin/cyclosarin exposure experienced by troops in the
Khamisiyah area described by Dr. Steele over a 4-day period. We
had brain scans or data from performance on standardized behavioral
tests for individuals under the plume at Khamisiyah and the
same data for veterans who were in locations where nerve gas
agents are thought not to have been present. We analyzed the relationship
between degree or dose exposure to sarin/cyclosarin and
outcomes on the brain scans and the performance tests. Our results
showed that there was a dose effect relationship between degree of
exposure to nerve gas agents and adverse outcomes. For example,
higher exposure was associated with smaller measurements of the
volume of white matter in the brain. It was also associated with
poor performance on a test of hand dexterity and speed while completing
a pegboard task. Senator Sanders gave you a little review
of some of this.
In another study, we carried out brain imaging and a brief set
of behavioral tests on Gulf War veterans who differed in the number
of health symptoms they were experiencing. The object was to
compare high- and low-symptom groups. We are still analyzing the
outcomes from this research. However, results to date suggest that
certain brain structures are smaller in Gulf War veterans with
higher numbers of symptom complaints than in veterans with few
complaints. For example, a portion of the cingulate gyrus was
smaller in the high-symptom veterans. This brain structure is involved
in memory function.
There has been widespread dismissal of Gulf War veterans'
health complaints as being psychiatric or imagined. However, the
data from our studies combined with increased rates of ALS and
brain tumors described by Dr. Steele provide objective evidence of
brain damage among Gulf War veterans. This damage appears to
range from subtle effects on brain structure and function to clinical
disease.
The greater definition of objective outcomes and possible outcomes
of Gulf War symptoms 16 years after the war is not unexpected.
It parallels the identification of critical factors in illnesses
in other populations. For example, as Senator Murray mentioned,
almost 20 years passed before Agent Orange exposure was linked
to certain health outcomes in Vietnam veterans.
The research described from our group in Boston and from other
groups points to the nervous system as the key determinant of Gulf
War-related health problems. It is essential to consider the diagnostic
and treatment implications of this research. I believe that
concerted planning for treatments should begin immediately.
Thank you for listening to my perspectives on this issue.
[The prepared statement of Ms. White follows:]
PREPARED STATEMENT OF ROBERTA F. WHITE, PH.D., MEMBER, RESEARCH ADVISORY
COMMITTEE ON GULF WAR VETERANS' ILLNESSES; PROFESSOR AND CHAIR,
DEPARTMENT OF ENVIRONMENTAL HEALTH BOSTON UNIVERSITY SCHOOL OF PUBLIC
HEALTH
Good morning, and thank you for asking me to describe my research with Gulf
War veterans to you. I am Roberta White, professor and chair of the Department
of Environmental Health at the Boston University School of Public Health.
With a large group of colleagues from many fields, I began studying Gulf War
veterans and their health problems in 1993 and was research director and
principal investigator for one of the initial three centers funded by the
Department of Veterans Affairs to study Gulf War-related illnesses. I have
received funding as principal investigator or co-principal investigator for
several successive grants to study Gulf War-related illnesses; I was fortunate
to have this work supported by VA, the Department of Defense, and the Centers
for Disease Control. For many years I was a member of the Federal inter-agency
committee on Gulf War illnesses. I have also seen Gulf War veterans as a
clinician at VA, where I was a staff neuropsychologist before taking my
current job.
Over the years of my career as a scientist, I have studied how chemicals and
environmental hazards affect the functioning of the human brain. In Boston, we
approached the problem of symptoms and illnesses in Gulf War veterans by
investigating the relationships between exposures to hazardous chemicals and
conditions in the Gulf War theater and health outcomes. In this research, we
have used brain imaging and behavioral tests as ways of understanding
abnormalities in brain function that may be seen in Gulf War veterans. This
work culminated recently in the publication of two papers focusing on Gulf War
veterans who were in the vicinity of Khamisiyah at the time of the detonation
of the weapons depot there and a neurology meeting abstract on brain imaging
differences between Gulf War veterans with high and low symptom complaints.
The two papers that summarize our work on exposures experienced by troops
during the Khamisiyah detonation used data from DOD that modeled the amount of
exposure to sarin and cyclosarin nerve gas agents among troop units located
around Khamisiyah over a 3-day period. We had brains scans or data from
performance on standardized tests of hand dexterity and intellectual function
from individuals under the plume in Khamisiyah and from some who were in
locations where nerve gas agents are thought to have been absent. We analyzed
the relationship between degree or ``dose'' exposure to sarin/cyclosarin,
ranging from none to a level above the recommended minimal daily exposure
level, and outcomes on the brain scans and performance tests. Our results
showed that there was a dose-effect relationship between degree of exposure to
nerve gas agents and adverse outcomes on the brain scans and behavioral tests.
For example, higher exposure was associated with smaller measurements of the
volume of white matter in the brain and with poorer performance
on a test of hand dexterity and speed while completing a pegboard task.
The neurology meeting poster presentation featured initial results from a
study that has just been completed and for which we are still analyzing
outcomes. The results suggested that certain brain structures are smaller in
Gulf War veterans with higher numbers of symptom complaints than in veterans
with few symptoms. For example, an area of the cingulate gyrus, which is
involved in memory function, was smaller in the high-symptom veterans.
There has been widespread dismissal of Gulf War veterans' health complaints as
being ``psychiatric'' or imagined. However, the data from our studies,
combined with the increased rates of ALS and brain tumors described by Dr.
Steele, provide objective evidence of brain damage among Gulf War veterans.
This damage appears to range from subtle effects on brain structure and
function to clinical disease.
The greater definition of objective outcomes and possible causes of Gulf
War-related symptoms 15 years after the war is not unexpected and parallels
the identification of critical factors in illnesses among other veteran
populations. For example, almost 20 years passed before Agent Orange exposure
was linked to certain health outcomes in Vietnam veterans.
Given the role of the nervous system in their symptomatic complaints and the
appearance of neurological illnesses in Gulf War veterans, it is essential to
consider the diagnostic, treatment, and intervention implications of the
research that I have described. I believe that concerted planning for
treatment interventions should begin immediately. It should focus on
neurological symptoms, including diminished energy; strategies aimed at
enhancing brain function, including thinking, memory and mood; and approaches
to neuro-immunological and auto-immune dysfunction.
Thank you for listening to my perspectives on the serious issue of continued
ill health among our Gulf War veterans.
Senator MURRAY. Thank you, Dr. Wright.
Mr. Binns, we will turn to you.
STATEMENT OF JAMES BINNS, CHAIRMAN, RESEARCH
ADVISORY COMMITTEE ON GULF WAR VETERANS' ILLNESSES
Mr. BINNS. Madam Chairman, Ranking Member Burr, Members
of the Committee, for the past 5 years, it has been my privilege to
serve as Chairman of the Research Advisory Committee on Gulf
War Veterans' Illnesses. I am honored to address your Committee,
which includes so many who have championed the cause of ill Gulf
War veterans for so long.
Let me begin with the conclusion of the extensive 1998 report on
Gulf War illnesses of the Committee on Veterans' Affairs, on which
many of you served. ``The most important thing that VA and DOD
can now do is to provide timely, accessible, and appropriate treatment
to Gulf War veterans with these illnesses and attempt to prevent
such illnesses in future deployments.''
It is now 9 years later, 16 years after the war. As you have
heard, 175,000 veterans, one in four of those who served, remain
seriously ill. There are still no effective treatments. Those who are
most ill have developed neurodegenerative diseases and brain cancer.
And American military personnel and civilians remain at risk
of similar exposures. Reuters reported last week on the test of a
sarin warhead by Syrian and Iranian engineers, and I remember
the Tokyo sarin subway attacks each time I board the Washington
Metro.
The Federal Government has spent over $300 million on Gulf
War illnesses research. Some of that research was productive, as
you have heard. But much was spent on psychological stress, part
of a deliberate effort to downplay these illnesses as the sort of
thing that happens after every war rather than the result of toxic
exposures. Only two treatment studies have ever been conducted,
with negligible results. This is a tragic record of failure and the
time lost can never be regained.
I am pleased to report, however, that new programs are finally
underway to address the needs you identified in 1998. At VA, Secretary
Nicholson appointed new leadership at the Office of Research
and Development, and at the initiative of Senator Hutchison
of this Committee, Congress added $15 million to the VA budget
for Gulf War illnesses research and VA has contracted with the
University of Texas-Southwestern to launch a Manhattan-style
project to discover diagnostic markers and treatments.
The Department of Defense, however, has historically funded
over two-thirds of Gulf War illnesses research, in excess of $30 mil-
lion annually. Since the start of the current war, this program has
been eliminated.
In 2006, led by Senator Sanders while a Member of the House,
Congress initiated an innovative new pilot program at DOD focused
on studies of promising treatments already approved for
other illnesses. It is open to all researchers. The success of this program,
which attracted 80 proposals, demonstrates the interest of
the scientific community in solving this problem, and I hope that
you will ask to hear more about it from the second panel and in
particular Colonel Janet Harris, who is the commander of the program
and who is here today supporting it.
DOD officially, however, has again excluded this program from
its 2008 budget. I urge you all to support the effort of Senator
Sanders to support this proven and critical program to the $30 million
level.
Thus, while promising research programs are at last in place,
they only exist because of the leadership and support of Congress.
Indeed, at the same time as dedicated VA scientists and DOD scientists
are working on these problems, VA and DOD public statements
continue to minimize these illnesses at every opportunity,
misleading Congress and the scientific community.
For example, a so-called fact sheet recently provided by VA to
Senators Rockefeller, Murray, and Bond asserted that ``Gulf War
veterans suffer from a wide range of common illnesses which might
be expected in any group of veterans their age.'' That, as you have
heard, is garbage. You are going to hear more of the same from the
DOD spokesman later this morning. It is the big lie. It just isn't
true.
Thus, I enthusiastically welcome this hearing and beseech the
Committee's close attention to Gulf War illnesses research as these
promising but fragile new programs begin to grow and bear fruit.
They depend upon your support and your oversight. Otherwise, you
will find them dead on the weed pile, and the critical needs you
identified in 1998, treatments for ill veterans and victims of future
attacks, ever more urgent today but no closer to reality, will remain
empty words.
[The prepared statement of Mr. Binns follows:]
PREPARED STATEMENT OF JAMES BINNS, CHAIRMAN,
RESEARCH ADVISORY COMMITTEE ON GULF WAR VETERANS ILLNESSES
Mr. Chairman, Ranking Member Burr, Members of the Committee, for the past
5 years, it has been my privilege to chair the Research Advisory Committee on
Gulf War Veterans Illnesses. I am honored to address your Committee, which
includes so many who have championed the cause of ill Gulf War veterans for so
long.
Let me begin with the conclusion of the extensive 1998 report on Gulf War
illnesses of the Committee on Veterans' Affairs, on which many of you served:
``[T]he most important thing that VA and DOD can now do is to provide timely,
accessible and appropriate treatment to Gulf War veterans with these illnesses
. . . and attempt to prevent such illnesses in future deployments.''
It is now 9 years later, 16 years after the war. According to the Department
of Veterans Affairs most recent study, 25 percent of Gulf War veterans suffer
from chronic multi-symptom illness above the rate in other veterans of the
same era. Thus, sixteen years after the war, 175,000 veterans--one in four of
those who served--remain seriously ill. There are still no effective
treatments. Those who are most ill have developed neurodegenerative diseases
and brain cancer. And American military personnel and civilians remain at risk
of similar exposures. Reuters reported last week on the test of a sarin
warhead by Syrian and Iranian engineers, and I remember the Tokyo sarin subway
attack each time I board the Washington Metro.
The Federal Government has spent over $300 million on Gulf War illnesses
research. Some of that research was productive, as you have heard from Dr.
Steele and Dr. White. But much of the money was misspent on the false theory
that these illnesses were caused by psychological stress, part of a deliberate
effort to downplay these illnesses as the sort of thing that happens after
every war, rather than the result of toxic exposures. Only two treatment
studies have ever been conducted, neither with significant results.
This is a tragic record of failure, and the time lost can never be regained.
I am pleased to report, however, that new programs are finally underway to
address the needs you identified in 1998. At VA, former Secretary Principi
determined that VA would no longer fund studies based on stress, and Secretary
Nicholson appointed new leadership at the Office of Research and Development.
At the initiative of Senator Hutchison of this Committee, Congress added $15
million to the VA research budget for Gulf War illnesses research, and VA has
contracted with the University of Texas, Southwestern Medical Center, a
leading site of Gulf War illnesses research, to launch a Manhattan-style
project to discover diagnostic markers and treatments. I am extremely pleased
to see VA Gulf War illnesses research at last in the hands of scientists
committed to solving the problem.
The Department of Defense, however, has historically funded over two-thirds of
Gulf War illnesses research, in excess of $30 million annually. Since the
start of the current war, this program has been eliminated.
In 2006, led by Senator Sanders while a Member of the House, Congress
initiated a new pilot program for Gulf War illnesses research at DOD. This
innovative program gives priority to studies of existing treatments already
approved for other illnesses, and so offers the possibility of identifying
treatments that could be put to immediate use. It is open to all researchers,
inside or outside of government, through peer-reviewed competition, and is
administered by the Congressionally Directed Medical Research Program.
The success of this pilot program, which attracted eighty proposals,
demonstrates the interest of the scientific community in solving this problem.
DOD, however, has again excluded the program from its proposed 2008 budget. I
urge you all to support the effort of Senator Sanders and several other
Members of this Committee to restore this proven program at the $30 million
level consistent with the recommendations of the Research Advisory Committee.
Thus, while promising research programs are at last in place, they only exist
because of the leadership and support of Congress. Indeed, at the same time as
dedicated scientists at VA and DOD are working on these programs, VA and DOD
public statements continue to follow the timeworn script and minimize these
illnesses at every opportunity, misleading Congress and the scientific
community. For example, a so-called ``fact sheet'' provided by VA in May to
Senators Rockefeller, Murray, and Bond asserted that ``Gulf War veterans
suffer from a wide range of common illnesses, which might be expected in any
group of veterans their age.'' That, as you have heard, is garbage.
This fact sheet is the work of the VA Office of Public Health and
Environmental Hazards, the same office which refuses to update the stress-oriented
clinical guidelines on Gulf War illness provided to VA doctors. It is also the
office charged with implementing the law requiring VA to contract with the
National Academy of Sciences' Institute of Medicine for reports on the health
effects of toxic exposures, for use in benefits determinations. For 7 years
these reports have been structured to restrict scientific information
considered in their conclusions, in express violation of the statute. This
government manipulation of science and violation of law to devalue
the health problems of ill veterans is something I would not have believed
possible in this country until I took this job. Until this practice is
stopped, the products of Gulf War illnesses research will be distorted,
misleading the Secretary, Congress, veterans' doctors, and the scientific
community.
In view of these obstacles, I enthusiastically welcome this hearing and
beseech the Committee's close attention to Gulf War illness research as these
promising but fragile new research programs begin to grow and bear fruit. They
depend upon your support and oversight. Otherwise you will find them dead on
the weed pile, and the critical needs you identified in 1998--treatments for
ill veterans and victims of future attacks . . . ever more urgent today but no
closer to reality--will remain empty words.
Senator MURRAY. Mr. Binns, thank you very much, and thank
you to all of our panelists today for your compelling testimony.
Julie Mock, let me just begin by telling you thank you so much
for what you have done for our country. You have done your job
and served us all well and I can only imagine how difficult it has
been for you since your service, for both you and your children and
all of your family and the impacts that have occurred to you.
As someone who served this country and put her life on the line
for all of us, do you feel that our government has met its obligations
and commitments to your family?
Ms. MOCK. No. Clearly, they haven't. Gulf War veterans still are
struggling as they go to the VA to be connected for their services.
The VA has been dismissive historically. Gulf War veterans, for example,
who are being diagnosed with multiple sclerosis are being
told that they no longer have multiple sclerosis and dismissed from
the MS Centers of Excellence without any appropriate protocol for
follow-up. That is one good example that I can share with you.
Senator MURRAY. What kind of message do you think this sends
to future generations of military?
Ms. MOCK. The government won't be there. There are a lot of
hollow promises. Our soldiers enlist or commit themselves to the
military and they are not going to have anything when they come
back. If they are ill or they are injured, I don't think they believe
they are going to be cared for when they come back.
Senator MURRAY. Thank you, and I think that is a serious concern
to all of us. It should be to all of America, and I appreciate
that. And one last question for you. You and I have talked many
time about multiple sclerosis. You were diagnosed with MS how
long after you had been back?
Ms. MOCK. I began experiencing symptoms about 3 years after
I returned, but I wasn't diagnosed until 2003.
Senator MURRAY. Many of our Gulf War veterans that have been
diagnosed with MS are running into an arbitrary time limit that
the VA has, that you have to be diagnosed within 7 years, correct,
of your service?
Ms. MOCK. You have to prove that you had symptoms within 7
years of discharge.
Senator MURRAY. I know you have a wide network of people who
you have been working with on this, and for many of them, is it
not true that it is very difficult for them to get that diagnosis and
they miss the deadline and, therefore, are not covered?
Ms. MOCK. It is very difficult for them to prove that the symptoms
began within 7 years. So by 1998, they should have been
showing symptoms, and it is not that they only needed to have
symptoms, but they needed to have documentation of the symptoms
and that is very difficult for many people to do. Symptoms for
multiple sclerosis start out very mild many times, the dizziness,
the coordination, the paresthesia, and it is difficult to pinpoint.
Senator MURRAY. Which is why I share with my Committee
Members why I have introduced legislation to remove that 7-year
time limit, because very often, it is very difficult to diagnose, and
if it is done after 7 years, then it is not VA-connected and a lot of
our men and women who served in the Gulf War and in previous
conflicts end up not being served well. So I appreciate all your
work on that, Julie.
Ms. MOCK. I would like to interject, also, that many of the symptoms
of Gulf War illness overlap with multiple sclerosis symptoms.
Senator MURRAY. Dr. Nass, you mentioned in your testimony
that a number of physicians at the VA believe that Gulf War illness
doesn't exist, it is psychosomatic, it is caused by stress. Do
you believe that this is the result of genuine difference of opinion
about the cause of the illness or simply the refusal to accept what
seems to be a mounting pile of evidence that a legitimate illness
exists?
Dr. NASS. I think it is a combination of things. I think, first, the
clinicians at the VA have not been well trained. My ex-husband
was, in fact, the Gulf War doctor at one of the VA hospitals and
shared with me the training materials he was given. Again, they
focused on stress and psychological issues and treatment of headache
and treatment of psychological problems.
As I told the House two months ago, I was surprised to get a new
patient in July who told me his VA doctor did not believe in Gulf
War syndrome.
Senator MURRAY. Did not believe in Gulf War syndrome?
Dr. NASS. That is correct. I think that is a problem. The literature
is so confusing. There has not been a good review article
about Gulf War Syndrome and so the medical profession is confused,
as well as policymakers.
Senator MURRAY. Dr. Nass, you co-authored a study that found
that although PTSD and depression is associated with higher rates
of reported health problems in our servicemembers, those conditions
did not entirely account for the numerous symptoms that are
reported by our servicemembers. Mr. Binns asserts in his testimony
that a lot of the funding for research on Gulf War illness has
been unwisely spent on psychological causes of Gulf War illness as
opposed to exposure to environmental toxins as a cause. What do
you think is the relationship between the presence of physical
symptoms attributable to Gulf War illness and psychiatric illness?
Dr. WHITE. Well, I certainly don't think that psychiatric illness
explains it. Many of the veterans that I have studied in the years
that I have been looking at this syndrome who have symptoms do
not have a psychiatric diagnosis. I have tried measuring stress or
Post Traumatic Stress in lots of ways other than just diagnosis,
like looking at how stressed did a person feel by their experience
in the war and whether that is related to the expression of symptoms
later on, and there is some relationship but it certainly
doesn't explain all of it.
Senator MURRAY. Thank you. Dr. Steele, in your testimony, you
mentioned that effective treatments for Gulf War illness have not
been found and few have ever been studied, and you go on to say
that the Research Advisory Committee places the highest priority
on research that leads to effective treatments. In your opinion, are
the VA and DOD placing enough emphasis on treatment in their
research of Gulf War illness?
Dr. STEELE. I would say, until recently, definitely not. There
have been only two studies published and neither of them provided
substantial benefit to a significant number of veterans. One study
showed a little bit of benefit to some veterans. But there were no
other studies funded at all besides those for many years. As Mr.
Binns said, recently, DOD had a pilot program with a small
amount of money to fund smaller treatment studies, and that has
just begun in the last year. Those studies were only recently funded.
And there are two clinical trials going on at VA, as well. But
they are really not focused on the kinds of problems that we are
talking about necessarily and they are not focused on the causes
for----
Senator MURRAY. What are these focused on?
Dr. STEELE. There is one focused on telemedicine cognitive behavioral
therapy. In other words, you can call up the VA and get
psychological therapy over the phone. There is another one that I
think is more on point and that is looking at sleep disorders in Gulf
War veterans and using the BI-PAP machine to help Gulf War veterans
with sleep disorders, and we do know that a lot of Gulf War
veterans----
Senator MURRAY. So only one of them is an effective treatment
study?
Dr. STEELE. They are both treatment studies. We will see if they
have any effect. We know that the cognitive behavioral therapy
study that was not over the phone had a negligible effect in improving
veterans' health. The sleep disorders could help veterans
with sleep disorders and we would welcome that. But the larger
problem relating to exposures to toxic chemicals and multi-symptom
illness and treating the kinds of illnesses that we also see in
the civilian population, we have no studies of that right now.
Senator MURRAY. OK. And Mr. Binns, let me just ask you, you
said that we are misspending a lot of money on the false theory
that these illnesses were caused by psychological stress. Can you
expound on why psychological stress is not a credible cause of Gulf
War illness?
