SPEAKERS CONTENTS INSERTS
Page 1 TOP OF DOCFULL COMMITTEE HEARING TO RECEIVE UPDATES ON RESEARCH, INVESTIGATIONS, AND PROGRAMS INVOLVING PERSIAN GULF WAR VETERANS' ILLNESSES
THURSDAY, FEBRUARY 5, 1998
House of Representatives,
Committee on Veterans' Affairs,
The committee met, pursuant to call, at 1 p.m., in room 334, Cannon House Office Building, Hon. Chris Smith (vice chairman of the committee) presiding.
Present: Representatives Smith, Quinn, Stearns, Cooksey, Chenoweth, LaHood, Evans, Kennedy, Filner, Gutierrez, Doyle, Peterson, and Snyder.
OPENING STATEMENT OF HON. CHRIS SMITH, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. SMITH. Good afternoon. For more than 6 years, there have been questions about the health conditions of Persian Gulf War veterans. The Committee on Veterans' Affairs has been diligent in investigating these concerns. In fact, today marks the 15th time this Committee has heard testimony on this matter, and I expect that with the vigorous leadership of our Chairman, Bob Stump, it will not be the last.
This Committee has also been at the forefront in formulating legislation designed to assist Persian Gulf veterans. For example, through the work of this Committee, any Persian Gulf veteran, whether sick or not, can now go to a VA facility for an examination and counseling. Also, a veteran who exhibits any condition which may be associated with the veteran's service in the Gulf is now eligible for priority care through the VA.
Last year, the Veterans Benefits Act of 1997, signed into law in November, created a $5 million competitive grant program under which up to 10 VA facilities would establish demonstration projects to test new approaches to treating and improving the satisfaction of Persian Gulf veterans suffering from undiagnosed illnesses.
Page 2 PREV PAGE TOP OF DOC As Vice Chairman of the National Security Committee, Chairman Stumpand I think everyone would take note of this, and he may be by a little laterfelt an obligation to attend the DOD budget hearing at which Secretary Cohen is currently testifying. Chairman Stump had asked that I would open this hearing, and other members will be chairing it as the day goes on.
About this time last year, the Committee held a hearing to examine the progress of the Persian Gulf illness-related research. Today, we follow up on that issue by bringing in government officials, academicians, and scientists to provide an update on what we hope is significant progress over the past year.
Persian Gulf veterans' illnesses have raised difficult scientific questions. It is vital, accordingly, that we gain the benefit of the insight of the scientific and other experts who have studied these questions.
We realize that many important research studies are still underway and that our state of knowledge remains incomplete. However, real and accurate answers do not come overnight.
Residents from across my district answered the call and served in the Persian Gulf War. And let me just say how important it is that I think every member of this Committee have had people, including some members of our Committee, who served in the Persian Gulf War.
Let me finally just ask my good friend Mr. Evans if he has any opening statements.
[The prepared statement of Congressman Smith appears on p. 60.]
OPENING STATEMENT OF HON. LANE EVANS, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF ILLINOIS
Page 3 PREV PAGE TOP OF DOC Mr. EVANS. Yes, I do, Mr. Chairman. I appreciate it. Thank you, Mr. Chairman. I want to commend your side for scheduling this hearing, and I look forward to the testimony.
As a result of this proceeding, our Committee should have a better understanding of the current health status of Persian Gulf veterans, the care that they are now receiving, and the care that they still need to receive. We should also better understand the research being conducted to help answer vexing questions about the cause and treatment of persistent Gulf War veterans' illnesses and VA's response to the claims for compensation filed by Persian Gulf War veterans.
Today the VA deems about 80 different hazards and 270 various disabilities, quote, ''acceptable,'' unquote, as a basis of adjudicating Persian Gulf veterans' service-connected disability compensation claims. It could well be years and more likely decades, if then, before science can definitively link all of these exposures to illnesses.
I'm currently preparing legislation to provide the basis for granting claims for service-connected disability to those who served in the Persian Gulf theater as well as other Persian Gulf-era veterans who have prepared to be deployed.
While a number of details must still be finalized, I expect to introduce this measure in the very near future. Prior to its introduction, I will invite all members of our Committee to become original cosponsors of this legislation.
In general, this legislation will provide a scientific basis for Persian Gulf compensation, but it does not presume that answers exist today to all the questions veterans still have about why they are sick.
Our experiences with radiation and Agent Orange should have taught us that science does not always provide definitive, unequivocal answers that conform to our timetables and deadlines. But Persian Gulf illness data available to science can make clear links to exposures in some cases. In other cases, the evidence linking specific causes to specific conditions is more controversial. And in still other cases, there is little or no available science. In addition, new information about potential exposures, like the demolition of the chemical warfare munitions site, may become available at some time in the future.