Mr. BINNS. Yes. First, I should mention that Secretary Principi
3 years ago did determine that VA would no longer spend money
on studies based on psychological stress, so VA has reached that
conclusion itself.
One study showed that--it was conducted by a British group--
showed that the number of people who have been in the Gulf War
who have any psychiatric diagnosis, if you look at people who are
the most ill population of that group, something like on the order
of 19 percent of them had a psychiatric disorder. It is similar to the
number that might have been in Bosnia, who have the psychiatric
disorder. That meant that over three-quarters of those who had
these severe illnesses do not have any psychological disorder.
If you have a chronic illness, you are bound to get a psychological
disorder. Depression is very much associated with any kind of
chronic illness. So the fact that only a quarter or less than a quarter
of these Gulf War veterans are depressed or have any kind of
psychiatric disorder tells me how mentally healthy they are. I
mean, this woman sitting next to me, I could not--I mean, I have
so much admiration for Julie, and there are thousands of people
out there like her.
Senator MURRAY. Thank you very much, and I will turn it over
to Senator Burr for questions.
Senator BURR. I thank my colleague.
Dr. Steele, you said at the conclusion of your testimony, progress
has been made in understanding the big picture questions about
Gulf War illness. The Research Advisory Committee believes that
remaining questions can and must be addressed. Let me ask you,
did the Committee identify what those questions that could and
must be addressed are?
Dr. STEELE. We are in the process of finalizing and prioritizing
those questions, but there are questions such as those related to
multiple sclerosis, Parkinson's disease, things like that, those studies
have not been done and can be done. But there are other questions
that are very important to address and that relates to the
specific biological mechanisms that underlie these illnesses, and
also specific treatments that can improve veterans' symptoms.
Senator BURR. Let me just encourage the Committee at the earliest
possible point, as you develop those questions, even if they are
not complete, share them with the Committee so that they can help
to guide us in the direction that we try to go.
Dr. STEELE. And that is the focus of our upcoming report that we
will be happy to share with you.
Senator BURR. Thank you. Ms. Mock, I don't think any of us can
thank you and your husband and your entire family enough for,
one, the service that you have provided, and two, the struggles that
you continue to go through as a family, as other families are. I noticed
in your testimony that you stated that your husband is still
serving on active duty, or is it----
Ms. MOCK. He is in the Reserves----
Senator BURR. He is in the Reserves.
Ms. MOCK.--the Army Reserves.
Senator BURR. And that he is fortunately healthy. Has he suffered
from any of the conditions that have been described with the
Gulf War illness?
Ms. MOCK. No, he hasn't. We were not in the same location, however.
He was about 14 miles from where I was, and I can tell you
that where I was at the 12th EVAC, there are three other people
who were within 100 yards of me who have been diagnosed with
multiple sclerosis.
Senator BURR. Mr. Binns, in your testimony, I think it is safe to
say you were fairly critical of the Department of Veterans Affairs
and their response to the Gulf War veterans. Last year, the Institute
of Medicine conducted an exhaustive review of 850 research
projects on the topic of Gulf War veterans' health and they concluded,
``The investigators have attempted to define a unique
health outcome of the war but none has been identified.'' Given
that finding by what I think all of us would consider a fairly distinguished
panel of scientists, what do you believe the VA should say
and what they should do for the veterans?
Mr. BINNS. If I may, I will ask Dr. Steele as a scientist to comment
on the finding of the Institute of Medicine Committee. The
finding that there is no unique syndrome, as she mentioned, is irrelevant.
The fact of the matter is that VA's most recent study
shows that there are 35 percent of Gulf War veterans who have
these symptoms and 10 percent of veterans of the same era who
did not deploy. That is to say there are illnesses of the same na-
ture, as Senator Sanders has mentioned, in others that did not go
to the Gulf. That is why they can say this is not a unique illness.
But the fact that 3.5 times as many people who went to the Gulf
have this illness as compared to those who didn't----
Senator BURR. Trust me, I think we have consensus on the Committee
that this is real, that the numbers are there.
I am curious from the standpoint of some of what you said suggested
that maybe the interpretation of the research was flawed or
that the research in total had not been evaluated.
Yet the Institute of Medicine did a fairly exhaustive review of all
the research. Am I incorrect, Dr. Steele?
Dr. STEELE. I would say not at all an exhaustive review of the
research.
Senator BURR. OK.
Dr. STEELE. They were charged by VA to look at a specific subset
of the research. This included only human studies of occupational
groups exposed to things similar to what Gulf War veterans were
exposed to. Their study did not, for example, look at the large body
of epidemiologic research that links symptoms in Gulf War veterans
to exposures in the war. They tended not to rely on self-reported
symptoms as something that might define some illness----
Senator BURR. And was this as directed by VA or was this the
Institute of Medicine's choice as to how they reviewed it?
Dr. STEELE. They are commissioned by VA and their charge was
given to them by VA.
Senator BURR. OK. Thank you. Dr. White, I noted in my opening
statement that treatment should be the primary focus of our efforts
as we try to assist those veterans who are ill from the Gulf War.
Based on your research, do you believe that you can have a uniform
approach to treatment, or do you believe that there has to be
an individualization of that assessment and that treatment? Or is
it both?
Dr. WHITE. I would say it is both. There are people who have
very specific systemic syndromes involving the nervous system or
the immune system. There are other people who have more generalized
syndromes. And I think you have to think about both populations
in thinking about research. I think the research that is out
there indicates some specific kinds of physiological mechanisms
that are coming to light that may be related to some of these disorders,
dysfunction and degeneration in the nervous system, immune
system problems, neuroendocrine problems. I think there is
starting to be a body of knowledge out there that can lead us toward
treatments, and I think very active, focused thinking by some
neuropharmacologists, some immunopharmacologists could help us
down the path toward looking at both kinds of problems.
Senator BURR. Last question. Dr. Nass, if I understand your testimony
correctly, you believe that the combinations of exposures to
different chemicals and substances in different people are, in fact,
the cause of the illness, and my question is this. Has your research
or any research that has been done that you know of uncovered
any genetic indicators about those who might be at risk for exposure,
illnesses, versus those who might not become ill regardless of
their exposures?
Dr. NASS. In my written testimony, which you probably got late,
I do cite several studies that looked into the genetics of people who
became ill, and we know that people metabolize drugs and toxic
substances very differently. It depends on the genes, the enzyme
pool, and the substrates you have to produce the products that are
necessary to detoxify. So that has been done by several people.
I am sorry, I forgot the second half of your question.
Senator BURR. Does it depend on those that might become ill, regardless
of their exposure?
Dr. NASS. Certainly, there is going to be a proportion of people
who will become ill without any of these military exposures. Since
fibromyalgia as well as chronic fatigue are the best models for the
Gulf War illness that we have discussed today. What we can say
is that fibromyalgia affects about 2 percent of the U.S. population,
90 percent of whom are women. Chronic fatigue syndrome, we
thought affected perhaps one-half percent or less of Americans, but
CDC just did a telephone survey and decided that it affected several
percent. That came out a couple of months ago. I don't think
it is going to hold water.
So, yes, I think if you subtract those percentages from the 25 to
30 percent, you still have a lot of people who are sick beyond the
baseline expected rates of illness.
Senator BURR. I thank you. I share your belief that a telephone
survey may not be the most accurate thing for us to drive policy
off of, but----
Dr. NASS. If I might, I know that Walter Reed has actually been
looking at the genomes of people who have become ill after anthrax
vaccine to see if there is a difference in the way they process the
vaccine. That has not been published.
Senator BURR. Clearly, we have known for some time that people
process vaccines differently based upon their genetic make-up. I
thank the Chair.
Senator MURRAY. Thank you. Senator Sanders?
Senator SANDERS. Thank you. Well, there is one study that has
not yet been funded and that is the study as to why the DOD and
the VA for so many years, throughout so many wars, have attempted
to deny the health problems that our soldiers have suffered.
Back to World War II, where we had radiation illness, soldiers
who were exposed to nuclear radiation had to fight hard to
get our government to recognize their problems. And as we have
heard today, in Vietnam, can you imagine that soldiers themselves
had to struggle with their own government, not with Vietnam but
with their own government for the recognition of what Agent Orange
has done, something which is now accepted. And we are still
here making that fight today.
I would just concur with what the other Senators have said to
Julie Mock and thank you so much for being here and what you
have done. I am sure that you performed with courage in the Gulf
War and I would just say that you are performing now with at
least as much courage in what you are doing here today, and what
you are doing in general is so important, so thank you very much.
If I can begin by asking Mr. Binns, we are fighting, and I think
we have had some success in the DOD appropriations bill, working
with Senator Byrd and other Senators, in getting additional fund-
ing for the Congressionally Directed Medical Research Program. In
your view, why does putting funding into that type of program
make sense, if it does to you?
Mr. BINNS. As you know, Senator Sanders, this grew out of the
small pilot program, $5 million worth, that you and, as you mentioned,
Congressman Shays inserted into the DOD budget in 2006.
The commanding general at Fort Detrick, I believe, was the one
who assigned it to the Congressionally Directed Medical Research
Program. Dr. Steele and I met with Colonel Harris and her colleagues
to describe what we had found and we were extremely
pleasantly surprised to find that, at last, we had found a group of
research managers within the Department of Defense who were
truly dedicated to patients. They had extensive experience with patients
with breast cancer, prostate cancer, other types of problems
that they research, and they set up a very logical research program
without any political overview.
So it includes a number of factors that were missing in the past.
One is, as I say, really a dedication to solving the problem. Second
is a group of merit reviewers who are reviewing what programs to
study who actually are knowledgeable about Gulf War illness and
actually include some of those who suffer from Gulf War illness,
veterans who are on their panels. I should let Colonel Harris describe
her program in more detail.
And most importantly, they have funded now a number of
projects which are treatment oriented. They have proven by what
they have funded--these programs have just been announced----
Senator SANDERS. And they are soliciting projects and ideas from
a wide range of researchers all over the country, is that correct?
Mr. BINNS. I believe even researchers in foreign countries would
be eligible to apply. There is no limitation on where this can come
from, and what is most significant to me, so many researchers have
responded to this program, even though it was a small pilot program.
I think that with a more substantial amount of time and
money, even greater response will be received.
Senator SANDERS. So, in other words, we are attracting some devoted
researchers, people who are focusing on this issue all over
the country from different perspectives and so forth?
Mr. BINNS. Exactly, and I believe some of these researchers are
from VA. Some are from the Department of Defense. I do not for
the minute impugn the dedication of scientists and doctors within
the Department of Defense. There are many who stand ready to try
to work on this.
Senator SANDERS. Let me ask anybody else on the panel, Dr.
Nass, Dr. Steele, Dr. White, what is your gut feeling as to where
we should be focusing new research? For example, it has only been,
as I understand, within the last number of years that we have
begun to see objectively demonstrated brain damage, in Gulf War
returns. Is that a subject of more future research, do you think?
Dr. WHITE. Well, I think that especially as we progress with
planned and existing research on high-and low-symptom complainers,
people with chronic multi-symptom illness and subtle
changes in brain function, that the structural changes in the brain
that have been noted in white matter, the possibility of white matter
degeneration leads to one set of possible treatments. The acetyl
cholinesterase inhibition hypothesis related to a number of the Gulf
War chemicals that Dr. Steele talked about could lead to some
other avenues of treatment.
I think that the clues are there in the literature. There is some
new stuff on hypothalamic abscess, pituitary abscess, differences
between people with PTSD and chronic multi-system illness in veterans.
I think all of this, when you put the proper group of people
together or go out with the proper RFAs for treatment protocols,
I think they will lead to something.
Senator SANDERS. Dr. Steele, did you want to add?
Dr. STEELE. Yes. I agree with Dr. White. Our Committee has
really strongly recommended that two paths be pursued. One is the
path where you tease out the specific biology of what has gone on
in the brain. What has happened as a result of these chemical exposures?
What does that do to the brain, to the circuits, to the inflammatory
processes, to the different parts? How do you identify
that, and then how do you identify drugs and treatments that help
that?
The other major path is to look at treatments that are used for
things that look like Gulf War illness or that have things in common
with Gulf War illness. So there are a lot of treatments right
now for fibromyalgia, for example.
Other people use different things for multiple chemical sensitivity.
Other people use things for the kinds of neurological damage
that Dr. White is talking about.
So, one, we want to get down to the details by taking one path
and looking at the specific biology of the problem, and then finding
pharmacological treatments for those problems. On the other path,
we want to do as has been suggested by the new DOD program,
and that is look at things that are already on the shelf, take them
off the shelf and see if they are helpful to Gulf War veterans.
Senator SANDERS. Now, obviously, our major focus is doing everything
that we can to understand why our soldiers have been made
ill and how we can treat them. Would I be correct, though, in understanding
that the more knowledge that we ascertain from these
studies, that it will benefit the civilian population of people who
are suffering from similar-type illnesses? Would that be a fair
statement, Dr. Steele?
Dr. STEELE. I think it is a very fair statement. We know that
there are parallels between things like chronic fatigue syndrome,
multiple chemical sensitivity, and Gulf War illness. They don't look
exactly the same in all studies, but there are parallels and we
think that some of the biology that underlies them may be similar.
So we do think that things that we find out about Gulf War illness
could help other people with similar conditions.
Senator SANDERS. Thank you Madam Chair.
Senator MURRAY. Thank you. Senator Isakson?
Senator ISAKSON. Thank you, Madam Chairman, and thanks to
all the Members for testifying today.
Mr. Binns, under whose auspices is the Research Advisory Committee
on Gulf War Veterans' Illnesses?
Mr. BINNS. The Committee was established by Congress under a
public law in 1998 and it is appointed by the Secretary of Veterans
Affairs.
Senator ISAKSON. And you also serve, Dr. Steele, on that Committee?
Dr. STEELE. Yes. I am the Scientific Director.
Senator ISAKSON. You can both answer this, if you like. In your
testimony, in particular, Mr. Binns, and yours, too, Dr. Steele, it
doesn't appear that a lot of the advice the Committee is giving is
being taken. Is that right or wrong?
Mr. BINNS. Within the last year, there has been a definite change
in the attitude of the VA Office of Research and Development. As
I said, Secretary Nicholson appointed new leadership here. Dr.
Kupersmith will speak later. And I think we are seeing a change
in the direction of VA research, but not a complete one yet, a
change.
Unfortunately, as I mentioned, VA's other official pronouncements,
which come from different departments of VA, continue to
minimize these problems.
Senator ISAKSON. I noticed in your testimony on one hand you
were complimentary of the $15 million designated to the University
of Texas that Senator Hutchison put in for the Manhattan-type
project, and on the next page the fact that the original Shay-Sanders
money that had been put in had not been requested by the Department,
is that correct?
Mr. BINNS. That money was at DOD.
Senator ISAKSON. That was at DOD?
Mr. BINNS. Yes. Essentially, you have had VA providing about
one-third of the research, DOD providing about two-thirds. The
two-thirds has gone away completely but for what Congress has inserted
up to the present minute.
There is no money at DOD other than what Congress mandates.
Senator ISAKSON. So the $15 million is at VA, though?
Mr. BINNS. That is correct.
Senator ISAKSON. Julie, I want to add what everybody has said
in thanking you for your service and your coming here today, with
all you have got to deal with. You are a real inspiration to all of
us.
I have a question with regard to the vaccines. You referred a couple
of times in your testimony to the vaccines that you were given
before you deployed, and then, Dr. Nass, you made specific references
to the smallpox vaccine and others. I will ask you first,
Julie, and then you can comment, Dr. Nass. Were any of the difficulties
that your sons have encountered in any way tied or symptomatic
of those vaccines?
Ms. MOCK. Honestly, I am not sure. I think we--regarding the
vaccines that we received, we don't have a good list of what we actually
did receive. Depending on where you were preparing for deployment,
you got a certain cocktail of vaccines, and when you were
preparing to deploy from another area, you received perhaps another
cocktail. So I have no idea exactly what we received.
Senator ISAKSON. Dr. Nass?
Dr. NASS. It is a very tough, politically charged question. The one
study of women who got anthrax vaccine inadvertently during their
first trimester of pregnancy showed that they had a 39 percent
greater risk of having a child with a birth defect. That study has
never been published, even though it was reported on as early as
late 2001.
This study compared women who got anthrax vaccine during the
first trimester of pregnancy to women who got anthrax vaccine at
any other time, so that if you compared them to women who had
never gotten anthrax vaccine, the birth defect rates might be higher.
And that research project looked at every woman in the military
who had received anthrax vaccine and had had a pregnancy. And
the paper records were obtained, not just the computer records, because
the study was criticized by the Army initially. However,
there are no good studies and nobody wants to touch this issue, because
the military wants the ability to use these vaccines, and
doesn't want to uncover any evidence that they are even worse
than we already know they are.
Senator ISAKSON. Thank you for your answers. Thank you,
Madam Chairman.
Senator MURRAY. Thank you. I just have a couple of questions.
Dr. Steele, can you comment on that, too, on the risks of birth
defects in Gulf War veterans?
Dr. STEELE. There have been quite a number of studies of rates
of birth defects in Gulf War veterans. The early studies were smaller
studies and only looked at military hospitalizations and didn't
find any increase. Since then, though, there have been larger studies
and more comprehensive studies and they have found increased
rates of birth defects, but still not high rates of birth defects. So
slight increases in certain types of birth defects, but overall, the
rate is still low. We don't have definitive information about which
specific birth defects are increased and how much because the studies
just haven't been big enough.
What we don't have are studies of children the ages of Julie's,
when they got sick. The birth defects studies look at either things
that you can find at birth or within the first year, and some children
don't develop their problems until later. There has been one
VA study that has looked at the family members of Gulf War veterans,
both spouses and children, and older children, but we
haven't seen published results from the children's study yet and we
are not even sure if they looked at these kinds of conditions. We
are thinking they only looked at psychiatric conditions. We just
don't know.
So we don't have data to know if there are higher rates of problems
such as Julie described in Gulf War veterans overall.
Senator MURRAY. So we may well have a number of children out
there that have birth defects that could be possibly related back to
the Gulf War that the parents don't even have a clue of knowing
that?
Dr. STEELE. That is possible, and we are thinking that what
would be classified as a birth defect could be elevated in some cases
but still we don't think there are large numbers. We are also,
though, concerned about these things that wouldn't be called birth
defects, things that don't happen until----
Dr. NASS. Neurobehavioral effects.
Dr. STEELE.--children are older. Yes.
Senator MURRAY. Dr. Nass, I am sorry----
Dr. NASS. I am sorry. I said neurobehavioral effects that do not
turn up in the first year, but when the child is talking and walking,
going to school, then they get diagnosed at a later age.
Senator MURRAY. I found it very troubling, what you said to Senator
Isakson that studies aren't being done because people don't
want to maybe find out what the results are. Julie, how does that
make you feel?
Ms. MOCK. I can't tell you how it makes me feel. It makes me
feel enraged, I guess. I see my children suffer.
We are very fortunate. We can provide what our kids need, but
hearing from other parents who don't have the resources that we
have or the wherewithal to find the help that their children need,
it is frustrating and it is a tragedy.
Senator MURRAY. And a tragedy to hear, as well.
Dr. White, let me ask you one final question, and that is that you
have been a co-author on two studies. One of them indicated that
there were subtle changes in the brains of deployed Gulf War veterans
as compared to non-deployed veterans, and the other one was
demonstrating worsening neurobehavioral functioning dependent
on the amount of sarin and cyclosarin exposure. As you mentioned,
I sent a letter along with Senators Bond and Rockefeller to Secretary
Nicholson and to Secretary Gates asking that they move forward
with more research to find better and effective treatment for
thousands of our Gulf War veterans, and when they responded to
us, both the VA and the DOD criticized your studies and said that
they were critical of the mathematical model used to calculate the
exposure data in the neurobehavioral study and they cited limitations
in the MRI study suggesting that the number of veterans
studied was too small to draw any conclusions. Could you respond
to that criticism?
Dr. WHITE. Well, first of all, the exposure modeling that we used
was from DOD and my understanding is that if it is inaccurate, it
may have underestimated exposure in the Gulf, in which case it
would have made it less possible for us to find results. So if the
data from--if the sarin modeling data are wrong and there is no
association, they had to have been systematically wrong in a way
for us to see a dose effect relationship, the relationship between the
dose and the effect that made me believe the results.
The other thing that made me believe the results was that I have
worked with Japanese scientists around people in the train incidents
in Japan and the behavioral findings and the MRI findings
were very similar in those two cases.
Finally, let me say the problem with all imaging studies is that
they tend to be small because they are expensive, it is hard to get
people in, it is a very complicated process to do a neuroimaging
study and 26 subjects is actually on the large side for an imaging
study.
The one that I talked to you about with the high-and low-symptom
complainers that we just finished actually has 59 veterans in
it. So we are hoping that will be a little more definitive than 26,
but 26 is the size these studies are.
Senator MURRAY. OK. Senator Burr? All right.
Well, I would like to thank all of our panelists. We may have
some questions from the Committee that we will submit to you in
writing and ask for you to submit answers. But again, thank you
to all of you for being here and I would ask our second panel to
come forward at this time.
I want to thank all of our second panel for being here, as well,
and I will begin by introducing Dr. Michael Kilpatrick. He is the
Deputy Director for Force Health Protection and Readiness Programs
in the Office of the Assistant Secretary of Defense for Health
Affairs. He is accompanied by Colonel Janet Harris. She is the Director
of Congressionally Directed Medical Research Programs in
the Department of Army.
We also have Dr. Joel Kupersmith. He is the Chief Research and
Development Officer in the VA, and he is accompanied by Dr. Timothy
O'Leary, the Director of Biomedical Laboratory and Clinical
Science Research and Development Services.
Thank you all for joining with us today. Again, your full statements
will appear in the record and I ask you to keep your remarks
to 5 minutes. We will begin with Dr. Kilpatrick.
STATEMENT OF MICHAEL E. KILPATRICK, M.D., DEPUTY
DIRECTOR FOR FORCE HEALTH PROTECTION AND
READINESS PROGRAMS, OFFICE OF THE ASSISTANT
SECRETARY OF DEFENSE FOR HEALTH AFFAIRS, DEPARTMENT
OF DEFENSE; ACCOMPANIED BY COLONEL JANET
HARRIS, PH.D., R.M., DIRECTOR, CONGRESSIONALLY DIRECTED
MEDICAL RESEARCH PROGRAMS, DEPARTMENT OF
THE ARMY, DEPARTMENT OF DEFENSE
Dr. KILPATRICK. Madam Chairman and distinguished Members
of the Committee, thank you for the opportunity to discuss the Department
of Defense's Force Health Protection and Readiness Program
with a focus on veterans of the 1990-1991 Gulf War. With
me is Colonel Janet Harris, Director of Congressionally Directed
Medical Research Programs.
Two primary objectives of the military health system are to ensure
a medically ready force and to provide world class care to
those who become ill or injured. We have a multitude of proactive
programs to educate our servicemembers, their families, and our
military leadership. We also have robust surveillance and research
programs to monitor the health of our force. The medical lessons
learned from the Gulf War led to the implementation of this Force
Health Protection concept, policies, and programs.
The combined analysis of DOD and VA Gulf War veteran clinical
evaluations of approximately 100,000 veterans showed that more
than 80 percent had recognized health problems and received conventional
treatment. Treatment programs are also available for
veterans with chronic unexplained symptoms, and again, it is important
to understand that once you have a diagnosis, that may not
explain all the symptoms that an individual veteran has.
In 1991, DOD established the Deployment Health Research Center,
the Deployment Health Clinical Center, and the Deployment
Health Surveillance Center to work closely with VA's War Related
Illness and Injury Study Centers. The Deployment Health Research
Center, in collaboration with the VA, designed the Millennium
Cohort Study to evaluate the long-term health effects of military
service, specifically deployments.
Since 1992, the Departments of Defense, Veterans Affairs, and
Health and Human Services have funded over 300 distinct projects
related to health problems affecting Gulf War veterans, as Senator
Burr mentioned. In September 2006, the Institute of Medicine did
publish a review of the medical literature on illnesses of Gulf War
veterans and their conclusion, ``no unique syndrome, no unique illness
or unique pattern of symptoms,'' in Gulf War veterans was the
finalization of that evaluation. The final statement of that IOM report
was, ``Our Committee does not recommend that more such
studies be undertaken for the Gulf War veterans, but there would
be value in continuing to monitor the veterans for some health
endpoints, specifically cancer, especially brain and testicular cancers,
neurological diseases, including ALS, and causes of death.''
The DOD Gulf War Illness Research Program was initially established
in 1994 and it was renamed the Force Health Protection Research
Program in 2002. While it continued to support diagnostic
and treatment research for Gulf War veterans, the focus was expanded
to include current and future military deployments. This
includes studies on the mechanisms of illness, chronic effects of
neurological substances, identifying neurological and
immunological abnormalities, and the identification of promising
treatments.
Pre- and post-deployment health assessments were begun in
1998. The post-deployment health assessment was augmented in
2003 and the post-deployment health reassessment was begun in
June of 2005 to reevaluate servicemembers some 3 to 6 months
after they return home. The two post-deployment health assessments
include a one-on-one interaction of the servicemembers with
a health care provider to determine need for further evaluation and
diagnostic work-up. The assessments are not medical diagnostic instruments,
but are screening tools to identify the need for medical
evaluation.
Medical referral rates on return home are 20 percent for active
duty and 24 percent for the Reserve component. Referral rates 3
to 6 months later are 19 percent for the active duty and 51 percent
for the Reserve component.
Deployment-related research maintains quality care and an environment
of expanding knowledge. Today, 358 deployment health
research-related projects are being conducted. Examples are 50
projects on traumatic musculoskeletal injuries, 96 projects on Traumatic
Brain Injury and spinal cord injury, 67 projects on mental
disorders, including PTSD, and 29 projects on infectious diseases.
The Department of Defense is very concerned about the shortterm
and long-term health effects of deployments and military
service for all its servicemembers. Our ability to analyze medical
data related to deployments in a proactive way is enabling us to
develop and modify programs to better prepare our servicemembers
and their families for the stressors of military service, to educate
them and our leadership on recognizing when to seek medical evaluation
for concerns, and to make changes when medically indicated.
We will continue to analyze the information to assure we are
doing everything possible to protect their health and to provide the
care and treatment they need and deserve while they are deployed
and when they come home.
Thank you for the opportunity to present this information to you
and I look forward to your questions.
[The prepared statement of Dr. Kilpatrick follows:]
PREPARED STATEMENT OF MICHAEL E KILPATRICK, M.D., DEPUTY DIRECTOR,
FORCE HEALTH PROTECTION AND READINESS PROGRAMS, DEPARTMENT OF DEFENSE
Mr. Chairman and distinguished Members of the Committee, thank you for the
opportunity to discuss the Department of Defense's (DOD's) Force Health
Protection and Readiness Program and the programs within the Military Health
System, with a focus on the aspects of those programs related to research on
veterans of the 1991 Gulf War.
Two primary objectives of the Military Health System are to ensure a medically
ready force and to provide world class care for those who become ill or
injured. The importance of these objectives is recognized throughout the DOD,
and we have a multitude of proactive programs in place to educate our
Servicemembers and their families and our military leadership. We also have
robust surveillance and research programs in place to monitor the health of
our force.
The medical lessons learned from the 1991 Gulf War led to the implementation
of the Force Health Protection concept, policies, and programs. Shortly after
the 1991 Gulf War, some of the 700,000 Servicemembers deployed during that
conflict began to present for care with symptoms they believed were related to
their deployment. The unclear cause of symptoms, in some cases, presented a
challenge for both military and Veterans Affairs (VA) providers.
As a result, the VA established the VA Gulf War Health Examination Registry
to identify possible endemic diseases or hazardous exposures resulting from
U.S. military personnel service in Southwest Asia. Subsequently, the Assistant
Secretary of Defense for Health Affairs initiated the Comprehensive Clinical
Evaluation Program to offer examinations to Gulf War veterans.
A combined analysis of the VA and DOD Gulf War clinical evaluation programs'
study of over 100,000 participants showed that more than 80 percent of
veterans evaluated had well-known health problems and received conventional
diagnoses and treatment. Moreover, 6 to 9 percent of evaluated veterans
reported that they did not have a clinically significant new illness. The
findings from over 100,000 clinical examinations have substantially aided
health care efforts. Veterans of the 1991 Gulf War who report health problems
are definitely ill. However, they do not have a single type of health problem.
Consequently, these veterans have to be evaluated and treated as individuals.
Assumptions based on participation in the 1991 Gulf War cannot be made about
the health of a veteran who presents for clinical evaluation. Each veteran
requires a medical history and screening examination, with treatment
tailored to the specific needs of the patient. For 1991 Gulf War veterans who
have well-known health problems, effective therapy is available. Treatment
also is available for veterans with chronic, unexplained symptoms.
In 1991, the DOD established the Deployment Health Research Center, the
Deployment Health Clinical Center (DHCC), and the Deployment Health
Surveillance Center to work closely with the VA's War Related Illness and
Injury Study Centers. The DHCC's mission began with a focus on illnesses
associated with the 1991 Gulf War and was expanded to include not only
clinical care of deployment veterans, but also deployment-related health
research and training, education, and communication responsibilities. The DHCC
added risk communication, clinical and health services research, and
epidemiological expertise to its staff, and now has a research portfolio
comprising a dozen demographic and epidemiology projects, nine health
services research projects, and clinical trials.
Major focus areas for DHCC research include post-war syndromes, especially
illness related to the 1991 Gulf War, medically unexplained physical symptoms,
and Post Traumatic Stress Disorder (PTSD) that occurs subsequent to combat,
sexual assault, or terrorist attack. The DHCC was involved in the creation of
the DOD/VA Post-Deployment Health Evaluation and Management Clinical Practice
Guideline. The guideline was completed in 2001, following Institute of
Medicine recommendations to incorporate deployment healthcare into primary
care and to regularly screen all military beneficiaries. The DHCC also
supports the DOD/VA guidelines for primary-care based detection and treatment
of depression, PTSD, and medically unexplained symptoms through staff
assistance, training programs, and research projects.
The Deployment Health Research Center, in collaboration with the VA, designed
the Millennium Cohort Study, to evaluate the long-term health effects of
military service, specifically deployments. The study was initiated in 2001.
Funded by the DOD, and supported by military, VA, and civilian researchers,
almost 140,000 Servicemembers will eventually participate in this
groundbreaking study. As force health protection continues to be a priority
for the future of the United States military, the Millennium Cohort Study will
be providing a crucial step toward enhancing the long-term health of military
Servicemembers.
Since 1992, the DOD, VA, and Health and Human Services (HHS) have funded
over 300 distinct projects related to health problems affecting Gulf War
veterans. The DOD Gulf War Illness research program was established in 1994
and was renamed the Force Health Protection Research Program in 2002. While it
continued to support diagnostic and treatment capabilities for 1991 Gulf War
veterans, the focus was expanded to include current and future military
deployments and how to respond better to the health care needs of those who
deploy. Research pertaining to illnesses of Gulf War veterans has also been
funded through the Military-Relevant Disease Management topic area of the
Congressionally Directed Medical Research Program. DOD support for a coherent
research program for illnesses of the veterans of the 1991 Gulf War has four
focus areas:
1. Identification of mechanisms underlying the illnesses;
2. Chronic effects of neurotoxic substances to which veterans were exposed
during deployment;
3. Studies that expand on earlier research identifying neurological and
immunological abnormalities in ill veterans; and
4. Identification of promising treatments.
DOD has made significant improvements and advances in deployment
health-related processes, based on research results and healthcare outcomes
since the 1990-1991 Gulf War. Pre-Deployment and Post-Deployment Health
Assessments (PDHAs) were begun in 1998. The PDHA was augmented in 2003 to
collect a standardized set of information about medical symptoms or concerns,
again because of medical lessons learned from those returning home from
deployments. The Post-Deployment Health Reassessment (PDHRA) was begun in
June 2005 to reevaluate the health of those who returned from deployments
some three to six months after their return. This reassessment was initiated
because of military medical research data showing increased physical and
mental health symptoms and concerns in Servicemembers after they were home and
reintegrating with their families and their work.
The PDHA and the PDHRA are both designed to include a one-on-one interaction
of each Servicemember with a healthcare provider to review the concerns
identified by the member on the assessment and to make a determination of the
medical indications for referral for further evaluation and diagnostic workup.
The assessments are not medical diagnostic instruments, but are screening
tools to identify the need for medical evaluation.
The PDHA enables the medical provider to determine if any further medical
evaluations are needed before making a medical recommendation on the
individual's deployability. We are consistently finding that about 4 percent
of those evaluated at the pre-deployment processing centers have medical
problems identified that preclude them from deploying at that time.
The PDHAs from the worldwide deployments of Servicemembers from January 1,
2003, to February 12, 2007, show that 93 percent of Active Duty Servicemembers
indicate their general health as ``good,'' ``very good,'' or ``excellent,''
22 percent indicate they have medical concerns, and 5 percent indicate they
have mental health concerns. Referral rates after discussion with a medical
provider show that 18 percent are referred for further medical evaluation. The
referrals are fairly equally divided among ``medical'' only, ``mental health''
only, and both ``medical and mental health.'' For the Reserve component, 90
percent rate their health as good, very good, or excellent; 41 percent
indicate they have medical problems; 6 percent indicate they have mental
health concerns; and 24 percent are referred.
The PDHRAs from the worldwide deployments of Servicemembers from June 2005
to March 2007, show that 85 percent of Active Duty Servicemembers indicate
their general health as ``good,'' ``very good,'' or ``excellent''; 33 percent
indicate they have medical concerns; and 27 percent indicate they have mental
health concerns. Referral rates after discussion with a medical provider show
that 16 percent are referred for further medical evaluation. The referrals are
fairly equally divided among ``medical'' only, ``mental health'' only, and
both ``medical and mental health.'' For the Reserve component, 82 percent
indicate their health is good, very good, or excellent; 56 percent indicate
medical concerns, 42 percent indicate mental health concerns; and 51 percent
are referred. An important element of the PDHA and the PDHRA is education of
the Servicemembers about medical conditions, both physical and mental, and the
signs and symptoms that indicate the need for further evaluation.
To better understand the mental health needs of the deployed forces, the Army sent a Mental Health Advisory Team (MHAT) to theater in September and October
2003. This was the first time that such an assessment was conducted during a wartime
deployment. The Army has sent MHATs to theater three subsequent times,
September to October 2004, October to November 2005, and August to October 2006,
to continue to evaluate adequacy of mental health support in theater and preparation
of medical and support staff for mental health care.
Deployment-related research is performed at local, Service, and interagency
collaborative levels to maintain quality care in an environment of expanding
knowledge. At the present time, 358 deployment health-related research
projects are being conducted across various organizations of the DOD, VA, and
HHS, as well as other Federal and academic organizations. These focus on a
wide variety of physical health and mental health topics. For example, there
are 50 projects on traumatic musculoskeletal injuries; 97 projects on
Traumatic Brain and Spinal Cord Injuries; 67 projects on mental disorders,
including PTSD; and 29 projects on infectious diseases. From 1992 to 2006,
more than 250 deployment health-related research projects were initiated and
completed. During the past 14 years, more than 850 articles were published in
peer-reviewed medical and scientific journals on deploymentrelated
medical research.
The DOD is very concerned about the short-term and long-term health effects of
deployments and military service for all of its Servicemembers. Our ability to
analyze medical data related to deployments in a proactive way is enabling us
to develop and modify programs to better prepare our Servicemembers and their
families for the stressors of military service, to educate them and our
leadership on recognizing when to seek medical evaluation for concerns and to
make changes when medically indicated. Since we repeatedly assess both
physical and mental health of our force, we will continue to analyze the
information to assure we are doing everything possible to protect their health
and to provide the care and treatment they need and deserve while they are
deployed and when they come home.
Mr. Chairman, I thank you for the opportunity to provide you and the Members
of the Committee with an overview of the Military Health System's Force Health
Protection research program. I am ready to answer your questions.
RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY DANIEL K. AKAKA, TO DR. MICHAEL
E. KILPATRICK, M.D., U.S. DEPARTMENT OF DEFENSE
Question. As early as 1998, the Senate Committee on Veterans' Affairs formally
recommended complete base-line and post-deployment health screens for
servicemembers, but a final system has not been instituted. Why has this
screening system taken so long to implement, and when can we expect full
implementation?
Answer. The pre-deployment health assessment and post-deployment health
assessment (PDHA) have been implemented since 1998.
The 1998 law required the Secretary of Defense to ``establish a system to
assess the medical condition of members of the armed forces (including members
of the reserve components) who are deployed outside the United States.'' The
law required the use of pre- and post-deployment examinations; this was
codified as 10 U.S.C. Section 1074f.
In 2003, The Department of Defense (DOD) enhanced the PDHA. In 2005, DOD
added the post-deployment health reassessment (PDHRA) to screen for health
concerns at 90 to 180 days after return from deployment. In 2006, DOD
implemented an annual periodic health assessment for each servicemember, in
addition to the PDHA and PDHRA.
The Government Accountability Office (GAO) has evaluated these health
assessment programs multiple times. In June 2007, GAO published a report
entitled ``Defense Health Care: Comprehensive Oversight Framework Needed to
Help Ensure Effective Implementation of a Deployment Health Quality Assurance
Program (GAO-07-831).'' One of the specific issues that GAO was requested to
address was ``whether DOD has established a medical tracking system to comply
with the requirements of 10 U.S.C. section 1074f pertaining to pre- and
post-deployment medical examinations.'' In the results of its study, the GAO
stated, ``DOD has established a medical tracking system to comply with the
requirements of 10 U.S.C., section 1074f, to perform pre-deployment and
post-deployment medical examinations through a variety of deployment health
activities.'' The GAO further stated, ``DOD's use of a variety of deployment
health activities, including the use of pre- and postdeployment health
assessment questionnaires along with reviews of servicemembers' medical
records is a reasonable interpretation of section 1074f.''
Question. The active monitoring of servicemember and the operational
environment in which they serve is critical. In light of the lessons of the
Gulf War, what steps has DOD taken to ensure there is adequate monitoring of
servicemember health during deployment, and how does DOD screen for low level
exposures to chemical agents in operational areas?
Answer. DOD is firmly committed to protecting the health of our Active and
Reserve Component members before deployment, while they are deployed, and
after they return. Occupational and environmental health surveillance is a key
component of the preventive medicine activities that take place during
deployments, including Operation Iraqi Freedom and Operation Enduring Freedom.
DOD recognizes the need to monitor the deployed environment for potentially
hazardous materials and to document and archive the results so that they can
be used as an aid in the diagnosis and medical care of exposed personnel.
After the 1990-91 Gulf War, DOD implemented a number of directives,
instructions, and policies to improve occupational and environmental health
(OEH) surveillance during deployments. As a result, the Services, the Joint
Staff, and the Combatant Commands have made substantial progress to better
address the immediate and long-term health issues associated
with deployment occupational and environmental exposures.
DOD's deployment OEH program includes a number of key preventive measures
that help to ensure Service members are protected from potentially hazardous
exposures. Several of these preventive measures include:
Comprehensive pre-deployment health threats and countermeasures
briefings.
Completion of a pre-deployment health assessment, including providing
a serum sample before deployment.
Completion of all necessary immunizations and the dispensing of
preventive medications and personal protective equipment before deployment.
Performance of baseline, routine, and incident-related occupational
and environmental monitoring, with documentation in the medical records of
any hazardous exposures encountered during the deployment.
Completion of a post-deployment health assessment, including
questions about health concerns and OEH exposures, and providing a serum
sample within 30 days of returning home.
Completion of a post-deployment health reassessment three to 6 months
after returning from deployment, including questions about health concerns
and OEH concerns.
Referral to a health care provider, as appropriate, for follow-up
and evaluation of health concerns reported on the post-deployment health
assessment or reassessment.
Well-trained and equipped Army, Navy, and Air Force medical personnel conduct
on-going, in�theater OEH surveillance, and closely monitor air, water, soil,
food, and disease vectors for health threats. Three types of OEH data are
collected and reported:
``Baseline data,'' which are collected on air, water, and soil
samples at the time base camps are established;
``Routine (or periodic) data,'' such as follow-up air, soil, and
water monitoring data used to detect any changes in concentrations of
potential contaminants over time; and
``Incident-related data,'' which includes data acquired during
investigations of chemical spills, industrial accidents, food or waterborne
illness outbreaks, and chemical/biological agent exposures or attacks.
All OEH monitoring data is documented, and archived in a systematic manner,
as follows:
All environmental samples are identified with a date, time, and
location that can be potentially linked with individuals who were at a
particular location at a specified date and time.
Possible hazardous exposure incidents are thoroughly investigated,
extensive environmental monitoring accomplished, appropriate medical tests
ordered, and rosters of exposed personnel assembled.
Area and date-specific environmental monitoring summaries are
developed by the Services to document environmental conditions potentially
affecting health and to serve as means to inform health care providers of
those environmental conditions and possible health risks associated with the
conditions.
When requested, the Services' Health Surveillance Centers (the US Army Center
for Health Promotion and Preventive Medicine (USACHPPM)), the Navy
Environmental Health Center, and the Air Force Institute for Operational
Health) provide additional technical and consultative assistance to deployed
medical teams, laboratory analysis and interpretation of samples,
pre-deployment OEH hazard assessments, and OEH risk characterization reports
for deployed forces. All deployment OEH data and reports are archived
centrally at the USACHPPM. The Army is the lead Service for joint occupational
and environmental health surveillance data archiving.
Monitoring for chemical warfare agents is a special concern in operational
areas. Experts evaluate the threat of the potential use of a chemical agent
based on intelligence and past experience in that country. A number of field
chemical detectors are currently in use in operational areas, such as the
Improved Chemical Agent Monitor (ICAM) and the M22 Automatic Chemical Agent
Detector Alarm (ACADA). The ICAM is a hand-held instrument that provides
indication of G-type and V-type nerve agents, as well as H-type blister agent
(mustard agent) concentrations. The ICAM may be used for a variety of
missions, including area reconnaissance and area surveillance, monitoring of
decontamination operations, and medical triage operations.
The ACADA is a portable point sampling system, which detects and identifies
GA, GB, GD and VX nerve agents, and detects mustard and Lewisite blister
agents. Improvements to the ACADA allow it to detect some toxic industrial
chemicals.
Question. There is great concern over the safety of vaccinations
currently and previously provided to servicemembers, specifically smallpox
and anthrax. At least two witnesses of the first panel of today's hearing
expressed concern that DOD is being less than forthcoming with research on the
safety of vaccines. In the late 1990's, DOD contracted with the RAND
Corporation for the production of an eight volume set on Gulf War exposures.
At this time, the section on immunizations and Gulf War illnesses, which was
completed in 1999 and revised in 2004, has not yet been released. Can you
explain why this information has not been made available to ill veterans and
other medical researchers?
Answer. We regret the delays incurred on this publication and we look forward
to its final production and dissemination as soon as possible.
This remaining volume of RAND's work related to illnesses of 1990-91 Gulf War
veterans, has been in various phases of completion and production for the past
several years. This volume focuses on the issues pertaining to the use of
vaccines (specifically the botulinum toxin and anthrax vaccinations) among
1990-91 Gulf War servicemembers. The report reviews the scientific literature
as it pertains to the health effects of these two vaccines and in light of
this evidence aims to reach a conclusion about whether these vaccines may have
affected the health outcomes of the veterans of this war. In late 2002, with
the support of the Assistant Secretary of Defense for Health Affairs, the
report was pulled from production to be updated to include relevant literature
based on the use of the vaccine following 2001 anthrax attacks and to undergo
a technical peer review.