Page 4 PREV PAGE TOP OF DOC Those symptoms or medical conditions found to be prevalent in the Persian Gulf veteran population should be presumed service-connected. This does not necessitate a definitive link between a specific agent and the symptoms or the diagnosis but does provide a firm grounding in science.
No less important, it will give Persian Gulf veterans who are suffering today, years after their service to their country, the benefit of the doubta benefit which they all have earned.
Mr. Chairman, I'm glad that you're holding the hearing and look forward to the testimony before us today.
[The prepared statement of Congressman Evans appears on p. 52.]
Mr. SMITH. Thank you very much, Mr. Evans.
Without objection, if other members have statements, we will make them a part of the record unlessdid you want to
Mr. KENNEDY. Yes. Mr. Chairman, if you wouldn't mind, I'd like to make an opening statement. Thank you very much.
OPENING STATEMENT OF HON. JOSEPH KENNEDY, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF MASSACHUSETTS
Mr. KENNEDY. Mr. Chairman, 7 years ago when the Persian Gulf War ended, a hearing was held here in Washington to investigate reports that the Persian Gulf veterans were suffering from a series of mysterious symptoms, but there were no veterans at the witness table in the committee room.
In 1992, Lane Evans and I held a hearing in Boston to gather testimony from sick veterans who could tell us about their health problems. At that time, sick veterans were being called malingerers or worse by the Defense Department. People didn't believe that they were really sick.
Page 5 PREV PAGE TOP OF DOC But by early 1993, it was clear that there was a problem. Literally hundreds of veterans were calling our offices to report symptoms ranging from skin rashes to respiratory problems to kidney failure and cancer that they believed were linked to their service in the Gulf conflict.
The Pentagon continued to deny any link but was forced to take a closer look at the facts once countries that were members of the Persian Gulf coalition began reporting exposures from their own troops to chemical and biological weapons.
Finally, in April of 1996, the CIA released a report showing solid evidence that thousands of chemical weapons have been stored at Khamisiyah and that our troops may have been exposed to those deadly agents after allied forces bombed storage facilities.
Now here we are 7 years after the war. We finance 103, 103, separate research projects at a cost of $49 million. And we've had a presidential panel study the veterans' health problems.
Both DOD and the VA have not answered the veterans' questions about what caused them to get sick and when they will get effective treatment. The veterans are frustrated and rightly so. They suffer from a myriad of illnesses like stomach disorders and painful muscles and joints, just to name a few of them.
The veterans don't want to hear the argument that their illnesses are caused by stress. When I talk to veterans and they tell me what they do want to know is what caused them to get sick. And what they also want is research to be done to find effective treatment.
They are brave men and women who answered the country's call at the time of need. They deserve a full accounting of how their service might be linked to these horrible illnesses that have so devastated their family lives and careers.
So based on my conversations with veterans, I'd like two things. I think two things need to be done. First, I talked with the Persian Gulf veteran Brian Martin of Michigan.
Page 6 PREV PAGE TOP OF DOC Brian was a specialist at the Army demolition team, and he was the person who filmed the bombing of the storage facilities at Khamisiyah. He has now stomach and colon problems and has an actual scar on his brain which is called decreased uptake and diffusion of the temporal lobe. He said the VA doesn't know which chemical he was exposed to.
Brian Martin now runs the international advocacy for Gulf War syndrome, which is a coalition of 60 grass roots organizations with 18,000 veterans as members.
Brian said veterans believe the VA's main problem is that they don't have enough information from research to provide effective treatment for the symptoms that they can't diagnose. He's testified before Congress several times and told me that veterans feel like: Thanks for the research into the cause of what made us sick, but please do some research that will find effective treatment. And the veterans think that DOD's research has been DOA.
So I'm drafting a bill that I'd like to ask the members of our Committee to review and join me as original cosponsors. I don't believe that we have a focused, coherent research strategy. The bill will give priority to researching Persian Gulf veterans' exposure to biological and chemical weapons and the resulting effects on their health to find effective treatment.
In addition, the bill will call for setting up a database to monitor the health of Persian Gulf veterans who are being treated within the VA health care system and those who are being treated in private health care. I'm putting this into the bill because a veteran told me and my staff that DOD and the VA have had no follow-up system to monitor Persian Gulf veterans' clinical progress after their initial physical exam.
Second, I've asked the GAO to evaluate the research that's been started. If the evaluation shows any of these studies that won't contribute to effective health care for sick veterans, then we should pull the plug and change the direction. I'll share the results of the GAO's evaluation with the members of the committee as soon as we get it.
Page 7 PREV PAGE TOP OF DOC Finally, Mr. Chairman, with this cat and mouse game that Saddam Hussein is playing right now with U.N.'s weapons inspectors, we may be approaching the eve of another conflict in the Persian Gulf. Just yesterday the White House press secretary said that time is running out for a diplomatic solution in Iraq.
If we need to send in ground troops, we must do all we can to make sure that they don't come back as a second wave of Persian Gulf syndrome victims. If ground troops go in, DOD must guarantee that gas masks and protective suits are not defective and that they will protect the soldiers from any exposure to hazardous substances.
In addition, before the 1991 Persian Gulf War, the soldiers were given investigational drugs, such as PB, as a pretreatment to protect them against exposure to chemical weapons. These drugs were administered without informed consent. And some of the veterans believe that those drugs might be part of their health problems.
We don't know if that's true. However, I want to try to gain assure from the Pentagon that informed consent procedures will be carried out if our troops must go into the Gulf again, although it is my fervent hope and I'm sure all of ours that that is not the case.
Thank you very much, Mr. Chairman.
Mr. SMITH. Thank you, Mr. Kennedy. Mr. Filner.
Mr. EVANS. If I could have a unanimous consent request? Mr. Chairman, I'd like to enter into the record a letter to our colleague John Tierney of Massachusetts regarding this hearing. May I ask that this letter and its attachments be made a part of the record?
Mr. SMITH. Without objection, the letter with attachments will be made a part of the record.
[The letter to John Tierney appears on p. 55.]
Page 8 PREV PAGE TOP OF DOC Mr. EVANS. Thank you, Mr. Chairman.
Mr. SMITH. Mr. Filner.
OPENING STATEMENT OF HON. BOB FILNER, A REPRESENTATIVE FROM THE STATE OF CALIFORNIA
Mr. FILNER. Thank you, Mr. Chairman. And I thank you and Chairman Stump for holding these hearings today. Although, as you've mentioned, we've had a dozen of them or more, I don't think we have come to the bottom of the situation as yet.
Let me try to put a human face on the attitude that I will take during these hearings today. I have two constituents named Sean and Leslee Dudley. Four or five years ago, they began to experience symptoms which they could not get adequately diagnosed anywhere. And initially they were treated for chronic fatigue syndrome.
They began to read about the Persian Gulf War illnesses, and thought that they had symptoms very similar. But when they tried to make this known to both the Department of Defense and the Veterans Administration, they were told that this could not be possible, they were civilians. They had not been to the Gulf. They were not in the armed forces. They were civilians who worked near the Marine Corps Recruiting Depot in San Diego, my hometown.
They were getting sicker and sicker. I met them when they were so sick I did not think I would see them on my next trip home because they were so ill.
They searched around for treatment and eventually came into contact with a researcher who was dealing with Persian Gulf War illness. He saw that this was the exact same situation that he had been treating in Gulf War illnesses and began to treat them with an antibiotic protocol, which he had developed. Within several months, they saw a tremendous turnaround. Now it is a year from when I first met them. They are proceeding toward some degree of normal health.
Page 9 PREV PAGE TOP OF DOC Their situation, I think, puts into human perspective some of the issues that all of us are concerned with. At first, the Dudleys were thought not to have anything that anybody could recognize. It was all in their mind. It was stress. Nobody thought it was a legitimate illness.
When they found somebody outside of the mainstream who would recognize it and begin treating them, they became activists in the attempt to help other people. And what they ran into in the Department of Defense and into in the Veterans Administration was a bureaucratic rigidity, a refusal to even hear what they had to say because it came into conflict with all of the assumptions that both departments shared.
They could not even get a hearing on the fact that here they had a treatment that seemed to work: Why weren't both the VA and DOD interested at all?
These are civilians, by the way, who believe that they caught this illness from others who had been exposed to whatever it is that caused it. Therefore, there is contagion involved. They have documented cases of other family members and pets of Gulf War veterans who have this illness.
I have never seen anywhere in the official literature that admitted any possible contagion. But the Shays Committee that has looked into this with some degree of credibility in my belief, and finds, in their words, that the programs are ''irreparably flawed.'' And they make recommendations to improve that.
The Presidential Advisory Committee, whom we will hear from, the first witness, said that ''The credibility gap between the public's views of government efforts to address these and the reality cannot be bridged without bold policy action.'' I quote from your report.
I have read all the testimony that I'm going to hear today. I have talked to folks in both departments. I still do not see, as Mr. Kennedy, Mr. Evans, and Mr. Smith pointed out, that the seriousness of the situation, the recognition of the fact that people are ill, and that there may be research that can lead to an improvement outside of the mainstreamI don't see any of that recognized at all in this testimony today. I do not see the bold action. I do not see a change in the policy.