The RAND production process includes a rigorous and sequential technical peer
review process--a process that takes time. This process is an essential
element of RAND's commitment to objectivity and quality. This peer review
process includes critical review from external technical experts, the RAND
quality assurance management team, RAND program leaders, and the sponsor. The
time required for each reviewer to provide a critical assessment of the
manuscript and for the author to respond with revisions is commensurate with
the length, scope, and significance of the manuscript itself. This particular
draft has now been reviewed by five technical peer reviewers. Once the current
revisions are completed, it will also be reviewed again by the RAND quality
assurance team and program directors before submission to DOD.
The author is currently making final revisions to the manuscript in response
to comments received during the external technical review that occurred in
late summer 2006. Once the author completes these revisions, DOD will have an
opportunity for review and comment. Once DOD provides sign off and publication
clearance, the report will be printed and disseminated, at which time DOD will
post the document on the Force Health Protection web site to make it available
to veterans, researchers, and any one else with interest.
RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. PATTY MURRAY TO DR.
MICHAEL E. KILPATRICK, M.D., U.S. DEPARTMENT OF DEFENSE
Question. Dr. Kilpatrick, where is the Rand study done by Dr. Golomb on the
anthrax vaccine? Why has it not been published?
Answer: This remaining volume of RAND's work related to illnesses of 1990-91
Gulf War veterans has been in various phases of completion and production for
the past several years. This volume focuses on the issues pertaining to the
use of vaccines (specifically the botulinum toxin and anthrax vaccinations)
among 1990-91 Gulf War servicemembers. The report reviews the scientific
literature as it pertains to the health effects of these two vaccines and in
light of this evidence aims to reach a conclusion about whether these vaccines
may have affected the health outcomes of the veterans of this war. In late
2002, with the support of the Assistant Secretary of Defense for Health
Affairs, the report was pulled from production to be updated to include
relevant literature based on the use of the vaccine following 2001 anthrax
attacks and to undergo a technical peer review.
The RAND production process includes a rigorous and sequential technical peer
review process--a process that takes time. This process is an essential
element of RAND's commitment to objectivity and quality. This peer review
process includes critical review from external technical experts, the RAND
quality assurance management team, RAND program leaders, and the sponsor. The
time required for each reviewer to provide a critical assessment of the
manuscript and for Dr. Golomb to respond with revisions is commensurate with
the length, scope, and significance of the manuscript itself. This particular
draft has now been reviewed by five technical peer reviewers. Once the current
revisions are completed, it will also be reviewed again by the RAND quality
assurance management team and program directors before submission to DOD.
The author is currently making final revisions to the manuscript in response
to comments received during the external technical review that occurred in
late summer 2006. Once the author completes these revisions, DOD will have an
opportunity for review and comment. Once DOD provides sign off and publication
clearance, the report will be printed and disseminated, at which time DOD will
post the document on the Force Health Protection web site to make it available
to veterans, researchers, and any one else with interest.
We regret the delays incurred on this publication and we look forward to its
final production and dissemination as soon as possible.
RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. BERNARD SANDERS TO DR.
MICHAEL E. KILPATRICK, M.D., U.S. DEPARTMENT OF DEFENSE
Question. On page three of your testimony you state: ``Veterans of the 1991
Gulf War who report health problems are definitely ill. However, they do not
have a single type of health problem.'' How do you reconcile this statement
with the latest VA Longitudinal Health Study of Gulf War Era Veterans and
other epidemiological studies mentioned by Dr. Steele that consistently have
shown that 25-30 percent of Gulf War veterans have multisymptom illness over
and above the rate in nondeployed peer?
Answer. This question confuses two separate concepts: (1) ``a single type of
health problem'' and (2) ``one group of veterans has a higher rate of symptoms
than a different group of veterans.''
The scientific consensus is that veterans of the 1991 Gulf War have a large
number of diverse health problems. For example, the Institute of Medicine
(IOM) reviewed more than 850 medical studies in its 2006 report, entitled Gulf
War and Health, Volume 4: Health Effects of Serving in the Gulf War. The IOM
concluded that there is ``no unique syndrome, unique illness, or unique
symptom complex in deployed Gulf War veterans.'' In addition, the IOM stated:
``While examining health outcomes in Gulf War-deployed veterans, numerous
researchers have attempted to determine whether a set of symptoms reported by
veterans could be defined as a unique syndrome or illness. Investigators have
attempted to define a unique health outcome, but none has been identified.''
It is also true that veterans of the 1991 Gulf War report most symptoms more
frequently than non-deployed veterans. The IOM concluded that ``veterans of
the Gulf War report higher rates of nearly all symptoms examined than their
non-deployed counterparts.'' Because Gulf War veterans report multiple
symptoms, they cannot have ``a single type of health problem.''
In 1995, the Centers for Disease Control and Prevention (CDC) performed a
study of 1,155 Gulf War veterans and 2,520 non-deployed veterans. (Fukuda, et
al., 1998) Each veteran was asked about 35 symptoms. Gulf War veterans
reported significantly higher rates of 34 of the 35 symptoms than the controls
(all except hay fever and other allergies). The authors developed a working
case definition of a ``chronic multisymptom illness (CMI),'' using the ten
symptoms that were the most frequent in Gulf War veterans. The working case
definition of CMI was one or more chronic symptoms, in at least 2 of 3
categories (fatigue, mood-cognition, and musculoskeletal), for at least 6
months. CDC cautioned that CMI was not ``a definitive label for a single,
distinct illness.'' CMI is not a recognized medical disease, such as
hypertension or diabetes; therefore, CMI does not have an ICD-9 code. CDC
used this empirically derived definition to compare the rates of CMI in Gulf
War veterans and controls (45 percent vs. 15 percent). CDC concluded: ``Our
finding that 15 percent of non-deployed also met illness criteria was equally
important and suggests that the multisymptom illness we observed in this
population is not unique to Gulf War service.'' They also concluded: ``Poorly
characterized illness, including fatigue, neurocognitive, and musculoskeletal
complaints, has affected veterans of many other wars.''
The VA Longitudinal Health Study of Gulf War Era Veterans (Blanchard, et al.,
2006; Eisen, et al., 2005; Kang, et al., 2000) began in 1995 and has resulted
in many publications. The first phase was a survey of 11,441 Gulf War veterans
and 9,476 non-deployed veterans, who were asked about 48 symptoms. Gulf War
veterans reported higher rates of all 48 symptoms than did the controls. The
second phase of this national VA study involved comprehensive medical
examinations of a subgroup that included 1,061 Gulf War veterans and 1,128
non-deployed veterans. The authors used the CDC definition of ``chronic
multisymptom illness''; that is, one or more symptoms from two or more of the
categories of fatigue, musculoskeletal pain, and/or mood and cognitive
abnormalities, for at least 6 months. Veterans of the 1991 Gulf War reported
significantly higher rates of CMI than non-deployed veterans did (28.9 percent
vs. 15.8 percent). The overall conclusion was: ``Ten years after the 1991 Gulf
War, CMI is twice as prevalent in deployed veterans but still affects 15
percent of non-deployed veterans.''
The authors of this national VA study did not conclude that the 1991 Gulf War
veterans had ``a single type of health problem.'' (Blanchard, et al., 2006;
Eisen, et al., 2005; Kang, et al., 2000) In fact, the rates of many different
illnesses were evaluated in the two groups of veterans. These illnesses
included peripheral neuropathy, skin conditions, hypertension, hepatitis,
obstructive lung disease, diabetes, thyroid disease, anemia, and renal
disease. The rates of some illnesses were higher in the non-deployed veterans
(controls) than in the 1991 Gulf War veterans, including hypertension
(12.6 percent in non-deployed veterans vs. 9.1 percent in Gulf War veterans),
peripheral neuropathy (5.9 percent vs. 4.8 percent), and obstructive lung
disease (5.9 percent vs. 4.5 percent).
REFERENCES:
Institute of Medicine. Gulf War and Health, Volume 4: Health Effects of
Serving in the Gulf War. Washington, DC: National Academies Press, 2006.
Fukuda K, Nisenbaum R, Stewart G, Thompson WW, Robin L, Washko RM, Noah DL, Barrett DH, Randall B, Herwaldt BL, Mawle AC, Reeves WC. Chronic multisymptom
illness affecting Air Force veterans of the Gulf War. JAMA. 1998 Sep
16;280(11):981-8.
Blanchard MS, Eisen SA, Alpern R, Karlinsky J, Toomey R, Reda DJ, Murphy
FM, Jackson LW, Kang HK. Chronic multisymptom illness complex in Gulf War I
veterans 10 years later. Am J Epidemiol. 2006 Jan 1;163(1):66-75.
Eisen SA, Kang HK, Murphy FM, Blanchard MS, Reda DJ, Henderson WG,
Toomey R, Jackson LW, Alpern R, Parks BJ, Klimas N, Hall C, Pak HS, Hunter
J, Karlinsky J, Battistone MJ, Lyons MJ; Gulf War Study Participating
Investigators. Gulf War veterans' health: medical evaluation of a U.S. cohort.
Ann Intern Med. 2005 Jun 7;142(11):881-90.
Kang HK, Mahan CM, Lee KY, Magee CA, Murphy FM. Illnesses among United
States veterans of the Gulf War: a population-based survey of 30,000 veterans.
J Occup Environ Med. 2000 May; 42 (5):491-501.
Question. Do you think it is appropriate for the DOD to continue to research
into treatments of Gulf War Illnesses?
Answer. DOD agrees with the conclusions of the Institute of Medicine (IOM)
regarding research priorities on illnesses in veterans of the 1991 Gulf War.
The IOM reviewed more than 850 medical studies in its 2006 report, entitled
Gulf War and Health, Volume 4: Health Effects of Serving in the Gulf War. IOM
concluded: ``Our committee does not recommend that more such studies be
undertaken for the Gulf War veterans, but, there would be value in continuing
to monitor the veterans for some health end points, specifically, cancer,
especially brain and testicular cancers, neurological diseases including
amyotrophic lateral sclerosis (ALS), and causes of death.''
DOD and the Department of Veterans Affairs (VA) have funded multiple projects
related to these health end points, as follows:
Cancer: VA has funded studies to evaluate the rates and types of
cancer in Gulf War veterans over time.
Neurological diseases, including ALS: DOD and VA have funded
multiple studies of neurological diseases in Gulf War veterans, including
ALS. VA started a National ALS Registry in 2003 to identify and evaluate ALS
diagnosed in all veterans nationwide.
Causes of death: VA has monitored the causes of death in Gulf War
veterans, since the end of the conflict in 1991. This mortality study will
continue indefinitely.
Question. Some have said that now that veterans that served in the Gulf War
are no longer active duty ``soldiers'' that they are not the concern of the
DOD and they are VA's problem. Do you agree with such statements?
Answer. The Department of Defense (DOD) cares about the health of
servicemembers from the time of accession to the time of separation and
beyond. Although DOD can only provide medical care to active-duty members and
military retirees, DOD works with the Department of Veterans Affairs (VA) to
understand the health of veterans, so that improvements can be made to protect
the health of servicemembers in the future. The Millennium Cohort Study is an
example of a major collaborative effort between DOD and VA. This 21-year study
of 140,000 servicemembers will evaluate the long-term effects of military
service and combat deployments.
Question. Why didn't the DOD request money specifically for Gulf War Illnesses
research in fiscal year 2008?
Answer. Research projects on illnesses in 1991 Gulf War veterans are included
within the Force Health Protection research program. The DOD research program
on illnesses in 1991 Gulf War veterans was established in 1994. This program
was renamed the Force Health Protection program in 2002. While the program
continued to support research on illnesses in 1991 Gulf War veterans, the
focus was expanded to include current and future military deployments and to
include methods to respond better to the health care needs of deployed
servicemembers. DOD is concerned about the short-term and long-term health
effects of deployments and military service for all of its servicemembers.
Therefore, the expanded research program will improve the health of
servicemembers of all eras.
Deployment health-related research is performed at local, Service, and
interagency collaborative levels to maintain and improve quality care in an
environment of expanding knowledge. At the present time, DOD is funding 183
deployment health-related research projects. These focus on a wide variety of
physical health and mental health topics. For example, there are 18 projects
on traumatic musculoskeletal injuries; 40 projects on traumatic brain and
spinal cord injuries; 27 projects on mental disorders, including Post
Traumatic Stress Disorder; 23 projects on infectious diseases; and 21
projects on environmental and occupational exposures.
Question. Will the DOD request research Dollars specifically for Gulf War
Illnesses in fiscal year 2009?
Answer. The Department of Defense (DOD) believes research should identify
causes of health concerns among servicemembers who deploy, but does not
believe it is necessary to restrict research to a subset of deploying members.
Therefore, DOD will request research funding in fiscal year 2009 for the Force
Health Protection research program, but not specifically for illnesses in 1991
Gulf War veterans.
The DOD research program on illnesses in 1991 Gulf War veterans was
established in 1994. This program was renamed the Force Health Protection
program in 2002. While the program continued to support research on illnesses
in 1991 Gulf War veterans, the focus was expanded to include current and
future military deployments and to include methods to respond better to the
health care needs of deployed servicemembers. DOD is very concerned about the
short-term and long-term health effects of deployments and military service
for all of its servicemembers. Therefore, the expanded research program is
designed to improve the health of servicemembers of all eras. At the present
time, DOD is funding 183 deployment health-related research projects.
Question. Do you think that researching Gulf War Illnesses and treatments for
these illnesses can have a positive impact on care for and protection of
current and future U.S. servicemembers given the prevalence of toxic exposures
and other chemical threats on the modern battlefield?
Answer. The research projects in the Force Health Protection research program
will benefit veterans of all eras. Research projects on illnesses in 1991
Gulf War veterans are included within the Force Health Protection program.
The Department of Defense (DOD) is concerned about the short-term and
long-term health effects of deployments and military service for all of its
servicemembers. Therefore, DOD is funding 183 deployment health-related
research projects. In particular, 21 projects specifically focus on the
effects of toxic exposures and other chemical threats on the
modern battlefield.
Question. A recent news story in the New York Sun (Veterans' Rare Cancers
Raise Fears of Toxic Battlefields, August 6, 2007, attached below) reported
that some soldiers returning from the war in Iraq are beginning to experience
a strange set of illnesses including cancer. Has DOD taken any action on this
issue?
Answer. The Department of Defense (DOD) is fully committed to maintaining the
health of all its servicemembers, especially those who have deployed to a
combat zone; and DOD is monitoring the health of servicemembers who have
returned from Iraq and Afghanistan. The Army Medical Surveillance Activity
(AMSA) published a report on the health of servicemembers who had deployed to
Operation Iraqi Freedom (OIF) or Operation Enduring Freedom (OEF) and had
returned to the US during the period of January 1, 2002 to September 30, 2006.
(MSMR, 2007) This study evaluated the rates and types of hospitalizations
during the first 12 months after the return home. The hospitalization rate for
all types of cancer was 0.1 percent.
In a 2006 report, AMSA compared the rates of medical diagnoses of individuals
who had deployed to OIF or OEF during their first year back in the US, with
the diagnoses of other active-duty members. (MSMR, 2006) Records of
hospitalizations and clinic visits were evaluated for the period of December
2001 to December 2005. The overall rate of new diagnoses was approximately
one-third lower in the deployed group than in the controls. The overall rate
of all types of cancer in the deployed group was 0.5 percent, which was
similar to the rate in the control group. The rate of cancer diagnosis was
higher than the rate of cancer in the 2007 study (above), because the 2007
study included hospitalization data only. The 2006 data included diagnostic
data from outpatient clinic visits, which would include less serious
cancers, such as skin cancer.
Diagnosis of cancer is tragic, especially if it is a cancer that is difficult
to treat. The Institute of Medicine has stated that health outcomes of
veterans should be followed over time and that cancers are an important group
of diseases to evaluate. DOD agrees and plans to follow the health of these
veterans over time.
REFERENCES
[No authors] Hospitalization experience within 1 year after returning from
Afghanistan or Iraq, January 2002-September 2006. Medical Surveillance Monthly
Report 2007 May; 14(2):2-10.
[No authors] Medical experiences of servicemembers within 1 year after
returning from deployments in central Asia/Middle East, active components, US
Armed Forces. Medical Surveillance Monthly Report 2006 March; 12(2):2-9.
Question. The benefits of research on Gulf War Illnesses will help current and
future soldiers, not to mention the public at large. As we all know, there
have been numerous instances in Iraq where insurgents there have exploded
chlorine bombs in attacks against our troops and Iraqi civilians and soldiers.
As the Washington Post explained in a March 8th, 2007 article ``[t]hree trucks
rigged with chlorine and explosives blew up in the Sunni insurgent center of
Anbar province Friday, killing at least eight people and sickening hundreds
. . . Chlorine causes wheezing, coughing and skin irritation and can be fatal
in heavy concentrations.'' We all know that the signature wound of the Iraq
war is the Traumatic Brain Injury. But we all also understand that our
soldiers are not just exposed to these types of blasts but also other toxins
and chemical agents. We have learned in this war and in past wars that those
that battle against our troops will do anything they can do to harm them
including exposing them to harmful toxins. Do you agree that this research on
Gulf War Illnesses has the ability to help us develop diagnostic tools and
treatments for such exposure?
Answer. The Department of Defense (DOD) research program on this issue
encompasses much more than just Gulf War Illness. DOD has been concerned
about the potential health effects of toxic chemicals since the first use of
chemical warfare agents in World War I, including the use of chlorine gas.
For that reason, for many decades DOD has supported extensive research on the
potential health effects of toxic chemicals, including chlorine gas and other
chemical agents. DOD has supported comprehensive research on methods of
detection and analysis of chemicals, countermeasures to prevent adverse
effects, diagnostic tools, including biomonitoring, and treatments.
DOD has long recognized the adverse effects of moderate to high concentrations
of toxic chemicals. In the 1990's, in response to the need for a more
targeted research plan on the potential health effects of low-level chemical
exposure, DOD developed a comprehensive approach to respond to Defense
Technology Objective CB.51, which is Low-Level Operational Toxicology of
Chemical Warfare Agents. DOD continues to support robust research programs
related to toxic chemicals, including the research programs of the US Army
Medical Research Institute of Chemical Defense and the Edgewood Chemical
Biological Center.
DOD has funded many research projects related to diagnostic tools and
treatments for chemical exposure at universities and independent research
institutes. These projects have included investigations of sarin and other
chemical warfare agents, pesticides, and other chemicals, and studies of
diagnostic tools such as acetylcholinesterase, butyrylcholinesterase,
neuropathy target esterase, and paraoxonase. DOD has funded projects at the
following universities and institutes: University of North Carolina,
University of Nebraska, University of Texas, University of Montana,
University of California at Davis, Purdue University, University
of Florida, Duke University, Southern Illinois University, Oklahoma State
University, University of California at Los Angeles, Midwest Research
Institute, and Lovelace Research Institute.
Dr. Kupersmith?
STATEMENT OF JOEL KUPERSMITH, M.D., CHIEF RESEARCH
AND DEVELOPMENT OFFICER, VETERANS HEALTH
ADMINISTRATION, DEPARTMENT OF VETERANS AFFAIRS;
ACCOMPANIED BY TIMOTHY O'LEARY, M.D., PH.D., DIRECTOR
OF BIOMEDICAL LABORATORY AND CLINICAL SCIENCE
RESEARCH AND DEVELOPMENT SERVICES, DEPARTMENT
OF VETERANS AFFAIRS
Dr. KUPERSMITH. Madam Chairman and Members of the Committee,
thank you for the opportunity to appear before you today
to discuss the Department of Veterans Affairs Persian Gulf research
programs. With me is Dr. Timothy O'Leary, Director of Biomedical
Laboratory and Clinical Science Research.
For more than 80 years, VA research has responded to veterans'
needs with landmark contributions to medicine. VA investigators
led the way in developing the cardiac pacemaker, pioneered concepts
that led to the development of the CAT scan, and improved
artificial limbs. VA investigators are among the best in their field,
with three Nobel Laureates and six Lasker Award winners. While
the focus of VA research has been on benefiting current and future
veterans, ultimately, VA research impacts the entire Nation.
During and after their return from the Kuwaiti theater of operations,
a proportion of Gulf War veterans reported a range of
chronic symptoms and health problems at rates that exceeded nondeployed
veterans. These symptoms include persistent headaches,
joint and muscle pain, extreme fatigue, cognitive problems, gastrointestinal
difficulties, sleep disturbances, and skin abnormalities.
Although the precise causes for these symptoms remains elusive,
the fact that these veterans are ill and suffer adverse effects on
their daily lives remains unquestioned.
Accordingly, VA continues to support a broad research portfolio
dedicated to understanding chronic multi-system illness, long-term
health effects of potentially hazardous exposures, and conditions
that may be occurring with higher prevalence in Gulf War veterans.
Here are the results of a few past projects.
In 1995, the National Health Survey of Gulf War veterans and
their families used mail surveys to demonstrate that Gulf War veterans
were nearly twice as likely to report symptoms that included
joint, muscle, respiratory, gastrointestinal, and skin problems.
Complaints of emotional and cognitive difficulties were also common.
Dr. Seth Eisen, who is now part of the VA Office of Research
and Development's Senior Leadership Team, conducted a 10-year
follow-up to the 1995 National Health Survey. The study concluded
that although the physical health of deployed and non-deployed
veterans was generally similar, fibromyalgia, chronic fatigue syndrome,
skin conditions, and gastrointestinal problems remained
more prevalent among the deployed than the non-deployed veterans.
A VA clinical trial on the use of the antibiotic doxycycline by patients
with chronic symptoms who were infected with a microorganism
microplasma found improvement at 3 months. However, this
improvement did not last for the remainder of the trial. This may
be related to the higher incidence of nausea and light sensitivity
reported by patients taking the drug. This highlights that we must
be very careful when testing new therapies to do no harm.
Another VA clinical trial compared cognitive behavioral therapy,
aerobic exercise, and a combination of the two therapies and demonstrated
that cognitive behavioral therapy, with or without exercise,
produced modest but significant improvement in physical
functioning, fatigue, mental health functioning, cognitive symptoms,
and stress.
VA remains committed to pursuing new treatments for ill Gulf
War veterans. Clinical trials are currently underway to examine
new therapies for sleep disturbances and gastrointestinal problems
and to test the feasibility of behavioral therapy via telephone.
Another major focus of VA's current Gulf War research is to identify
biomarkers or biologic indicators that can distinguish ill Gulf
War veterans from their healthy counterparts. Biomarkers may
provide clues to understanding why these veterans are ill and may
provide a means of testing the effectiveness of new therapies. VA
projects in this area range from genetic markers, to advanced
neuroimaging procedures, to altered protein profiles in blood or cerebrospinal
fluid.
You have already heard from Dr. White this morning about one
of these neuroimaging projects. Additional neuroimaging projects
will be performed as part of our contract with the University of
Texas-Southwestern Medical Center.
While the bulk of VA's current research is aimed at understanding
chronic multi-symptom illness, we have not neglected the
importance of other diagnosable conditions, such as brain cancer,
amyotrophic lateral sclerosis, and multiple sclerosis. VA maintains
additional research portfolios in each of these areas, since they impact
veterans of all deployments.
Because of concerns about the risk of MS and brain cancer in
Gulf War veterans, VA is funding studies to examine the prevalence
and risk for developing these conditions. In addition, VA has
established a Gulf War Brain Bank to collect and store postmortem
specimens for future investigators.
It is important to note that VA research continues to have a constructive
relationship with the Research Advisory Committee on
Gulf War Veterans' Illnesses. This dedicated service by these Committee
Members in support of veterans who served in the Gulf War
is greatly appreciated.
In conclusion, VA remains committed to funding scientifically
meritorious research projects that improve our understanding of
Gulf War veterans' illness and enhance our ability to diagnose and
treat ill Gulf War veterans. Moreover, the knowledge we gain from
these efforts may improve our ability to prevent and treat illnesses
affecting participants of current and future deployments.
Madam Chairman, that concludes my statement. I am pleased to
respond to any questions that you or the Committee Members may
have. Thank you.
[The prepared statement of Dr. Kupersmith follows:]
PREPARED STATEMENT OF JOEL KUPERSMITH, M.D., CHIEF RESEARCH
AND DEVELOPMENT OFFICER, DEPARTMENT OF VETERANS AFFAIRS
Mr. Chairman and Members of the Committee, thank you for the invitation to
appear before you today to discuss the Department of Veterans Affairs (VA)
Persian Gulf War research programs. I appreciate this opportunity to discuss
the vital role VA research has in ensuring the health and well-being of our
Nation's veterans. With me is Dr. Timothy O'Leary, Director of Biomedical
Laboratory and Clinical Science Research and Development. I would like first
to give a brief overview of the VA research program.
OVERVIEW OF THE VA RESEARCH PROGRAM
Dating back more than 80 years, VA research has responded to veterans' needs
with landmark contributions to medicine. VA investigators have led the way in
developing the cardiac pacemaker, pioneered concepts that led to the
development of the CAT scan and improved artificial limbs. VA investigators
are distinguished as among the best in their field with three Nobel Laureates
and six Lasker Award winners. VA research is a valuable investment with
remarkable and lasting returns.
Because more than 70 percent of VA researchers are also clinicians who take
care of patients, VA is uniquely positioned to move scientific discovery from
investigators' laboratories to patient care. In turn, VA
clinician-investigators identify new research questions for the laboratory
at the patient's bedside, making the research program one of VA's most
effective tools to improve the care of veterans. The fundamental
goal is to address the needs of the entire veteran population from the young
recruit who returns with injuries from recent conflicts to the aging veteran,
and to use research findings proactively to benefit the future veteran.
It is important to note that VA has implemented a substantial and
comprehensive research agenda to develop new treatments and tools for
clinicians to ease physical and psychological pain, improve access to VA
healthcare services and address the full range of health issues of Operation
Iraqi Freedom and Operation Enduring Freedom (OIF/OEF) veterans.
VA research is an intramural program that is also fully integrated with the
larger biomedical research community through VA's academic affiliations and
collaborations with other organizations. VA scientists partner with colleagues
from other Federal agencies, academic medical centers, nonprofit organizations
and commercial entities nationwide, further expanding the reach and scope of
VA research.
While the focus of VA research is on benefiting current and future veterans,
it also impacts veteran families and caregivers, VA healthcare providers,
Veterans Service Organizations, other components of the Federal research
establishment, academic health centers and practitioners of healthcare across
the country. Ultimately, VA research impacts the entire Nation.
Let me now discuss VA's Persian Gulf War research programs.
BACKGROUND
In response to Iraq's occupation of Kuwait in August 1990, the United States
deployed military personnel to Southwest Asian in support of Operations Desert
Shield and Desert Storm. At the conclusion of the first year of operations on
July 31, 1991, the United States had deployed 696,841 military personnel from
all five services to the Kuwaiti Theater of Operations (KTO).
During and after their return from the KTO, a proportion of Gulf War veterans
reported a range of chronic symptoms and health problems at rates that
exceeded non-deployed era veterans. These symptoms include: persistent
headaches, joint pain, extreme fatigue, muscle pain, cognitive problems,
gastrointestinal difficulties, sleep disturbances and skin abnormalities.
As of November 2004, more than 30 percent of veterans who served in the 1990-
1991 Gulf War had been service-connected for conditions associated with their
military service, although fewer than 3,300 had been service-connected for the
special ``undiagnosed illness'' category established for Gulf War veterans. It
is recognized that there exists a much larger number of Gulf War veterans with
multiple, chronic symptoms who have not sought or received service-connected
status.
OVERVIEW OF THE FEDERAL RESEARCH PORTFOLIO ON GWVI
In an effort to better understand the health conditions and health problems
experienced by Gulf War veterans, VA, the Department of Defense (DOD) and the
Department of Health and Human Services (HHS) have supported numerous research
projects related to Gulf War veterans' illnesses (GWVI). As of September 30,
2006, the three Departments have funded a total of 330 distinct projects
pertaining to the health consequences of military service in the Gulf War, as
described in Annual Reports to Congress on federally Sponsored Research on
Gulf War Veterans' Illnesses, totaling $314 million. VA has funded 153 of
these projects--eight in conjunction with DOD--totaling $84.8 million. As of
the close of FY 2006, 223 projects (68 percent of the 330 projects) were
completed and 107 projects (34 percent) were new or ongoing.
The Federal research portfolio on GWVI can be generally divided into five
research focus areas:
Brain and Nervous System Function (e.g., studies on neurological or
psychological deficits and/or alterations);
Environmental Toxicology (e.g., studies focused on specific
environmental exposures such as pesticides, oil well fires, jet fuel,
vaccines and medical prophylactic agents);
Immune Function and Infectious Diseases (e.g., studies on
alterations in immune function, host defenses or detection and treatment of
infectious diseases);
Reproductive Health (e.g., studies on sexual or reproductive
dysfunction); and
Symptoms and General Health (e.g., studies on pulmonary disease,
cancer, chronic multisymptom illnesses and mortality).
While each Department funds its GWVI research independently, each closely
coordinates its efforts with the others to avoid duplication of effort and to
foster the highest standards of competition and scientific merit review for
all research on GWVI. The Research Subcommittee of the interagency Deployment
Health Working Group currently conducts this coordination and compilation of
the Annual Reports to Congress on federally Sponsored Research on Gulf War
Veterans' Illnesses.
STATUS OF THE VA RESEARCH PORTFOLIO ON GWVI
In FY 2006, VA supported 67 GWVI research projects for a total of $12.9
million. Nineteen of these were new projects examining brain and nervous
system function, environmental toxicology, immune function and infectious
diseases and symptoms and general health. VA is projecting a direct
expenditure of $6.8 million for new and ongoing research projects in FY 2007.
The expenditures in FY 2006 and FY 2007 are in addition to the allocation of
$15 million per year to support a contractual agreement with the University
of Texas Southwestern Medical Center for research related to illnesses
affecting Gulf War veterans.
The VA Gulf War research program has been at the forefront of the field from
the outset. In 1995, VA initiated The National Health Survey of Gulf War
Veterans and Their Families. The first two phases of this study used surveys
of self-reported symptoms mailed to 15,000 Gulf War veterans and 15,000
non-deployed veterans to demonstrate that Gulf War veterans were nearly twice
as likely to report diverse symptoms, including joint, muscle, respiratory,
gastrointestinal and skin problems. This population also reported higher
rates of chronic fatigue (5.6 percent for Gulf War veterans vs. 1.2 percent
for non-deployed veterans) and symptoms of Post Traumatic Stress Disorder
(PTSD) (12.1 percent for Gulf War veterans vs. 4.3 percent for non-deployed
veterans). The final phase of the study, which completed recruitment
in 2001, relied on complete physical examinations (including a neurological
exam) of 1,061 Gulf War veterans and 1,128 non-deployed veterans and found
that Gulf War deployment was associated with a significantly increased risk
of chronic fatigue syndrome (5.6 percent for Gulf War veterans vs. 1.2 percent
for non-deployed veterans) 10 years after redeployment. In addition, Gulf War
deployment was associated with increased prevalence of PTSD, other
psychological disorders and poorer self-reported quality of life. The study
findings did not indicate increased prevalence for objectively measured
cognitive impairment. Researchers found no significant physical health
outcomes of clinical concern among spouses of deployed or non-deployed
veterans. In addition, the investigators found that Gulf War deployment of
a parent was not associated with any significant differences in the frequency
of birth defects compared to children of non-deployed veterans.
In 1998, VA began planning for two treatment trials referred to as the
``EBT'' (exercise-behavioral therapy) and ``ABT'' (antibiotic treatment)
trials. Both addressed similar patient characteristics and were open to all
veterans who served in the Gulf War between August 1990 and July 1991. To be
eligible for inclusion in the trials, a veteran must have had at least two of
three symptoms (fatigue, musculoskeletal pain and cognitive dysfunction) that
began after August 1990, the symptoms must have persisted for more than 6
months and they must have been symptomatic when the study began.
VA conducted the $9.6 million EBT study between 1999 and late 2001, and 1,092
veterans participated at 18 VA and 2 DOD medical centers. All groups continued
their usual healthcare. In addition, three groups received cognitive behavior
therapy (CBT), aerobic exercise or a combination of the two therapies. The
results, reported in the March 19, 2003, issue of the Journal of the American
Medical Association, showed that CBT, with or without exercise, provides
modest but significant improvement in physical functioning, mental health
functioning, cognitive symptoms, fatigue and distress.
Enrollment for the ABT trial began in May 1999 and eventually included 491
Gulf War veterans at 26 VA and 2 DOD sites. The study's primary hypothesis
was that antibiotic treatment, with doxycycline for 12 months, would improve
the health status of patients with chronic symptoms who tested positive for
Mycoplasma infection at baseline. Secondary hypotheses included that the
doxycycline treatment would reduce symptoms of fatigue, pain and memory
problems; and that doxycycline treatment would convert patients who were
Mycoplasma positive to Mycoplasma negative. The trial was completed in
December 2001, when patient follow-up was finished. Although the $10 million
trial did not result in a new treatment modality for Gulf War veterans, the
failure to substantiate any of the hypotheses has enabled
investigators to focus their time and resources to other lines of inquiry.
VA also supported a recent study led by Dr. Seth Eisen, now Director of VA's
Health Services Research and Development Service, to assess and compare the
prevalence of fibromyalgia, chronic fatigue syndrome, skin conditions,
dyspepsia, physical health-related quality of life, hypertension, obstructive
lung disease, arthralgias and peripheral neuropathy in a group of deployed
and non-deployed Gulf War veterans. The study concluded that 10 years after
the Gulf War, the physical health of deployed and non-deployed veterans is
generally similar, with four of the conditions studied found to be more
prevalent among deployed than non-deployed veterans: fibromyalgia, chronic
fatigue syndrome, skin conditions and dyspepsia. There were no significant
differences between deployed and non-deployed veterans related to the other
studied conditions.
VA's commitment to funding clinical trials to identity new therapies for ill
Gulf War veterans continues to this day. Three pilot clinical trials are
currently underway to examine two new therapies for sleep disturbances and
gastrointestinal problems, and to test the feasibility of performing CBT via
telephone with Gulf War veterans; CBT was found to provide modest but
significant improvement in physical functioning, mental health functioning,
cognitive symptoms, fatigue and distress in the earlier exercise-behavioral
therapy trial done on an inpatient basis.
Another major focus of the current Gulf War research portfolio is to identify
objective markers (i.e., biomarkers or tests) that can distinguish ill Gulf
War veterans from their healthy counterparts. Such biomarkers serve two vital
purposes. First, they may provide critical clues to understand mechanisms
responsible for how and why these veterans are ill. Second, they may provide
objective measures for testing the effectiveness of new therapies. VA
currently funds 12 such projects, ranging from genetic markers, to advanced
neuroimaging procedures, to altered protein profiles in blood or
cerebrospinal fluid.
Accordingly, VA supports a broad research portfolio composed of studies
dedicated to understanding chronic multi-symptom illnesses, long-term health
effects of potentially hazardous substances to which Gulf War veterans may
have been exposed to during deployment and conditions or symptoms that may be
occurring with higher prevalence in Gulf War veterans.
Recently, the Institute of Medicine reviewed the available published
literature and concluded that Gulf War and other combat veterans may be at
increased risk for amyotrophic lateral sclerosis (ALS, also known as Lou
Gehrig's disease) as a result of their service. Of the studies included in
this review, the largest prevalence study devoted to that devastating disease
was one funded by VA in cooperation with DOD. The study, which included all
2.5 million Gulf War era veterans, identified and confirmed by medical record
review ALS cases occurring over a 10-year period starting from August 1990.
Investigators found that among Gulf War veterans, the rate of disease was 6.7
per million. Among other military personnel, it was 3.5 per million. Since
researchers still do not know why Gulf War veterans have a higher rate of ALS,
VA expanded the study to include a national registry for veterans with
ALS and a genetic tissue bank (ALS-DNA) for this registry. The goals of the
registry are to identify as completely as possible all veterans with ALS, not
just Gulf War era veterans, and to provide a mechanism for VA to inform
veterans with ALS about clinical drug trials and other studies for which they
may be eligible. VA continues to fund other ALS research, including clinical
trials and animal model of the disease, to study potential disease mechanisms
and test new therapies.
Because of persistent concerns about the risk of multiple sclerosis (MS) and
brain cancer in Gulf War veterans, in 2008 VA will begin a large study to
identify the date of onset and clinical subtype of all Gulf War MS
service-connected cases between 1990 and 2006. This study will also attempt
to quantify the risk for developing MS in Gulf War veterans deployed to the
combat theater versus those not deployed, as well as the risk for developing
MS in Gulf War veterans potentially exposed to smoke from oil well fires or
sarin. Another project is examining the overall and cause-specific mortality
risk of ALS, MS or brain cancer in a group of more than 620,000 Gulf War
veterans and assessing the in-theater exposure characteristics associated
with those deaths. VA supports several additional projects examining MS,
as well as basic science and rehabilitation research centers with a focus
on MS. Further, VA has established a Gulf War brain bank to collect and store
postmortem specimens for future investigations.
COLLABORATION WITH THE RESEARCH ADVISORY COMMITTEE ON GWVI
It is important to note that VA research continues to have a positive working
relationship with the Research Advisory Committee on GWVI (RAC), a
congressionally mandated committee that advises the Secretary of Veterans
Affairs. In response to advice provided by the RAC, VA research has performed
an annual portfolio review to ensure the appropriateness of all projects
contained in the portfolio. The RAC's advice has also been sought when
designing new Requests for Applications to solicit additional research
proposals from VA investigators; the RAC was also consulted for
recommendations of appropriate reviewers of these proposals.
The efforts by the RAC have improved the VA GWVI research portfolio and
continue to bring us closer to finding new treatments for ill Gulf War
veterans. The dedicated service by RAC members in support of veterans who
served in the Gulf War is greatly appreciated.
Early on, VA recognized the need to assure training of our healthcare
providers to allow them to best respond to the specific healthcare needs of
Gulf War veterans. With that in mind, and in collaboration with DOD, VA
clinicians developed two Clinical Practice Guidelines that give VA healthcare
providers access to the best medical evidence for diagnoses and treatment. VA
clinicians also developed a study guide to provide information about the
problems and concerns of Gulf War veterans and information about VA programs
to help these veterans. Cumulatively, from October 1990 through October 2004,
VA clinicians provided high quality inpatient and outpatient care to 335,558
Gulf War veterans, or nearly half of the servicemembers deployed to that
conflict.
CONCLUSION
In conclusion, VA remains committed to funding scientifically meritorious
research projects that improve our understanding of GWVI and enhance our
ability to diagnose and treat ill Gulf War veterans. Moreover, the knowledge
we gain from these efforts may improve our ability to prevent and treat
illnesses affecting participants of current and future deployments.
Mr. Chairman, that concludes my statement. I am pleased to respond to any
questions you or the Committee Members may have.
Thank you.
RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. DANIEL K. AKAKA TO THE
SENATE COMMITTEE ON VETERANS' AFFAIRS
Question 1. What steps has VA taken, or plans to take, to expand the screening
of Gulf War veterans for the range of Gulf War Illnesses?
Response. Over the last 16 years since the Gulf War cease-fire, the Department
of Veterans Affairs (VA) has provided high quality health care to over 335,000
Gulf War veterans, or about half of the nearly 700,000 troops deployed in that
confliot.
VA has a broad array of programs to effectively respond to the range of
illnesses seen among Gulf War veterans. Shortly after the 1991 Gulf War
cease-fire, VA established a special Gulf War Veteran Health Examination
Registry program, which has provided specialized examinations for over
100,000 Gulf War veterans as well as 7,325 veterans from Operation Iraqi
Freedom.
Every VA medical center has an environmental health clinician and a
coordinator assigned to assist veterans in obtaining health registry
examinations. Eligible veterans receive a free specialized comprehensive
health examination with blood work, urinalysis (electrocardiogram and chest
x-ray where medically indicated) and answers to questions relating to any
environmental exposures. Review of the diagnoses of these veterans has not
revealed any unusual or unique source of the health problems
they have experienced. The program remains useful for addressing the special
clinical care, education and outreach needs of Gulf War veterans with
deploymentrelated health concerns.
Gulf War veterans as well as Operation Enduring Freedom/Operation Iraqi
Freedom (OEF/OIF) veterans concerned about possible exposure to depleted
uranium (DU) can be evaluated using a special DU exposure protocol that VA
began after the 1991 Gulf War. This program offers free DU urine screening
tests by referral from VA primary care physicians to veterans who have
concerns about their possible exposure to this agent. Gulf War and OIF
veterans are eligible to participate in the VA DU evaluation
protocol/screening program for Gulf War and OIF veterans. OEF
veterans are eligible to participate in the VA DU evaluation
protocol/screening program for non-Gulf War veterans.
In response to health concerns about new combat veterans with retained
embedded fragments from combat injuries in Afghanistan and Iraq, including
blast injuries from improvised explosive devices, the Veterans Health
Administration (VHA) is establishing the Toxic Embedded Fragments Surveillance
Center (TEFSC) at the Baltimore VA Medical Center (VAMC). Lessons learned from
the Baltimore VAMC depleted uranium program show that retained metal fragments
are not inert in the body and may change over time to produce potential toxic
health effects. Such effects may be minimized and managed through careful
ongoing medical surveillance.
In addition, VA developed new clinical guidelines for combat veteran health
care that provide VA health care providers guidelines, based on the best
available medical evidence for diagnosing and treating Gulf War veteran and
all combat veterans relative to (1) post-combat deployment health, and (2)
unexplained pain and fatigue.
In 2001, as part of VA's overall health response for veterans returning from
the 1991 Gulf War, VA established two War-Related Illness & Injury Study
Centers (WRIISCs) at Washington, DC, and East Orange, NJ. Today, they are
providing specialized health care for combat veterans from all deployments who
experience difficult to diagnose or undiagnosed but disabling illnesses.
VA is expanding this program to better meet the health care needs of new
combat veterans suffering from mild to moderate Traumatic Brain Injury. Many
of the longterm chronic health effects from Traumatic Brain Injury appear
similar to the difficult-to-diagnose and treat illnesses currently being
treated by the WRIISC programs today. To that end, VA is establishing a third
WRIISC at the Palo Alto VA Health Care System, in Palo Alto, CA. The new Palo
Alto WRIISC will take advantage of the unique assets available there,
including a polytrauma unit; interdisciplinary program on blast injuries which
integrates the medical, psychological, rehabilitation, and prosthetic needs
of injured servicemembers; its programs in Traumatic Brain Injury, spinal
cord injury, blind rehabilitation, and Post Traumatic Stress Disorder; and
research into new and emerging areas of combat injuries and illnesses.
Question 2. Additionally, does VA have the capacity and resources to provide
all veterans potentially exposed to Sarin nerve gas an assessment to determine
if they have suffered any neurological damage?
Response. VA has the capacity and the resources to thoroughly evaluate any
veteran with evidence of neurological disease on clinical examination. VA is
particularly concerned about possible long-term health effects from exposure
to trace levels of sarin nerve gas that might have been experienced by some
veterans during the 1991 Gulf War.
To help anticipate what illnesses VA health care providers might expect among
veterans exposed to low-levels of nerve agents, VA requested that the National
Academy of Sciences (NAS) Institute of Medicine (IOM) evaluate the many
hundreds of relevant published human and animal studies on this issue. The
initial 2000 NAS committee report concluded that available scientific evidence
could not show an association between trace sarin exposure and subsequent
long-term adverse health effects. In response, the Secretary of Veterans
Affairs determined that there was not an adequate basis to support
establishing presumptive service connection for any long-term health problems
resulting from low-level sarin exposure.