Page 10 PREV PAGE TOP OF DOC As we prepare today perhaps to introduce our troops again into the same geographic area, it seems to me that the utmost of national security concerns is the truth, wherever that may lead.
If inoculations or testing of anti-chemical and biological warfare were involved and, therefore, we ourselves caused this illness, I think we have to recognize that fully because we are about to do the same thing. We have started inoculating troops again without ever knowing what had caused the first situation, at least in public testimony. I believe that there is knowledge and testimony within the organizations that have not yet come to light.
So, Mr. Chairman, I bring to this hearing a little bit of a skepticism based on my several years of dealing with the Dudleys as we have tried to help them come to a normal life and understand their own disease and have come into roadblock after roadblock after roadblock with the existing bureaucracies. And I think we need to change that.
Mr. SMITH. Thank you, Mr. Filner.
I have been advised that Dr. Caplan is under a time constraint. So I would ask that if members do have opening statements, to perhaps reserve that for the beginning of the second panel or I'll just admit it for the record and we'll make it a part of the record.
I'd like to introduce our first panel, first of three panels. It consists of: Dr. Arthur Caplan, a member of the Presidential Advisory Committee on Gulf War Veterans' Illnesses; Dr. Donald Mattison, Chairman of the Board of Health Promotion and Disease Prevention at the Institute of Medicine, who is accompanied by Dr. Dan Blazer, Chairman of the Committee on the Comprehensive Clinical Evaluation Program at IOM.
Dr. Caplan, if you would begin?
STATEMENTS OF ARTHUR CAPLAN, Ph.D., MEMBER, PRESIDENTIAL ADVISORY COMMITTEE ON GULF WAR VETERANS' ILLNESSES; DONALD MATTISON, M.D., CHAIRMAN, BOARD OF HEALTH PROMOTION AND DISEASE PREVENTION, INSTITUTE OF MEDICINE, ACCOMPANIED BY AND DAN G. BLAZER, M.D., CHAIRMAN, COMMITTEE ON THE COMPREHENSIVE CLINICAL EVALUATION PROGRAM, INSTITUTE OF MEDICINE
Page 11 PREV PAGE TOP OF DOC
STATEMENT OF ARTHUR CAPLAN
Mr. CAPLAN. It is an honor to have the opportunity to offer testimony to this Committee. I'd say it's also a rare opportunity that I get to meet with a group who has probably sat through as many hearings and statements as I have on this subject.
My field is ethics, specifically ethical issues in medicine and the life sciences. That's what I teach at the University of Pennsylvania. But, more importantly for the Committee, I was a member of the Presidential Advisory Committee on Gulf War Veterans' Illnesses, which completed its work last October 31.
I want to be clear to you all today that the testimony I am presenting, while based on my service on that committee, only represents my own views and opinions. I am not going to presume to speak for my fellow committee members.
I would like to offer my opinions to you about a number of issues your Committee is trying to address and struggle with, some of which you have talked about in your opening statements: What needs to be done to find answers to questions about Gulf War illness; what needs to be done to attend to health problems in veterans from the Gulf War; and, probably most importantly today, what lessons must be learned and zealously applied to future possible deployments in the Gulf or other areas of the world where American military personnel and support personnel might go.
Mr. Chairman, I feel obligated to begin my testimony to you by reaffirming something that our committee noted in its interim report; its final report; and when our tenure got extended in January of 1997 for another 9 months, a special report. There should be no doubt that some veterans returned home from the Persian Gulf War ill. Some of these illnesses are clearly service-connected.
Page 12 PREV PAGE TOP OF DOC The questions of what exactly Gulf War illness is has proven to be a most vexing matter. No single set of symptoms, no classic presentation of complaints has emerged which encompasses all of the different health problems that veterans told us about in an extensive period of public hearings and that have been amply documented in numerous scientific studies and assessments.
There have been pronouncements over the year, including this year, to our committee and in the media that there is no entity, no disease, no Gulf War illness. But the lack of a clear-cut set of criteria that permits easy diagnosis or a single clear-cut disease shared by all who served who have complaints and ailments should not obscure or detract from the fact that some veterans became sick and some remain sick as a consequence of their service. No one on this Committee should doubt that.
The obvious question which follows is: Why? Why were people sick? The range of complaints and ailments, differences in the degree to which the military personnel were exposed to the same agents and factors, an absence of obvious patterns in the overall distribution of illness complaints makes it most unlikely that any single agent or cause was responsible.