The August 2004 NAS sarin update came to the same conclusions as the earlier
2000 report. In other words, and consistent with their earlier findings, the
NAS committee was not able to find a scientific basis to associate any disease
with exposure to low levels of sarin.
Question 3. The research presented on the web site of VA's Office of Public
Health and Environmental Hazards is over 5 years old. Are veterans getting the
most upto-date information in a timely manner, and when can veterans expect an
update to this important resource?
Response. VA places a high priority on ensuring wide-ranging outreach to all
veterans, including veterans of the Gulf War. VA's Office of Public Health and
Environmental Hazards Web site on Gulf War veteran health issues
(www.va.gov/GulfWar) focuses primarily on health care and clinical issues
rather than on research.
VA has provided a great deal of material to Gulf War veterans and their
families, including information newsletters, brochures, wallet cards, posters,
and other materials, both in print, online and as ``pod casts,'' to ensure
that veterans and their families are kept up to date on VA health care and
other benefits that may affect them.
Some VA outreach materials specifically targeting 1991 Gulf War veterans and
their families is available online at www.va.gov/GulfWar and www.va.gov/
EnvironAgents (see summary of this outreach information, Attachment 1).
Since 1992, VA has published 38 editions of the Gulf War Review newsletter.
The next edition will appear in Fall 2007. That edition will highlight a
number of new NAS reports, and should be of significant interest to Gulf War
veterans and their families.
VA has a wide range of training and educational materials on Gulf War veteran
health issues, aimed at health care providers as well as for veterans and
their families.
Many of these programs have now also been expanded to prepare for veterans
from OEF/OIF and their families. All of these programs represent ``lessons
learned'' from VA's experiences responding to the health care and other
benefits needs of veterans returning from the 1991 Gulf War, and from the
Vietnam War before that.
The most authoritative sources of health information for veterans of the 1991
Gulf War is the series of congressionally mandated Gulf War and health reports
prepared by IOM. These reports review a wide range of Gulf War risk factors,
including health effects from exposure to oil well fire smoke. Summaries of
these reports are available online at www.va.gov/EnvironAgents for the benefit
of both veterans and health care providers.
In addition, VA's Office of Research and Development (ORD) disseminates an
annual report, written jointly with the Departments of Defense (DOD) and
Health and Human Services (HHS), which summarizes federally supported research
on Gulf War veterans' health (available online at http://www.research.va.gov/
resources/pubs/pubs--individual.cfm?Category=Gulf%20Reports).
Question 4. Does VA believe that extramural research is the future of VA's
research and development efforts?
Response. No. VA highly values its intramural research program. One of the
greatest strengths of VA research is that it is an intramural program where
clinical care and research occur together under one roof. For this reason, it
has the capacity to bring scientific discovery from the patient's bedside to
the laboratory bench and then back to the care of patients, making this
program one of VA's most effective tools to improve the care of veterans.
Embedding research within an integrated health care system with a
state-of-the-art electronic health record creates a national laboratory for
the discovery of new medical knowledge and the translation of that
knowledge into improved health for veterans. Furthermore, the opportunity to
conduct research through the intramural program assists VA in recruiting
outstanding clinicians and creates a culture of continuous learning and
innovation ensuring VA's continued leadership in health care.
RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. PATTY MURRAY TO THE
SENATE COMMITTEE ON VETERANS' AFFAIRS
Question 5. Dr. Kupersmith, in 1997, VA's Office of Policy, Planning, and
Preparedness, working with VBA, VHA, and other VA organizational elements,
created the Gulf War Veterans Information System (GWVIS). This system is used
to identify Gulf War servicemembers and monitor, in part; their VBA
compensation and pension benefit use. This provides the best available current
data identifying the 6.6 million Gulf War servicemembers. Unfortunately, it
no longer includes data on the healthcare usage rates of Persian Gulf War
veterans.
Question 5(a). Why does the Gulf War Veteran Information System report no
longer track the healthcare usage among Gulf War veterans in its report?
Response. This information was initially useful for planning for VA health
care for these new veterans, but it is less useful for evaluating the health
of the average Gulf War veteran because it is not a representative sample and
only assesses veterans who come to VA for health care.
To more definitively evaluate the health of Gulf War veterans in general, VA
has turned to a range of well-designed epidemiological studies, including, for
example, VA's ongoing mortality study that evaluates the rates and causes of
death among all Gulf War veterans in comparison to ``control'' groups of
demographically similar but not deployed veterans and the general civilian
population. That study has shown that veterans of the 1991 Gulf War have
essentially identical mortality compared to their non-deployed peers, and less
than one-half the mortality rates compared to similar civilian Americans.
Question 5(b). Why is a similar report not being used to track servicemembers
and veterans in today's conflicts in Iraq and Afghanistan?
Response. Since 2003, VA has been producing a quarterly report on VA health
care use by separated veterans who have served in OEF/OIF, titled Analysis of
VA Health Care Utilization Among US Southwest Asian War Veterans. Based upon
data supplied to VA by the Department of Defense (DOD), this report tracks the
health care use, diagnoses and other information for all newly separated
OEF/OIF veterans. The latest quarterly report, dated July 2007, records
717,196 OEF/OIF veterans who have left active duty and become eligible for VA
health care since fiscal year (FY) 2002, of which 35 percent (252,095) have
obtained VA health care since fiscal year 2002 (cumulative total).
Question 6. The current clinical practice guidelines for Gulf War Illness
referred to by the VA as ``Medically Unexplained Symptoms'' has not been
updated in over 5 years and seems to indicate a psychological cause of the
illness, rather than environmental exposures. Given the existing research,
why haven't the current practice guidelines been updated to reflect the most
recent research findings?
Response. In collaboration with DOD, VA developed two clinical practice
guidelines on combat veteran health issues specifically in response to health
concerns of veterans of the 1991 Gulf War. These include a general guideline
to post-deployment health, and a second dealing with unexplained pain and
fatigue. The clinical guidelines give our health care providers diagnosis and
treatment guidelines based on the best medical evidence of illnesses that are
a particular concern among veterans of the 1991 Gulf War. VA recommends these
for the evaluation and care of all returning combat veterans, including
OEF/OIF veterans.
The subject matter experts within VA and DOD are continually assessing the
need to modify their joint clinical practice guidelines as new research
provides evidence-based justification for changes.
Question 7. An August 2005 study in the American Journal of Public Health by
Dr. Tim Bullman and others, found that Gulf War veterans exposed to nerve
agents during the March 1991 weapons demolitions in Khamisiyah, Iraq, appear
to have a higher risk for brain cancer death than veterans who were not
exposed. Additionally, an IOM report in September of 2006 found evidence that
suggests there may be an elevated rate of Lou Gehrig's disease among Gulf War
veterans.
Question 7(a). Given all this, why is there no permanent mechanism in place to
grant presumptive disability for Gulf War veterans with amyotrophic lateral
sclerosis (ALS) or brain cancer?
Response. VA is concerned with all veterans who are diagnosed with ALS. As
noted, preliminary studies, discussed in a recent report from IOM, Amyotrophic
Lateral Sclerosis in Veterans: Review of the Scientific Literature, show there
may be some association between the onset of ALS and all military service--not
just for veterans of the 1991 Gulf War. VA requested that IOM review the
possible connection between military service and this disease following a
series of scientific studies showing a possible increased risk of ALS among
veterans from the 1991 Gulf War, the Korean War, the Vietnam War and World War
II.
Clearly, VA must pay attention to the findings and conclusions of this recent
IOM report. However, after careful review of IOM's findings, VA has concluded
that the existing research is not conclusive. Therefore, VA's current position
is that the question of whether ALS should have presumptive service connection
requires additional study.
In regard to the need for additional research, VA funds a broad research
portfolio. This includes research focused on understanding the cause(s) of ALS
and on developing appropriate treatments. VA expects that more definitive
answers will result from this research. As an example, several VA
investigators are conducting research specifically about ALS as it relates to
military service during the 1991 Gulf War. In addition, VA looks forward to
research conducted in the private sector and from others in the Federal
sector.
Despite the lack of conclusive research about the causes of ALS, VA offers
high quality treatment and care for veterans diagnosed with this disease. ALS
is a catastrophic illness, and veterans with significant disability are
eligible for VA health care. VA remains committed to providing the best
possible care to veterans diagnosed with this disease and in sponsoring a
broad range of research on treatment, diagnoses and care for ALS patients.
Question 7(b). Dr. Kupersmith, have you informed the VA that relevant evidence
exists to support a permanent presumptive disability for Gulf War veterans
with ALS and brain cancer?
Response. The cited scientific study (Mortality in US Army Gulf War Veterans
Exposed to 1991 Khamisiyah Chemical Munitions Destruction. TA Bullman, CM
Mahan, HK Kang, WF Page. American Journal of Public Health, August 2005,
95(8), 1382-1388) reported an increased risk for brain cancer among 1991 Army
Gulf War veterans possibly exposed to low-levels of chemical warfare nerve
agents at Khamisiyah shortly after the 1991 Gulf War cease-fire. Concerns
about health problems from possible low-level sarin exposure followed
revelations that some Iraqi munitions destroyed by U.S. forces at Khamisiyah
contained this agent. In 1997 and 2000, DOD sponsored modeling of potential
sarin exposure and concluded no Gulf War veteran experienced large exposure,
although about 100,000 veterans could have been exposed to ``very low levels''
(so small as to cause no immediate or obvious poisoning), consistent with
DOD's conclusions that there were no reports of any troops experiencing severe
and immediate sarin exposure.
The cited study reported no difference in overall death rates or overall death
rates from cancer between the exposed and non-exposed Gulf War veterans.
Moreover, overall mortality and mortality for any specific cancer including
brain cancer among these veterans was about half that of the comparable
civilian U.S. population. However, researchers found exposed veterans were
significantly more likely to have died from brain cancer compared to unexposed
veterans, or about 12 excess brain cancer deaths among the 100,487 exposed
veterans over a 9-year period.
There are some important issues with this study that limit its interpretation.
First, Khamisiyah exposure modeling has been soundly criticized as unreliable
by both the Government Accountability Office and by IOM. In their 2004 Update
on sarin health effects, IOM concluded ``Because of the uncertainty in the
[Khamisiyah] exposure assessment models. . . studies [based on that model] do
not provide strong evidence for or against the presence of neurologic
effects.'' Second, the study's authors themselves point out that since sarin
is not a known carcinogen, it may be that the demolitions at Khamisiyah
released other hazardous agents that could have caused the apparent increased
risk of brain cancer death. Sarin specifically and organophosphorus nerve
agents in general, including commonly used pesticides, are not considered to
be carcinogens. Further, the use of multiple statistical comparisons
(apparently more than 60) used in this study could easily have lead to a
spurious statistically significant association.
The study's authors note that additional research is needed to confirm these
findings. The research finding on brain cancer among Gulf War I veterans has
to date been an isolated result of one research study and has not been
verified by numerous other studies of Gulf War veteran populations in the
U.S., UK, Canada, and Australia, which sent troops to fight in the first Gulf
War.
Finally, a 2000 Congressionally mandated review and a 2004 update conducted
by IOM concluded, based upon their review of a large body of scientific
literature including reports using the DOD Khamisiyah modeling, that the
evidence did not support any long-term health effects following sub-clinical
sarin exposure such as that at least potentially experienced by some Gulf War
veterans (Gulf War & Health Vol. 1: Depleted Uranium, Pyridostigmine Bromide,
Sarin, Vaccines Institute of Medicine, National Academies Press, 2000, 408 pp,
and Gulf War & Health: Updated Literature Review of Sarin. Institute of
Medicine, National Academies Press, 2004, 120 pp, at www.nap.edu.).
VA is committed to further research of Gulf War I veterans. Should future
research show a connection between Gulf War I service and brain cancer, the
possibility of presumptive disability will be reassessed.
RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. BERNARD SANDERS TO THE
SENATE COMMITTEE ON VETERANS' AFFAIRS
Question 8. A recent news story in the New York Sun (Veterans' Rare Cancers
Raise Fears of Toxic Battlefields, August 6, 2007, attached) reported that
some soldiers returning from the war in Iraq are beginning to experience a
strange set of illnesses including cancer. Dr. Kupersmith, has the VA heard
about these concerns?
Response. VA is aware of this information and continues to support a robust
deployment health research portfolio that includes studies examining the wide
array of health effects from military exposures--particularly new conditions
or those that are occurring more frequently in veterans from the current
conflict. New studies are then formulated that respond to these new issues.
When making programmatic or policy decisions, VA weighs a broad spectrum of
sources of information, including, but not limited to, information from VA's
funded studies, other peer reviewed publications and IOM.
VA is very concerned about long-term environmental health issues surrounding
any military deployment, and in particular for the current deployments in
Afghanistan and Iraq. Based on our experience responding to the health
concerns of veterans of the 1991 Gulf War, VA has in place today a number of
strong programs that will be invaluable for addressing the environmental and
other deployment-related health concerns of this new generation of combat
veterans, including exposure to depleted uranium and some of the other
examples in the attachment provided by Senator Sanders. Examples include:
Special DU program. Gulf War I veterans concerned about possible exposure to
depleted uranium (DU) can be evaluated using a special DU exposure protocol
that VA began after the 1991 Gulf War. This program offers free DU urine
screening tests by referral from VA primary care physicians caring for
veterans who have concerns about their possible exposure to this agent.
Veterans from the current conflicts in Afghanistan and Iraq are also eligible
to participate in the VA DU evaluation protocol/screening program.
New Toxic Embedded Fragments Surveillance Center. In response to health
concerns about new combat veterans with retained embedded fragments from
combat injuries in Afghanistan and Iraq, including blast injuries from
improvised explosive devices, VHA is establishing the Toxic Embedded Fragments
Surveillance Center (TEFSC) at the Baltimore VA Medical Center.
Lessons learned from the Baltimore VA DU program show that retained metal
fragments are not inert in the body and may change over time to produce
potential toxic health effects. Such effects may be minimized and managed
through careful ongoing medical surveillance. Potential long-term toxicity is
now a concern for new combat veterans suffering from injuries that produce
many different types of embedded metal fragments. New studies indicate that
some metals, such as certain tungsten alloy fragments, are highly carcinogenic
in rats and may pose a health hazard in veterans. Some metals are also known
or presumed to be human reproductive hazards, including lead, cadmium, nickel,
and copper. In response, VA is expanding the Baltimore VA Depleted Uranium
surveillance program into the new Toxic Embedded Fragments Surveillance
Center.
VA Long-Term Health and Mortality Studies. VA has initiated mortality and
morbidity studies designed to provide solid scientific answers about the risks
of OEF/OIF veterans for various types of cancers and other diseases. These
are similar to ongoing morbidity and mortality studies conducted by VA that
follow the health of Vietnam War veterans and 1991 Gulf War veterans.
A New VA War-Related Illness & Injury Study Center (WRIISC). The new
WRIISC will focus on combat veterans with mild and moderate Traumatic Brain
Injury: To respond to the health care needs of new combat veterans suffering
from mild to moderate Traumatic Brain Injury, VHA is establishing a third
WRIISC at the Palo Alto VA Health Care System. Many of the long-term chronic
health effects reported for Traumatic Brain Injury resemble the sort of
difficult to diagnose and treat illnesses currently being evaluated and
treated by the existing WRIISC programs.
Enhanced Outreach to New Combat Veterans on Deployment-Health Issues. VA
has many new outreach and information products to offer combat veterans and
their families, including:
The Secretary of Veterans Affairs sends a letter to every newly
separated OEF and OIF veteran, based on records for these veterans provided to
VA by DOD. The letter thanks the veteran for their service, welcomes them
home, and provides basic information about health care and other benefits
provided by VA.
In collaboration with DOD, VA published and distributed one million
copies of a short brochure called A Summary of VA Benefits for National Guard
and Reservists Personnel. The new brochure does a tremendous job of
summarizing health care and other benefits available to this special
population of combat veterans upon their return to civilian life (available
online at www.va.gov/EnvironAgents).
Health Care and Assistance for U.S. Veterans of Operation Iraqi
Freedom is a brochure on basic health issues for that deployment (available
online at www.va.gov/EnvironAgents).
OEF and OIF Review is a new newsletter mailed to all separated
OEF/OIF veterans (nearly 700,000 individuals as of May 2007) and their
families, on VA health care and assistance programs for these newest veterans
(available online at www.va.gov/EnvironAgents).
VA Health Care and Benefits Information for Veterans is a wallet card
that nicely summarizes all VA health and other benefits, along with contact
information, in a single, wallet-sized card for easy reference (available
online at www.va.gov/EnvironAgents).
Question 9. As you know, the VA is supposed to regularly send out the Gulf War
Review newsletter. Its purpose is to ``help veterans of the 1991 Gulf War and
their families be more aware of VA's health care and other benefits that are
available for them, and of new research results on Gulf War veterans' health.
The Gulf War Review newsletter, is supposed to be regularly mailed out to over
400,000 veterans from that conflict.
Question 9(a). Can you tell the Committee when the last time was that the VA
sent out the Gulf War Review newsletter?
Response. The latest issue of the Gulf War Review was published July 2006. The
next issue of the Gulf War Review will be released after receiving the new IOM
report on health effects from deployment-related stress. The IOM report is
expected to be released in October 2007 with the next Gulf War Review release
by the end of calendar year 2007.
Question 9(b). It is my understanding that the Newsletter is only sent out
electronically, is that correct?
Response. The Gulf War Review has been published between 1 to 4 times per year
since 1992. In 2004, the editors decided to test acceptability of an ``on
line'' only version of the newsletter, and the last ``hard copy'' mailed
version was dated October 2004. In response to prior suggestions by the VA
Gulf War Advisory Committee, VA has decided to make the next issue of the
``Gulf War Review'' available in hard copy as well.
Question 2(c). How many veterans of the Gulf War currently have computers and
can obtain this newsletter electronically?
Response. VA has not surveyed veterans of the 1991 Gulf War to determine how
many veterans have computers. We appreciate that many veterans do not have
access to electronic data, and consequently we are constantly attempting new
forms of outreach including posters, brochures, wallet cards, etc.
Question 9(d). Do you think that this newsletter gets to all of its intended
recipients?
Response. VA recognizes that any single approach to reach intended recipients
would not be ideal. VA is always working to enhance communications with
veterans and their families by working with new approaches and ideas to
improve this process. VA is constantly attempting to improve outreach and
communication to a broad range of veterans on a wide variety of health and
other issues. To that end, VA publishes posters, brochures, newsletters,
wallet cards, Web products including pod casts and other materials to improve
this process.
Question 10. Why has VA not yet published the results of the Longitudinal
Health Study of Gulf War Era Veterans that shows 25 percent of Gulf War
veterans suffer from multi-symptom illness over the rate in non-deployed
counterparts, when the preliminary results of the study were presented to the
Research Advisory Committee two years ago? Can you tell us when it will be
published?
Response. The overall study results, including the prevalence of ``multi-symptom
illness,'' have been analyzed by VA researchers who conducted this study.
This is an enormous amount of data which requires careful analysis, and then
the report has to go through submittal to a journal, peer review, correction
and then acceptance and publication. A manuscript is currently being prepared.
Question 11. The American Legion has recently presented to Congress its Views
and Estimates on Congressional Action needed for veterans' care. In that
document they state:
``38 U.S.C. 1118 mandates how the Secretary should respond to the
recommendations made in the IOM reports. The Secretary is required to make
a determination of whether or not a presumption for service connection is
warranted for each illness covered in the report no later than 60 days after
the date the report is received. If the Secretary determines that presumption
is not warranted for any of the illnesses or conditions considered in the
report, a notice explaining scientific basis for the determination has to be
published in the Federal Register within 60 days after the determination
has been made. Gulf War and Health, Volume 2 was released in 2003, 4
years ago. Since then, IOM has released several other reports and V A has
yet to publish its determination on those reports as well.''
Can you tell the Committee when VA will publish its determination on these
reports?
Response. The notice concerning the congressionally mandated report from
National Academy of Sciences Institute of Medicine committee on Gulf War
veteran's health, Volume 2 (Insecticides and Solvents), was published in the
Federal Register on August 24, 2007 at 72 Fed. Reg. 48734 (2007). VA has not
yet published Federal Register notices for the remaining IOM committee
reports. However, the Secretary has previously notified Congress of his
determination that no presumptions are presently warranted based on the IOM
committee reports Volumes 3 (Combustion Products, etc.) and 4 (Health Effects
of Serving in the Gulf War), in letters dated February 24, 2006 (for Volume 3)
and May 7, 2007 (for Volume 4). VA is currently reviewing the most recent IOM
committee ``Gulf War and Health'' report (Volume 5), which covers infectious
diseases of Southwest Asia.