My own opinion is that Gulf War illness may actually constitute more then one illness, which may have been brought about by more than one cause, and may also include illnesses brought on by exposure to many factors, not a single agent, in the Gulf War environment.
Our committee in its reports, including the final report we issued just a few months back, called special attention to one factor in particular, stress, as an important contributing factor to the problems that beset some of those who were in the Gulf.
When we mentioned this factor, this led some to conclude that our committee, too, felt that Gulf War illness is all in the minds of veterans, that some veterans must be making up their symptoms, or that only those too weak or frail or unfit for service would succumb to the psychological impact of deployment in an alien environment and exposure to combat fought with terrible technological weapons. I want to state to this Committee that I find these reactions to the citing of stress as a contributing factor to Gulf War illness absurd and even at some times offensive.
Page 13 PREV PAGE TOP OF DOC Stress can effect health. This is a well-documented fact. We know it from animal studies, and we know it from studies of human beings who work and live in stressful environments and situations. To pretend that stress is something that influences our health in peacetime but not in war is patently silly.
That said, it is my opinion that stress, when we talked about it on the committee, is only one of a number of factors that may have contributed to some of the illness symptoms that some of the veterans suffered and they still suffer from.
It is not the sole cause of Gulf War illness. It is not the primary cause. It is simply one among a number of factors that we have to think about when we try and understand why so many people in so many different locations, from being deployed on the front lines all the way to the rear, suffer this vast array of symptoms that we call under the single banner Gulf War illness.
Well, the obvious question, then, is what to do about trying to find out the answers to questions of causation. And I have to tell you that many of my colleagues on the Presidential Advisory Committee on Gulf War Illnesses were and remain optimistic that focused, carefully conducted, peer-reviewed research will lead us to answers. I'm not sure. My own opinion is, that may not be true.
The Gulf War was fought under unusual circumstances. Large numbers of reservists were called into action at a rapid pace. For the first time, many women served at or near the front lines. The war itself was prosecuted with lightning speed.
Technology was deployed during this war that, thankfully, kept American casualties to an absolute minimum while causing great devastation to our enemy but that brought in its wake certain risks. Environmental hazards were omnipresent on the battlefield.
What I'd like this Committee to understand basically is that trying to go backwards 9 years in time to figure out who was where exposed to what when combinations of factors may be responsible for many different types of illnesses may be more than science is going to be able to reckon with.
Page 14 PREV PAGE TOP OF DOC Should we then abandon the effort to find the answer to what caused Gulf War illness? Absolutely not. The reason to push on is that the single most important lesson in my view of the Gulf War is that the only way to prevent another tragedy is to redouble our efforts into research to establish what the health effects are of various agents and factors that were in play in the Gulf theater and could be again should we be back there again.
It is vital that Congress insist that the armed Services and the Department of Defense make a concerted effort, moreover, to establish a baseline of health and surveillance that would allow us not to get into this situation one week from now or one month or one year from now.
We need to have uniform standardized policies for pre-deployment in-depth health assessments as well as for demobilization. These did not exist in Desert Storm and Desert Shield. And, in my opinion, I'm here to tell you today I don't think they exist now.
Despite the injunction that health monitoring and assessment in our reports receive top priority from the military in an era of technological wars fought in alien environments at a rapid pace, this has not happened. There is still insufficient attention to issues of adequate physicals, in-depth health assessments for samples of active and reserve troops, comprehensive and usable recordkeeping, standardization of medical information across the Services, storage of tissue samples for assessment, adequate monitoring of vaccine use and other preventive measures for deployed troops. We still aren't even sure that the equipment we're putting out there to measure chemical and biological warfare detection meets the standards that we ought to expect of it.
The problem that we face, then, is that we should have learned a lesson from the Gulf War, which is; if we don't understand the health of the people we send there in depth before they go, it's going to be difficult for us to figure out why some of them become sick when they get back.
Page 15 PREV PAGE TOP OF DOC We are not taking the steps, in my opinion, to make sure that we don't repeat this tragedy again. That is where our research should focus. In addition, we should focus our research as well on the presumption that those who were sick may not get an answer. And, therefore, what we have to do is give the veterans the benefit of the doubt and make sure that our government is spending the money that it takes to provide them with therapy, treatment, and palliation.
I'm not saying give up on trying to answer the question of what made people sick. What I do think has to happen is a bold effort to make sure that they get treatment; that they get disability; that we do right by the veterans who were there; and then we make sure that you all, if I might respectfully suggest, make sure that the infrastructure is in place to make sure that we're not in a situation where another contemporary conflict brings us back sick or ill or disabled veterans, leaving us uncertain as to why they wound up in that state in the first place.
[The prepared statement of Mr. Caplan appears on p. 75.]
Mr. SMITH. Because there's a roll call vote on the floor, the committee will stand in recess for about 5 to 10 minutes. Thank you.
Mr. SMITH. The committee will continue its hearing. Dr. Mattison, I believe you would be next. Please proceed.
Dr. MATTISON. Thank you.
STATEMENT OF DONALD MATTISON
Page 16 PREV PAGE TOP OF DOC Dr. MATTISON. Mr. Chairman, members of the committee, my name is Don Mattison. I am Dean of the Graduate School of Public Health at the University of Pittsburgh and Chair of the Institute of Medicine's Board on Health Promotion and Disease Prevention.
I am accompanied today by Dr. Dan Blazer, who is Dean of Medical Education at Duke and chairs the IOM Committee on the Evaluation of the Comprehensive Clinical Evaluation Program for Persian Gulf Veterans.
We appreciate the opportunity to provide testimony to you regarding a new IOM study. This study will evaluate the available scientific evidence and medical literature regarding an association between exposures during the Gulf War and potential health effects as experienced by Persian Gulf veterans.
As requested, I will also briefly review the findings of the recent IOM report which examined the adequacy of the Department of Defense's Comprehensive Clinical Evaluation Program and how those findings relate to similar programs administered by the Department of Veterans Affairs.
Dr. Ken Shine, the President of the IOM, regrets that he is unable to attend this hearing. However, he will make available himself, members of the Institute, and staff to provide information and testimony to the committee as necessary.
The Department of Veterans Affairs has requested that the IOM conduct a comprehensive review of the available scientific and medical literature regarding the association between exposures during the Persian Gulf War and adverse health effects experienced by Persian Gulf veterans.
This study will be conducted by a committee of experts drawn from a broad range of public health, scientific, and medical fields. Based on its review and findings, the committee will also make recommendations for additional scientific studies to resolve areas of continued uncertainty related to health consequences.
Page 17 PREV PAGE TOP OF DOC The IOM plans to conduct the study in three phases. During the first phase, the committee will develop criteria by which specific exposures and adverse health outcomes are to be chosen for study.
The committee will review different types of research findings from the scientific and medical literature; for example, data from animal studies, occupational exposures, and epidemiologic studies. They will conduct a review of the literature regarding prototypic exposures in order to develop methods for analysis and synthesis of findings. Scientific evidence concerning association of exposures and health effects will also be examined.
The committee will consider the strength of the scientific evidence and the appropriateness of those methods used to identify the association; the exposure levels of the study populations in comparison to Gulf War exposures; and whether there exists a plausible biological mechanism for a causal relationship between the exposure and the manifestation of the health effect.
During the second phase of the study, the remaining exposures will be subject to review and analysis. The final phase, to be conducted intermittently, will update the literature reviews and the associations that have been identified between exposures and adverse health outcomes. It is assumed that the IOM will begin this project this spring and complete the first phase by the Spring of the year 2000.
I would like to focus now on the findings of the recently released IOM report evaluating the adequacy of the Comprehensive Clinical Evaluation Program administered by the Department of Defense and how the report findings relate to similar programs administered by the Department of Veterans Affairs. I have appended a complete set of recommendations of the committee to my testimony but would like to summarize some of the findings for you.
The charge to this IOM committee was to examine the adequacy of the Comprehensive Clinical Evaluation Program diagnostic protocol as it relates to ill-defined and difficult-to-define conditions, and to stress and psychiatric disorders.
Page 18 PREV PAGE TOP OF DOC The committee chose based upon an examination of the conditions described as difficult-to-diagnose or ill-defined to refer to this spectrum of illness as medically unexplained symptom syndromes. Medically unexplained symptom syndromes are often associated with depression and anxiety. Yet, this does not imply that the syndromes are psychiatric disorders.
In addition, stress is a major issue in the lives of patients with this spectrum of illness and is a component of the patient's condition that cannot be ignored. With medically unexplained symptom syndromes, the potential for stress proliferation is great among both the persons deployed to the Persian Gulf and the family members.
Research has shown that stressors have been associated with major depression, substance abuse, and various physical health problems. Those deployed to the Gulf were exposed to a vast array of different stressors that carry with them their own potential health consequences.
It was the conclusion of that committee that ''in cases where a diagnosis cannot be identified, treatment should be targeted to specific symptoms or syndromes.''
The committee also recommended that ''providers acknowledge stressors as a legitimate but not necessarily the sole cause of physical symptoms and conditions'' and that providers should be educated to the fact that ''conditions related to stress are not necessarily psychiatric conditions.''