-------
ATTACHMENT
At the www.va.gov/GulfWar Web site, Gulf War veterans and their families have
access to:
VA's Gulf War Veterans Information Helpline (1-800-PGW-VETS)
The most recent VA Gulf War Newsletter (July 2006)
VA's Gulf War (and OIF) Registry Program Handbook (June 2007)
The Annual Report to Congress on Gulf War Veterans' Illnesses from
the VA/DOD Research Working Group
VA's Veterans Health Initiative (VHI) Independent Study Guide for
Providers on Gulf War Health Issues
VA's Depleted Uranium Handbook for Gulf War Veterans (February 2004)
VA's Evaluation Protocol for Gulf War and Iraqi Freedom Veterans with
Potential Exposure to Depleted Uranium (DU) Handbook
VA's Southwest Asia Poster (May 2004) (also distributed to all VA
Medical Centers, Regional Offices and Vet Centers)
BROCHURES AND INFORMATION BULLETINS
Health Care and Assistance for U.S. Veterans of Operation Iraqi
Freedom
Q&A Brochure--Gulf War Illnesses, August 2003 (English and Spanish)
Information Bulletin on Gulf War veteran health issues 10-41 and -42,
March 2004 (in Spanish)
Gulf War Fact Sheet April 2000
Depleted Uranium Frequently Asked Questions (FAQs)
VA Gulf War Registry Examination Handbook 2005
RESEARCH REPORTS AND SUMMARIES
Combined Analysis of the VA and DOD Gulf War Clinical Evaluation
Programs (A Study of the Clinical Findings from Systematic Medical
Examinations of 100,339 U.S. Gulf War Veterans)--September 2002
Gulf War Research: A Report to Veterans, October 2003 (English and
Spanish)
Journal Article Summaries on Gulf War veteran health issues
Gulf LINK Medical Information (Gulf LINK is DOD's site on Gulf War
veteran health issues containing Gulf War research-related information. It is
a collaborative effort of three departments-DOD, VA, and HHS.
GULF WAR RISK FACTOR REPORT REPRINTS (TAKEN FROM VA'S ``GULF WAR REVIEW''
NEWSLETTER)
Introduction
Deplete Uranium
Pesticides
Pyridostigmine Bromide
Infectious Diseases
Chemical & Biological Warfare Agents
Vaccinations including Anthrax & Botulinum
Oil Well Fire Smoke and Petroleum
At the www.va.gov/EnvironAgents Web site, Gulf War veterans and their families
have access to a wide range of information on health and other information
that may affect them, including:
BROCHURES
Depleted Uranium & Health Pocket Guide For Clinicians (May 2007)
Special Health Registry Examination Programs (including the Gulf War
Health Examination Registry Program) (June 2006)
Your Story: Tell Your Military History (November 2005)
FACT SHEETS
Iraqi Freedom Veterans: Information For Veterans Who Served in Iraq
In 2003-2004 and Beyond and Their Families (IB 10-166) December 2004
Enduring Freedom Veterans: Information For Veterans Who Served in
Afghanistan and for Their Families (IB 10-71) December 2004
Ionizing Radiation Brief: Fact Sheets For Those Concerned About
Possible Long-Term Health Consequences Of Ionizing Radiation Exposure
(December 2004)
NEWSLETTERS
Operations Iraqi Freedom/Enduring Freedom Review: Information for
Veterans Who Served in Iraq and Afghanistan and Their Families (July 2007)
Operations Iraqi Freedom/Enduring Freedom Review: Information for
Veterans Who Served In Iraq and Afghanistan and Their Families (April 2007)
POD CASTS (DOWNLOADABLE AUDIO FILES FOR VETERANS)
Poly trauma Centers (April 2007)
Blast Injuries (April 2007)
Transition Assistance Advisors (April 2007)
New Brochure Explains Registry Programs (April 2007)
Newsletter Editor Rosenblum Retires (April 2007)
Readjustment After Deployment (April 2007)
How To Apply For Disability Compensation From VA (April 2007)
En Espanol: Como aplicar para la compensacion de incapacidad en el
VA (Abril 2007)
Special Compensation (April 2007)
Quick Guide To Traumatic Brain Injury (April 2007)
WRIISC: National Referral Program (April 2007)
WRIISC: Transition and Orientation Class (April 2007)
UNDER SECRETARY FOR HEALTH INFORMATION LETTERS
Under Secretary for Health's Information Letter (IL 10-2006-010):
Potential Health Effects Among Veterans Involved In Military Chemical Warfare
Agent Experiments Conducted From 1955 to 1975 (August 14, 2006)
Chemical Warfare Agent Experiments among U.S. Service Members
(Updated August 2006)
VBA Letter and DOD Fact Sheet and FAQs For Veterans Involved in
Military Experiments at Edgewood/Aberdeen with Chemical Warfare Agents from
1955 to 1975 (June 30, 2006)
Under Secretary for Health's Information Letter (IL 10-2006-004):
Screening and Clinical Management of Traumatic Brain Injury (January 25, 2006)
Under Secretary For Health's Information Letter (IL 10-2005-020):
New Study Reporting Increased Risk Of Brain Cancer Deaths Among 1991 Gulf War
Veterans Possibly Exposed To Sarin Chemical Warfare Agent At Khamisiyah, Iraq
(September 15, 2005)
DOD Letter, Fact Sheet and FAQs for Gulf War Veterans Who Served Near
Khamisiyah, Iraq (September 27,2005)
Under Secretary for Health's Information Letter (IL 10-2005-004):
Health Effects among Veterans Exposed To Mustard Gas And Lewisite Chemical
Warfare Agents (March 14, 2005)
Under Secretary for Health's Information Letter (IL 10-2004-013):
Guidance For The Diagnosis And Treatment Of Leishmania Infection (October 6,
2004)
Under Secretary for Health's Information Letter (IL 10-2004-007):
Possible Long-Term Health Effects from The Malarial Prophylaxis Mefloquine
(Lariam) June 23, 2004
Under Secretary for Health's Information Letter (IL 10-2003-014):
Long-Term Effects of Heat-Related Illnesses (November 20, 2003)
VETERANS HEALTH ADMINISTRATION DIRECTIVES
VHA Directive (2005-020)--Determining Combat Veteran Eligibility
(June 2, 2005)
VETERANS HEALTH ADMINISTRATION HANDBOOK--VA HEALTH CARE, BENEFITS AND
ELIGIBILITY INFORMATION FOR VETERANS
VHA Handbook 1303.2, Gulf War (Including Operation Iraqi Freedom)
Registry Program (March 2005)
``VA Health Care and Benefits Information for Veterans'' is a new
wallet card that nicely summarizes all VA health and other benefits for
veterans, along with contact information, in a single, wallet-sized card for
easy reference (available online at www.va. ov/EnvironAgents).
In collaboration with DOD, VA published and distributed one million
copies of a new short brochure called ``A Summary of VA Benefits for National
Guard and Reservists Personnel.'' The new brochure does a tremendous job of
summarizing health care and other benefits available to this special
population of combat veterans upon their return to civilian life (available
online at www.va. ov/EnvironAgents).
VA Health Care Benefits Eligibility (Link to VA Health Eligibility
Home Page)
Special VA Health Care Eligibility for Veterans Who Served In Combat
Theaters Fact Sheet, IB 10-162 (December 2003)
IMPROVEMENTS IN HEALTH CARE ELIGIBILITY
Based on VA's experience providing health care to veterans of the
1991 Gulf War, VA supported legislation that provides enhanced enrollment
(Priority Group 6) placement for veterans who served in a theater of combat
operations after November 11, 1998. This authority provides a 2 year
post-discharge period of cost-free care or services for conditions potentially
related to this service.
Provides full access to VA's Medical Benefits Package for recently
separated combat veterans.
Summarized in the brochure and poster distributed to all VA
facilities called ``Special VA Healthcare Eligibility for Combat Veterans,''
(available online at www.va.gov/EnvironAgents).
POSTER
Two Years Free VA Medical Care-New Combat Veterans (Sept 2006)
Special Reports on Gulf War Veteran Health Issues from the National Academy
of Sciences Institute of Medicine (The full reports are available online at:
www.nas.edu.)
Health Risk Factors by the National Academy of Sciences Institute of
Medicine
Gulf War & Health Volume 1 (2000): Depleted Uranium, Pyridostigmine
Bromide, Sarin, Vaccines
Gulf War & Health Volume 2 (2002): Insecticides and Solvents
Gulf War & Health (2004): Updated Literature Review of Sarin
Gulf War & Health Volume 3 (2004): Fuels, Combustion Products, and
Propellants
Gulf War & Health Volume 4 (2006): Health Effects of Serving in the
Gulf War
Gulf War & Health Volume 5 (2007): Infectious Diseases
Senator MURRAY. Thank you very much.
Let me start by asking, you both were here. You heard the last
panel. Was it as disturbing to you to hear that the perception is
or the reality is that we are not doing research on vaccines because
we might find out something?
Dr. KUPERSMITH. Well, it is certainly disturbing for that to be
said. I can't certainly say that that is, in fact, the case, but we do
have a database to look at some of this, and we are also doing some
studies on cellular effects of anthrax vaccine to try to find out
whether it does some direct cellular harm. So we do have various
kinds of studies that are looking at this, but that is a disturbing
statement, certainly.
Senator MURRAY. Do you feel that that may be true in any way?
Dr. KUPERSMITH. I can't say that.
Senator MURRAY. Do you feel like it is hard to get research on
a lot of the vaccines done?
Dr. KUPERSMITH. I don't know that it is. I think we could develop
some research projects on vaccines that were focused. We do look
at populations in that regard, but--and as I said, we do have some
vaccine studies looking at illness--at effects on the cellular level.
Senator MURRAY. Dr. Kilpatrick?
Dr. KILPATRICK. Again, from the Department of Defense standpoint,
we are doing, I think, a very good job of making sure that
vaccinations are being documented, that they are being recorded
electronically.
Senator MURRAY. Do you think we are doing enough? Are we
really looking at these vaccines?
Dr. KILPATRICK. I think we are looking at them very hard. There
are some pilot programs. DOD is looking at people coming in, starting
with new recruits, and not giving them vaccines they have already
received while they going through school. High school now,
the school systems, are demanding many vaccines for school children.
Not a lot of research going on in that area, but as they are
coming into the military, we are asking, ``What have you had?
What is documented?'' and only giving the shots that you would
need for military service. We are looking at studying the pilots of
giving one shot, then a delay period and then a second shot rather
than two at the same time. So there is research going on.
There was a huge study looking at the smallpox vaccine when it
was first given. It was really done in a research mode with people
reporting every day for 30 days after getting the vaccine as to what
symptoms they had and that was looked at electronically by researchers.
All of the anthrax vaccine has been recorded, a lot of researchers
at that. I know there was a mention about pneumonias in theater.
Anthrax vaccine was one of the first things looked at and there was
absolutely no relationship between the timing of the anthrax vaccines
and the occurrence of pneumonia in those cases.
Senator MURRAY. Well, there is a perception out there--it could
be a reality--that there is not being enough done because we don't
want to find out. Does that bother you as a professional, as a doctor?
Dr. KILPATRICK. As a professional, it certainly bothers me there
is such a perception. We just need to do more to help educate people.
We need to be more transparent. We need to let people know
what is going on.
Senator MURRAY. Are we being more transparent?
Dr. KILPATRICK. Work is being done, and I am not sure when you
tell the world your results.
You usually tell them after you have completed the study rather
than we have 20 studies underway.
Senator MURRAY. Well, I am sure----
Dr. KILPATRICK. We could change that----
Senator MURRAY. And I am sure you are aware that DOD has
a long and sort of shameful history involving Gulf War syndrome.
DOD obscured the truth about Gulf War illness. 1We hid information.
Senator Sanders referred to much of that in his opening statement.
Generally not forthcoming. We had to pull teeth to be able
to get DOD to recognize that Gulf War illness was a reality, and
I remember those hearings well back in 1993, where people were
coming to me as a U.S. Senator and describing these horrible conditions
and the DOD was saying it is all in their head. So given
that history, it is understandable that people don't trust the military.
How do you respond to that?
Dr. KILPATRICK. I think we have to continue to tell information
and provide the facts and data in a very timely and forthcoming
way. We need to make sure that the servicemembers know at the
time they are getting the vaccines or they are getting treatment or
they are being evaluated for illnesses. We need to do an excellent
job of making sure that our medical providers understand the complexities
of illness after deployments. I think that is a major focus
of Force Health Protection, to get the medical providers to understand
what the servicemembers have experienced and to be able to
do appropriate medical diagnostic work within that realm rather
than being dismissive, as happened too often with Gulf War veterans.
Senator MURRAY. Dr. Kupersmith, back in 1997, the VA's Office
of Policy, Planning, and Preparedness, working with a number of
organizations, created the Gulf War Veterans Information System
to identify Gulf War servicemembers and monitor their VBA compensation
and pension benefit. This provides the best possible
available current data that identifies the 6.6 million Gulf War
servicemembers, but it no longer includes data on the health care
usage rates for the Persian Gulf War veterans. Can you tell us why
the VA no longer tracks that?
Dr. KUPERSMITH. I would have to look into that. I can't--yes. We
will take that question for the record.
Senator MURRAY. OK. I would very much like to know why we
are no longer tracking that and why we are apparently not doing
it for today's servicemembers in Iraq and Afghanistan.
Dr. KUPERSMITH. Yes.
Senator MURRAY. And you can't answer that question?
Dr. KUPERSMITH. We will respond to that, yes.
Senator MURRAY. Well, I would like a timely response on that because
I think it is very critical. I appreciate that.
I will turn it over to Senator Burr.
Senator BURR. Dr. Kilpatrick, who wrote your testimony?
Dr. KILPATRICK. Sir, I was very involved in writing that testimony.
Senator BURR. Let me ask it again. Who wrote your testimony?
Dr. KILPATRICK. I wrote that testimony.
Senator BURR. Thank you, sir. Dr. Kupersmith, who wrote your
testimony?
Dr. KUPERSMITH. We had a group of four individuals including
myself who wrote the testimony.
Senator BURR. Did you write it late and is that the reason we
got it late, or was it held up by VA?
Dr. KUPERSMITH. I apologize for your receiving it late. I don't
know why that happened.
Senator BURR. Dr. Kilpatrick, why was yours late?
Dr. KILPATRICK. I must apologize to you for it being late. If you
can do something to speed the time between the time the draft is
written and the approval is given and it arrives for your use, that
would be most helpful.
Senator BURR. If you would share with me where the delay came
from, I will be glad to try to solve it.
Dr. KILPATRICK. As far as I understand, the delay was at OMB.
Senator BURR. I thank you for that.
Senator MURRAY. I am sorry, at OMB?
Senator BURR. OMB, which, I might say, is a cultural problem
within all administrations.
What is DOD policy on disclosure of vaccinations? Are troops informed
of what vaccinations they have been given?
Dr. KILPATRICK. That should be the policy now. During the Gulf
War, it was a unique incidence that went on and it had to do with
Vaccine A and Vaccine B. We had anthrax and botulism vaccine
available for the troops during the Gulf War. The decision was
made in late January to give vaccine to troops that most likely
would be exposed. We did not have enough vaccine for the troops
in theater, all the troops in theater, and so it was coded Vaccine
A for anthrax and Vaccine B for the botulism.
Senator BURR. And were they aware that they got Vaccine A or
Vaccine B?
Dr. KILPATRICK. That varied from location to location. Having
talked to a lot of Gulf War veterans, some were told this is anthrax
or this is botulism. Others were told it is A, it is B. Others were
told it is classified----
Senator BURR. Would their medical records show what they were
given?
Dr. KILPATRICK. I have talked, again, to veterans.
Some of them actually have it in their records. I would say that
is a minority. Paper records were what was being used at that
time. There were no electronic capabilities, and so giving shots in
the field and having paper records catch up with a person's health
record was almost an impossibility.
Senator BURR. Dr. Binns said in his testimony that over twothirds
of Gulf War illness research, in excess of $30 million annually,
is funded--has been funded historically by DOD. Since the
start of the current war, the program has been eliminated, and I
know my understanding is in this year's appropriations, DOD
made no request for that $30 million. Can you explain why?
Dr. KILPATRICK. I can give you information on that and I will ask
Colonel Harris to talk about what actually is happening. As I mentioned
in my oral statement and testimony, the title of Gulf War
Illness Research was changed in 2002 to Force Health Protection
Research and it is the same portfolio of research going on, it is just
not focused only on Gulf War veterans but all deployment-related
health information. Maybe Colonel Harris can amplify.
Senator BURR. Colonel, thank you for your work that has been
highlighted. If you have got anything to add, I would love to hear
it.
Col. HARRIS. Well, the Congressionally Directed Medical Research
Programs responds to needs that are put into the budget.
In Fiscal Year 2006, we received $5 million from the Army, which
was the result of an amendment that was put forth here in Congress.
Dr. KILPATRICK. And I think the Congressionally Directed Research
Program is different from the core military research program
that is force health protection-related because that is focused
on military operational medicine issues, run by another area at
Fort Dietrich.
Senator BURR. Dr. Kilpatrick, your testimony noted a number of
different efforts, I think undertaken by DOD following the experience
with veterans of the Gulf War. Has the Department of Defense
noticed any increase in illnesses or symptoms similar to those
afflicting veterans from the Gulf War?
Dr. KILPATRICK. We have a couple different projects or environmental
issues going on with today's troops coming back from theater.
At the end of the Gulf War, we were in the middle of a major
draw-down on the military size. Many people came back from the
war and went home. They had no access to health care in the VA.
Today's veterans coming back have a 2-year window coming back
from theater for access to the VA for any illness or disease or injury
that may be related to their deployment so they feel they have
access into the VA.
We are doing the post-deployment health assessment and re-assessment
now and what we are finding is that people are starting
to come forward as leadership is being educated to make sure
treatment is being afforded to servicemembers. We are finding,
looking at the illnesses or the diseases being reported in theater
and coming home, we are finding that about 15 to 20 percent of
people are having signs, symptoms, ill-defined illness, but that is
in the medical evaluation process and they are continuing to get
medical care, which is a different situation than the Gulf War veterans
experienced when they came home.
Senator BURR. In your testimony, you state, ``Assumptions based
on participation in the 1991 Gulf War cannot be made about the
health of a veteran who presents himself for clinical evaluation.'' I
realize that individual examinations are good medicine, but why is
it not relevant to consider that a veteran who served in the Gulf
War, when it is reported that nearly 30 percent of them are suffering
from some ill effects of health, why wouldn't you use that assumption
from a standpoint of some overriding clinical approach?
Dr. KILPATRICK. Again I think we are getting into the semantic
issue that the first panel highlighted. These veterans, when they
do present with illness, need to be taken at face value. I for 10
years have advocated that Gulf War veterans who are ill need care.
They need compassionate care from a provider who understands
the issues that they have experienced. And then you need to do the
individualized medical work-up. To do just a routine process on everyone
that comes through the door is not going to hone down on
the individual's problem. I think, as you heard from the first panel,
the symptoms are wide-ranging, from gastrointestinal problems to
pulmonary problems to neurological problems----
Senator BURR. But I take for granted from the statement that
you made that when a veteran of the Gulf War presents themselves,
that there is no benefit to that doctor knowing that they
were a participant in that theater or not from a standpoint of the
battery of things that they take them through for evaluation. Is
that accurate?
Dr. KILPATRICK. Well, then I misrepresented or was not accurate
in what I would say. As an infectious disease doctor, you always
want to know where your patient has been, what the history has
been, and I think taking a military medical history, you want to
know, have you been deployed, and where were you, and what did
you do? That needs to be the focus.
So, I think that any veteran coming in, that should be part of
the dialogue for that individual, and that is what we really do have
in DOD. DOD and VA developed a clinical practice guideline that
asks for every servicemember coming into clinic, ``are you here for
a deployment-related issue?'' That is the first question they should
be asked when they come in the clinic. That then triggers the questions
on how----
Senator BURR. The Chair has been very kind with the time and
I will wait for the second round to ask additional questions, but I
hope you understand, with the wide range of illnesses yet unexplained,
unidentified from a standpoint of the cause, one might
present themselves not believing this is the result for 16 years of
having served in 1991 in the Persian Gulf. They may not have had
the luxury of going in and saying, I served at this point, and all
of a sudden that triggered a whole battery of things that should be
looked at versus a determination having been made before they are
seen that they served at this time, therefore triggered clinicians to
do certain things. I think you can have an assumption that probably
overrides it, and I will give Dr. Kupersmith an opportunity to
address it when we come back from the VA standpoint. I thank the
Chair.
Senator MURRAY. Senator Sanders?
Senator SANDERS. Thank you, Madam Chair.
Let me pick up on a question that Senator Burr asked.
Let me ask it to Dr. Kilpatrick. You indicated that your testimony
was late because it had to be cleared by the OMB.
I did not know that the OMB had specialists in Gulf War illness.
Why does it go to the OMB? Does it go to the political department
of the White House, as well?
Dr. KILPATRICK. Sir, I can't answer that totally. I know that the
process after it left my desk was to get clearance through----
Senator SANDERS. Let me express a real concern here. We are
wasting everybody's time if these are political statements that you
are making. We asked you to come here because you are scientists
and you are physicians and we want to hear your best evidence.
Frankly, I don't want to hear what the political wing of the White
House has to say on this issue. You are insulting all of us. I don't
want to hear what the OMB has to say unless they have some particular
expertise in Gulf War illness that I was not aware of. You
are here as a scientist. You are here as a government physician.
That is what we want to hear.
Let me respectfully suggest, Madam Chair, that the next time we
have people from the VA or the DOD, I don't want it to go to the
OMB and I don't want it to go to the political wing.
Senator MURRAY. Can I just ask, were either of your testimonies
changed as a result of going through that process?
Dr. KILPATRICK. One word, ``Persian'' in front of Gulf War, was
taken out.
Senator MURRAY. And----
Senator BURR. If I could add, Madam Chairman, and I say this
with all due respect to my colleague, I have been here 13 years. I
have not had a government witness in 13 years whose testimony
wasn't vetted by OMB. So this is not something that was created
as the result of this administration or this incident----
Senator SANDERS. I don't want----
Senator BURR.--but I am more than willing to stand beside you
and go after all of them----
Senator SANDERS. Good.
Senator BURR.--and to end this, because I believe that it is
healthy to get a personal perspective from those who we have got
in charge.
Senator SANDERS. These are scientists and these are experts, and
I presume, Senator Burr, you will agree with me that we want to
hear their knowledge, yes?
Senator BURR. I agree with you totally, but I would disagree you
that there is a political point here----
Senator SANDERS. I didn't want to--I just didn't want to raise
the great political issue here, but it is of concern.
You have also heard today concern that while huge amounts of
money, in fact, have been going to Gulf War research, there is a
general consensus, I think, within Congress that a lot of that
money has not been particularly well spent. On the other hand, I
have heard very positive reports regarding the Congressionally Directed
Medical Research Program, and I would like to address a
question, if I could, to Colonel Harris.
Colonel, I know you have been working with some $5 million,
and we hope to get you actually some more money. Could you give
us just some understanding of what you have been doing with the
funding for Gulf War illness that has come to your agency and
what you might do if more funding came?
Col. HARRIS. OK. The focus of the call for the Fiscal Year 2006
solicitation was to focus on treatments as well as to identify the
underlying pathophysiology so that you would be able to then target
future treatments for the illnesses that Gulf War veterans are
suffering from.
The Congressionally Directed Medical Research Programs uses a
two-tier review process with the first tier being a scientific peer review,
and then we have a panel of experts which we call an integration
panel that help us to determine what focus the research
needs to take as well as they assist in the selecting of the actual
studies that get funded.
We do a very broad solicitation or call because the idea is that
you want to bring in as many ideas as possible and then have the
opportunity to pick the best ones that are going to make it----
Senator SANDERS. If I could, this concept of a broad solicitation
makes a lot of sense to me. Is it accurate that you have received
60 responses, or 80, was it, requests came in for funding?
Col. HARRIS. That is correct. We actually, for the proposals, we
actually did, because it was a small amount of money--there was
$5 million--and we didn't know how large of a response we would
have in this area, we actually did a pre-proposal, so individuals
submit a smaller proposal that gives the basic outline of what they
want to do and then the integration panel reviewed those to narrow
the list down somewhat when we received full proposals. But
that was the original solicitation----
Senator SANDERS. It sounds to me like 80 proposals is quite a
large number. Were you surprised at that number of proposals
coming in?
Col. HARRIS. Eighty is quite a few for a $5 million solicitation.
Senator SANDERS. Does that suggest to you that all over this
country, there are different universities and foundations and physicians
and scientists who are interested in this issue?
Col. HARRIS. I mean, it is hard to make a judgment, but, I mean,
again, the numbers speak for themselves. When you put out a call
asking for looking at new ideas, because that was the focus of one
of the proposals--it was exploration hypothesis development
award, which is what are innovative ideas that might be causes behind
the Gulf War syndrome as well as then looking at more mature
ideas, looking at potential treatments.
Senator SANDERS. Thank you very much for what you have done
and we look forward to continuing working with you.
Senator MURRAY. Thank you very much.
Dr. Kupersmith, the current practice guidelines for Gulf War illness
referred to by the VA as medically unexplained symptoms, it
has not been updated for more than 5 years and seems to indicate
a psychological cause of illness rather than from environmental exposures
that we have heard so much about. Why haven't those current
practice guidelines been updated to reflect the current research
that we know?
Dr. KUPERSMITH. I think the practice of physicians has been updated
to reflect the current research, but I can't answer why that
particular guideline has not. We deal with the research specifically
and we don't--we inform the practice guidelines, but we do not create
them. But I do think that we have a very strong program of
educating physicians about taking a military history, for example.
We have a strong program for our residency training program and
educating----
Senator MURRAY. I am assuming you heard Doctor, I believe it
was Dr. Nass in the previous panel say that a patient had just
come in a few months ago and was told it was psychological.
Dr. KUPERSMITH. Well, I think that--I can't speak for the thousands
of physicians, every last of the thousands of physicians that
are in the VA. Certainly, it is not our overall statement or policy
at this point to say that what happened in the Gulf War is due to
psychiatric illness, and certainly our research over the past 3 years
has not taken that direction at all----
Senator MURRAY. So does this----
Dr. KUPERSMITH.--and that is what I can speak about best.
Senator MURRAY. So is this going to be updated so doctors get
the best information?
Dr. KUPERSMITH. I have to--I mean, again, I am not the one who
does that and I will get you that information about how the updating
of that is being done.
Senator MURRAY. OK. I would appreciate a timely response on
that.
Dr. KUPERSMITH. Mm-hmm.
Senator MURRAY. Back in August of 2005, there was a study in
the American Journal of Public Health by a Dr. Tim Bullman who
found that Gulf War veterans exposed to nerve agents during the
March 1991 weapons demolitions in Khamisiyah, Iraq appear to
have a higher risk for brain cancer death than veterans who were
not exposed. There is also an IOM report in September of 2006 that
found evidence that suggests there may be an elevated rate of Lou
Gehrig's disease among Gulf War veterans. So given all of this,
why is there no permanent mechanism in place to grant presumptive
disability for Gulf War veterans with ALS or brain cancer?
Dr. KUPERSMITH. I apologize again. You know, I deal with research,
which informs these things. I cannot speak for the benefits
or benefits that are given. Again, we can get you a response to
that.
Senator MURRAY. OK. I would like a response to that. It seems
to me that there should be some mechanism in place, knowing
what we have with the research we have, that there is presumptive
disability. Is there evidence there to support a presumptive disability,
from your perspective?
Dr. KUPERSMITH. You know, I would have to look very carefully
at what the criteria are for disability. I think the studies you cite,
one of which--there is a study done by a VA investigator that
found--that looked at brain cancer and found a slight increase, and
I believe ALS is part of comp and ben. But again, deal with research
and I--we inform both the clinical and the benefits process.
What criteria the benefits process uses to make those determinations
is in their hands, not in mine, and I can't speak for them.
Senator MURRAY. Colonel Harris, there is a lot of research out
there on Gulf War illness. Can you tell us what you think the
trends show in terms of what is the best theory or perhaps theories
which account for this illness?
Col. HARRIS. Well, I am actually a relative newcomer to the field
of Gulf War research and I think that the experts that you had on
the previous panel, you know, have looked at more of the scientific
studies. But the focus currently is trying to develop some biomarkers
so that you have a mechanism to be able to detect whether or
not an individual has a potential and has the exposure. Having a
biomarker will also assist in targets for treatment as well as being
able to track a person over time to see if they improve. Several of
the studies that were funded out of the 2006 solicitation, which just
have been awarded, actually are looking at different biomarkers.
Senator MURRAY. Senator Burr?
Senator BURR. Senator Sanders suggested that because you had
such great response to the request of research on the $5 million
that that was indicative of how much interest there was in academia
and other areas to uncover something, and I would only suggest
to you that the proliferation of BSL-3 and BSL-4 laboratories
on academic institutions around the country, I think now exceeding
almost 400, might be indicative of the great need on the part of
academic institutions to go out regardless of what the research is
and bid for the dollars with very aggressive proposals.
And I do hope and I trust, Colonel Harris, that we will chase the
most promising areas where you place that $5 million and how you
place it. I am sure you will, because we have some very talented
academic institutions around the country that are aggressively trying
to get every dollar regardless of the area of expertise. With the
right amount of money, every institution can become an expert on
everything, I am convinced, because they now have the infrastructure
that is needed to support the research dollars.
Dr. Kupersmith, I want to give you an opportunity to take a shot
at what I asked Dr. Kilpatrick about and that is his statement that
assumptions about health status can be made based on the service
in the Gulf War.
Dr. KUPERSMITH. I am sorry, but I--could you--I am not sure
what your question is.
Senator BURR. His quote specifically was, ``Assumptions based on
participation in the 1991 Gulf War cannot be made about the
health of a veteran who presents for clinical evaluation.'' Do you
believe knowing they were a 1991 participant is important to a clinician
that sees that veteran at the VA facility?
Dr. KUPERSMITH. Absolutely. Certainly, our research has found
an increase in a number of conditions, as has been stated, and certainly
that should inform how the physician diagnoses and treats
the patient.
Senator BURR. Mr. Binns testified in the last panel and he referred
to the VA fact sheet that was sent to a few Senators on this
Committee because it notes Gulf War veterans suffer from a wide
range of common illnesses which might be expected in any group
of veterans their age. Would you care to respond?
Dr. KUPERSMITH. Well, it is not our opinion and research that
these symptoms and signs should be dismissed at all. In fact, we
have brought into our leadership one of the authors of a paper. Dr.
Eisen is head of our Health Services Research Section who published
the increased incidence of a number of those conditions, so
we certainly don't feel that way.
Senator BURR. Well, he referred to the fact sheet as garbage.
Dr. KUPERSMITH. I do not want to characterize--I don't want to
use that term.
Senator BURR. I suggested in my opening statement that I believe
we should focus as much research on possible treatment options
for our veterans who participated in the Gulf War who are
still living with difficult illnesses so many years after the conflict.
Can you provide your thoughts on my comments and give me some
idea as to how the $15 million per year program in Texas will approach
the research funding as it relates to treatment versus
cause?
Dr. KUPERSMITH. Yes. I think you also said that--you made a
comment in another part earlier this morning about looking at the
genetic issues. That is something we are very interested in. The
Texas program will be looking at imaging, particularly
neuroimaging. It will be looking at animal studies to involve treatments.
It will be looking at genetics and genomics and it will be
looking at biomarkers of illness, and that is physical or chemical
markers, blood test markers, or possibly imaging markers of individuals
who have these syndromes.
So I think it is a pretty broad range of treatment and it also reflects,
I think, a somewhat different direction. Some of these largescale
studies that have been done may not be able to sufficiently
identify under the surface individuals who have--perhaps a smaller
group of individuals who may have a genetic predisposition to
a particular exposure or some other situation that arose in the Gulf
War theater. I think we will be looking for those things, as well.
Senator BURR. I want to take this opportunity to thank all four
of you who sit at the table for the job that you do. In many ways,
I can understand why it is not comfortable to be called up here to
testify on any given thing, but clearly you have a talent and a willingness
to commit to do it. I think it has been very helpful to hear
from the first panel. I think it has been insightful to hear from
those of you on the second panel.
If you walk away today with one common theme from this Subcommittee,
I hope it is that it is unacceptable to continue what we
have done in the past. It is absolutely vital that we chart a new
course and that course has to deal in large measure with the treatment
of these veterans while we continue to focus on areas of research
that would provide us better avenues for treatment.
Now, I share that with you and in frustration of not getting your
testimonies on time and the frustration of having to sit up here
and be distracted from the verbal testimonies of the first panel. I
can't let you leave without noting one thing with the answers that
you have given me. Both of you submitted testimony that was nine
pages long. I found a comment that related to treatment only one
time and that was in DOD testimony. So if I missed it, Dr.
Kupersmith, in your testimony, I apologize. If I missed multiple
places in your testimony, Dr. Kilpatrick, I apologize. But I believe
the answers that I have heard today give me optimism that we
have transitioned to a mindset of treatment. I would only hope that
the testimony would also embrace and suggest that treatment is
the predominant focus of where we are at VA or where you are in
your specific avenue. I didn't get that in my first read, and I will
read it again in great detail to find what I missed.
I thank the Chair.
Senator MURRAY. Thank you very much, Senator Burr, and
thank you to all of our witnesses, as well. I agree with the comments
of Senator Burr. I hope that all of us use this to move forward
to make sure that the VA and the DOD are going to continue
their efforts to address the effective diagnosis and treatment of
these veterans, but also to remember that how we deal with and
treat the veterans of any war will determine how future generations
of veterans believe they are going to be treated and it is absolutely
critical that we continue to monitor this.
With that, I want all of our witnesses to know that we will submit
additional questions to you today. We expect an answer
promptly within a week for the Committee record.
Thank you for that.
With that, this hearing is adjourned.
[Whereupon, at 11:54 a.m., the Committee was adjourned.]
A P P E N D I X
PREPARED STATEMENT OF PAUL SULLIVAN, EXECUTIVE DIRECTOR,
VETERANS FOR COMMON SENSE
Chairman Akaka and Members of the Senate Veterans' Affairs Committee, Veterans
for Common Sense thanks you for holding a hearing today on ``Research and
Treatment for Gulf War Illnesses.'' Veterans for Common Sense is a nonprofit
organization formed in 2002 focusing on veterans' benefits and healthcare,
national security, and civil liberties.
The serious Gulf War illnesses among 175,000 veterans remain a significant
problem that remains unresolved after more than 17 years. Strong action by
Congress is needed now in order to counter the many years of opposition to
research and treatment by both the Department of Defense (DOD) and Department
of Veterans Affairs (VA).
Our written statement focuses on four key areas that require the immediate
attention of Congress. Each of the four items discussed in our statement
address our Nation's and our government's responsibility to care for veterans.
When our veterans are sent to war, they should receive prompt medical care and
disability benefits when they return home. In a lesson learned from the
Vietnam War, our government should promptly study wartime toxic exposures and
closely monitor healthcare and benefit use among veterans.
First, Gulf War veterans have waited 17 years for medical treatment to improve
our health. VCS urges Senators to provide full funding for research into
medical treatments for our Gulf War veterans. VCS urges the Committee to work
with their colleagues on the Senate Armed Services Committee and in the House
of Representatives to make sure that Senate Amendment 2060 to H.R. 1585 is
retained in the final version of the National Defense Authorization Act that
the President signs this year.
VCS wants to make sure the full $30,000,000 is included so researchers can
find treatments for the 175,000 Gulf War veterans still suffering from chronic
multisymptom illnesses since 1991, according to VA's latest longitudinal
health study.
VCS supports this essential funding because the DOD Congressionally Directed
Medical Research Program is an innovative, open, peer-reviewed program focused
on identifying effective treatments, with a first priority for pilot studies
of treatments already approved for other diseases, so they could be put to use
immediately. If Congress doesn't act now, the cynicism, anger, and disbelief
among our veterans will rise as they continue waiting without any effective
treatments.
Second, Gulf War veterans and VA need simplified rules so disability claims
can be processed faster and more accurately. VCS urges Congress to enact
legislation granting a presumption of service connection for our Gulf War
veterans diagnosed with brain cancer or with amyotrophic lateral sclerosis
(ALS). Senators should follow-up on several recent scientific reports
confirming that Gulf War veterans are more likely to suffer from brain cancer
and from ALS than their non-deployed peers.
VA Secretary Anthony Principi already used his authority as Secretary to grant
service connection for ALS, and this temporary authority should be made
permanent. Service connection for veterans opens the door sooner for treatment
and disability benefits.
Third, VCS urges Congress to continue funding scientific research into the
many toxic exposures that faced our 700,000 Gulf War veterans serving in
Southwest Asia during 1990 and 1991. Of greatest concern are four types of
exposures: anthrax vaccines, depleted uranium, chemical warfare agents, and
pesticides.
Scientific studies now show there are significant adverse health effects from
the experimental anthrax vaccine, from the radioactive heavy metal depleted
uranium, and from pesticides. Since the vaccines, DU, and pesticides remain in
use by our military, it is reasonable to continue studying the impact of these
poisons on Iraq War and Afghanistan War veterans. Our veterans deserve to know
what made us ill and to receive treatment and benefits for illnesses related
to our military service.
VCS is especially concerned that VA repeatedly fails to conduct a medical
study on the long-term consequences of DU, even though at least one of the
Gulf War veterans with DU exposure currently monitored by VA developed cancer.
Recent DOD animal studies link DU with cancer and chromosomal damage. VCS also
notes that chemical warfare agents and pesticides appear linked to brain
damage, which may explain some of the difficult-to-diagnose conditions
suffered by so many Gulf War veterans.
Fourth, VCS urges Senators to expand the Gulf War Veterans Information System
(GWVIS) reports prepared each quarter by VA. These reports define the Gulf War
servicemember population and report on VA healthcare use, Vet Center
counseling use, and VA disability claim activity.
The GWVIS reports should be expanded to include information about Iraq War
and Afghanistan War veterans as well as VA expenditures related to all three
groups of veterans. Without these reports, VA and Congress would be unaware of
the behavior of these cohorts of veterans, and VA may once again find itself
$3 billion short, as it did in 2005, by failing to monitor Iraq and
Afghanistan War veteran activity within VA.
VCS remains concerned about VA's commitment to producing the reports because
the May 2007 GWVIS report failed to include healthcare use among Gulf War
veterans, a critical component of today's hearing. Congress, veterans groups,
and the public have a right to know the human and financial consequences of
the Gulf War, Iraq War, and Afghanistan War. Therefore, VCS strongly supports
the prompt passage of S. 117, ``The Lane Evans Veterans' Healthcare and
Benefits Improvement Act of 2007.'' VCS asks that our statement, Dan Fahey's
statement to the House Veterans' Affairs Committee, dated July 26, 2007, plus
a copy of the May 2007 GWVIS report be included in the official record of the
hearing. VCS looks forward to working with Senators on the important issues
identified here as well as on other issues impacting the health and welfare of
our Gulf War, Iraq War, and Afghanistan War veterans.
PREPARED STATEMENT OF DAN FAHEY TO THE HOUSE VETERANS' AFFAIRS
COMMITTEE, JULY 26, 2007
Dear Chairman Filner and Honorable Members of the House Veterans Affairs
Committee:
I respectfully submit to you this written testimony on the occasion of your
hearing on Gulf War veterans' illnesses to call your attention to serious
problems with the Department of Veterans Affairs (DVA) study of Gulf War
veterans exposed to depleted uranium (DU). Since 1993, I have interviewed
hundreds of veterans about battlefield exposures to dust and debris from
armor-piercing DU ammunition and presented my research findings to numerous
Federal investigations of Gulf War veterans' illnesses. I am including with
this testimony a copy of my most recent presentation at the 28 June 2007
meeting of the Institute of Medicine (IOM) committee that is reviewing
scientific and medical literature on the health effects ofDU exposure.
My IOM presentation provides more detailed information in support of this
statement.
The Department of Veterans Affairs study of DU is neither structured nor
functioning to provide basic information about the possible health effects of
DU exposure among Gulf War veterans. There are two major flaws with the study
that undermine its integrity and value.
First, the DVA study is undersized. From its inception in 1993, the study
included only a tiny fraction of the number of veterans with known or
suspected exposures to DU. Consequently, we have no information about the
possible health effects among the thousands of Gulf War veterans exposed to DU
in friendly fire incidents; during the recovery, transport, and inspection of
contaminated equipment; and as a result of the July 1991 munitions fire at
Doha, Kuwait.
Second, the DVA study has become politicized. In recent years, officials from
both the Department of Defense (DOD) and DVA have repeatedly presented false
and incomplete information about the existence of cancers and tumors among the
few dozen veterans being studied. The deceitful statements and omissions by
DOD and DVA officials undermine the integrity of the study and call to
question its purpose.
The DVA study of veterans exposed to DU is located at the Baltimore VA Medical
Center and directed by Dr. Melissa McDiarmid. When DVA created the study in
1993, only 33 Gulf War veterans were enrolled. These individuals had been
heavily exposed to DU as a result of being inside vehicles hit by DU rounds in
friendly fire incidents; some had been wounded by DU fragments while others
inhaled DU dust. A 1993 DVA report on the creation of the study noted: ``The
small size of the population . . . [makes it] highly unlikely that definitive
conclusions concerning cancer induction will be obtained from the study.'' By
2000, however, DOD belatedly admitted that ``thousands'' of Gulf War veterans
may have been exposed to DU during and after the Gulf War, including
approximately 900 veterans who are believed to have had heavy exposures to DU
during friendly fire incidents, vehicle recovery operations, and the Doha,
Kuwait, munitions fire. Despite this admission, since 2001 the DVA study has
examined only 46 individual Gulf War veterans. Since numerous
laboratory studies have demonstrated that DU may cause cancers, tumors,
neurological problems, and other effects, it is imperative to expand and
improve the DVA study in order to clarify the association between exposure to
DU and cancer induction or other illnesses among Gulf War veterans.
In addition to studying only a few dozen veterans, the DVA study director has
not honestly and completely presented study findings either publicly or in the
medical literature. This fact first emerged in 2001, when DOD and DVA
officials responded to European concerns that the use of DU munitions by U.S.
jets during the Kosovo conflict had affected the health of NATO troops and
civilians. At the height of the European controversy in January 2001, DVA
study director Dr. Melissa McDiarmid wrote in the British Medical Journal that
no veterans in her study had developed ``leukemia, bone cancer or lung
cancer,'' yet she inexplicably failed to mention that in 1999 one veteran in
the study had Hodgkin's lymphoma and a second veteran had a bone tumor.
Moreover, a 2006 journal article co-authored by Dr. McDiarmid supposedly
summarized all study findings for the period 1993 to 2005, yet this article
notably failed to mention the findings of the Hodgkin's lymphoma
and bone tumor among the few dozen study participants. During her 28 June 2007
presentation to the IOM committee assessing the possible link between
exposure to DU and health effects among veterans, Dr. McDiarmid again
neglected to mention the findings of the Hodgkin's lymphoma and bone tumor.
These deceitful statements and omissions suggest that the DVA study is less a
scientific study than a political tool used to downplay public concerns about
DU and to mislead investigations of the connection between DU and health
effects-such as the current IOM investigation-that could lead to an extension
of service-connected benefits to Gulf War veterans for cancers or other
illnesses.
I respectfully make the following recommendations to the House Veterans'
Affairs Committee:
Initiate a U.S. Government Accountability Office investigation to
clarify the purpose and findings of the DVA study, and to recommend how the
study could be restructured to better serve the interests of both veterans and
scientific inquiries into the health effects of exposure to depleted uranium;
and
Summon DVA study director Dr. Melissa McDiarmid to appear before the
Committee to testify under oath about the number and types of cancers and
tumors among study participants, and to explain why she has not honestly and
thoroughly reported findings of cancers and tumors in the medical literature
or to the IOM.
What is clearly needed at this point--16 years after Operation Desert Storm-is
a study of all veterans with known or suspected DU exposures to determine
rates of cancers, tumors, neurological problems, and other health effects
potentially related to DU exposure; furthermore, there is an urgent need for a
new study director who will accurately report study findings. I thank Chairman
Filner for his sustained interest and action to investigate Gulf War veterans'
illnesses and stand ready to assist the House Veterans' Affairs Committee in
its future work on this subject.