There is another committee of the Institute of Medicine that is currently completing its evaluation of the Department of Veterans Affairs Persian Gulf registry and uniform case assessment protocol for Persian Gulf veterans. Dr. Blazer is a member of that committee, whose charge is much broader than that of the CCEP committee because it includes an examination of the adequacy of: the protocol, its implementation and administration, outreach efforts to inform veterans of available services, and education of providers. The final report is due to be released later this year. We would be pleased to share copies of the report with you as soon as available.
Page 19 PREV PAGE TOP OF DOC Thank you for this opportunity to address you and the committee members. Dr. Blazer and I would be pleased to answer any questions that you might have.
[The prepared statement of Dr. Mattison, with attachment, appears on p. 83.]
Mr. SMITH. Dr. Mattison, thank you very much for your testimony.
Dr. Caplan, I'd like to ask you: In its report last October, the PAC recommended development of permanent legislation to, quote, ''address the pervasive perception of government neglect in handling Gulf War veterans' illnesses.'' Is this proposal intended to help regain trust or is it a remedy, a gap, to provide a remedy for a gap, in legal authority as of right now?
Mr. CAPLAN. A little bit of the latter, a lot more of the former. Trust is a major issue in this area. And as you talk to veterans and listen to their complaints about lack of inattention from the DOD, failure to follow up on their symptoms, finding obstacles in their path about how best to find resources within the VA and other health care systems, I think there's a legacy of distrust here. And I believe that it really is going to take an independent authority with legal standing with veteran participation to oversight these investigations and keep tabs on what's going on.
The PAC that I served on no longer exists. And it is very important that something else be put in place with appropriate authority and representation to command that trust.
Mr. SMITH. Dr. Blazer, did you want to comment on that?
Dr. BLAZER. Yes. I have no comment specifically but would be happy to answer any questions.
Page 20 PREV PAGE TOP OF DOC Mr. SMITH. Okay. Doctor, your committee offered suggestions for treating Persian Gulf veterans' symptoms, such as fatigue and pain, even if their illnesses cannot be diagnosed. Does it matter that the treating physician doesn't know whether the symptoms are related to stress versus some other cause?
Dr. BLAZER. I think that the important issue is to recognize that stress and other causes can coexist. Stressors may relate to events that occur external to the individual.
For example, in the Persian Gulf, we heard testimony that individuals were exposed to hundreds of dead bodies, certainly an experience that would have been very stressful to them. At the same time, stress can arise from having a symptom that cannot be explained when one goes to a physician. So it may arise from that perspective as well.
I think the point we wish to make in our evaluation of the CCEP was that stress should not be ignored as part of the symptom complex going on. We do not suggestit was mentioned earlierthat stress is the cause of every and all symptoms that we see.
Mr. SMITH. Dr. Caplan?
Mr. CAPLAN. Mr. Chair, just to follow up on that, I think one tendency in these discussions is to assume that if we eliminate certain causes and stress is put on the table, then everything in the way of illness is going to wind up in the stress bin. And that is false.
Stress is just being suggested as something that needs to be given consideration, but I think there is far more unknown about causes than there is known. And some of my skepticism about the complexity of what took place with respect to the health of the veterans is due to the fact that I'm not sure we're going to be able to tease all of that apart.
Mr. SMITH. Let me ask one final question.
In its testimony, Dr. Blazer, the GAO faulted the VA and the Department of Defense for failing to monitor Persian Gulf veterans' clinical progress after their initial examinations. Yet, the VA questions the feasibility of a monitoring effort in the absence of a well-defined illness. Can you comment on that?
Page 21 PREV PAGE TOP OF DOC Dr. BLAZER. I think there can be monitoring, and I think that monitoring can occur in a number of ways. One way that monitoring certainly could be improved would be to have good, solid, complete records from the individuals who were evaluated by the Veterans Administration. And this follows from a recommendation that we made regarding the CCEP.
A second would be to have a standardization of the way different symptoms are evaluated and whether they're recorded as being present or absent. Reliability across facilities without clear standards can be very poor. And improving reliability through training of physicians could go a long way toward improved monitoring.
I think also providing clear referral for follow-up would be another way that monitoring could take place.
Mr. SMITH. Thank you, Dr. Blazer.
Mr. KENNEDY. Thank you. Thank you very much, Mr. Chairman.
First of all, I did want to just acknowledge your leadership on this issue, Mr. Smith. I appreciate you chairing this hearing today and the fact that we are following up on this Committee in a way that I think is appropriate given the lack of interest that took place for such a long period of time.
I want to just come back to the sort of general issue here that I spoke about in my opening statement. I think that because of the history of what's occurred, we're now in a situation where sort of almost every member of Congress and every different organization in the government has got some particular interest that they have developed and to a point where, as I mentioned, I couldn't believe we spent $49 million on these studies. We have 103 of them, 103 studies going on right now.
I called the GAO and just asked them if they couldI looked at just the list of studies that have been requested. They cover everything under the sun.
Page 22 PREV PAGE TOP OF DOC So at a certain point, I began to get the impression from the veterans themselves that we can study this thing to death, but at a certain point, what they really need is treatment for their illnesses and that there is a sense I think at the moment that the veterans themselves, while they're getting treatment at the VA, they're not getting fixed. They're not getting better.
I'm sure that the Chairman and I would love to get together with you either at an appropriate time or whenever the Chairman decides that he'd like to ask you to come up, but
Mr. QUINN (presiding). Mr. Kennedy?
Mr. KENNEDY. Yes?
Mr. QUINN. You may continue.
Mr. KENNEDY. Oh, I thought you were yelling at me. (Laughter.)
Mr. QUINN. I have a hammer if I need to deal with you.
Mr. KENNEDY. I've got some nails.
Anyway, what I want to come back to, though, is whether or not you feel right now that you have the necessary tools and information to be able to treat the illnesses that the veterans have.
Dr. BLAZER. I don't think that question could be answered ''Yes'' or ''No.'' What I think we can say is that there are a number of symptoms that we do see. These may not fall into a clear, neat disease category, but these symptoms certainly can be treated. They're well-known to be treated.
There are many symptoms in medicine that are treated when we actually do not know the diagnosis or the cause of that particular symptom. Chronic pain is a certain example of that.
Mr. KENNEDY. But is there follow-up docI mean, the fact is that we're getting also information that the veterans come in. they get seen. They get sent back out.
Page 23 PREV PAGE TOP OF DOC They get some sort of treatment, but there isn't a sort of sustained kind of registry and follow-up so that people actually haveand, you know, I just ran into General Blanck the other day.
He said: Oh, you should see. We've got this tremendous health care initiative that's set up over at NIH, where you can come in and we treat you for free and everything is terrific.
And I said: Well, how many veterans actually take part? And I think he said like 109 or something. I mean, it was like compared to the sheer number of people that you have with these ailments, it's a minuscule amount.
So what I'm driving at here is that there seems to be kind of a disconnect between the studies that we're asking for, on the one hand, but the treatment and whether or not the treatment is actually providing the kind of help and assistance that a bunch of sick veterans are actually facing.
Dr. BLAZER. I think that's a second question. First off, I think the question you asked initially was: Can these symptoms and some of the symptom complexes be treated? The answer to that is yes.
The second question, which I think is behind your first question, is: Are they being treated adequately right now? I think that is not well-known, and I think that's exactly one of the things that another Institute of Medicine task force will be looking into. It does need to be looked at.
Mr. KENNEDY. You know, it's pathetic that all we do is we study the studies, for crying out loud. I mean, come on, guys.
Mr. QUINN. Dr. Caplan?
Mr. CAPLAN. Let me just say that one area where I think the veterans have complaints that this Committee and Congress could really do a better job on is not so much treatment but disability.
Page 24 PREV PAGE TOP OF DOC Time and time again when our Presidential Advisory Committee met, we heard people saying that when they sought disability and compensation for it, they encountered roadblocks.
And I will simply say based on what I listened to when I heard that the presumption, the benefit of the doubt ought to be going to the veteran. And I do not think that is taking place with respect to claims for disability. I think that's an area where movement is possible.
Mr. KENNEDY. Isn't it possible given the three of your sort of preeminent positions on this issue for the three of you to get together and to just give a very direct series of recommendations to this Committee on exactly what steps need to be taken?
You don't need to add. You don't need more studies here, gang. You just don't. What you should do is tell us to stop with the studies. You should say, ''Listen, 103 studies. We're going to spend''I don't know how many. If we spent 50 million bucks already, we're going to spend another 50 million on the remaining studies.
We ought to say, ''Look, here are the two or three things we really need to study. Here's what we need in order to follow up on making certain the veterans are getting appropriate health care. And here is what we need to be making sure that they're getting appropriate disability payments.'' I mean, it's not that complicated.
Dr. MATTISON. That I think is the scope of the study that I referred to in my discussion, which was to look specifically at exposures. This is an
Mr. KENNEDY. When is your study due?
Dr. MATTISON. The study would look at exposure
Mr. KENNEDY. When is your study due?
Dr. MATTISON. When is the study due? The first phase of the study would be due in the Spring of 2000.
Page 25 PREV PAGE TOP OF DOC Mr. KENNEDY. It's just pathetic, you know? It's ridiculous. Don't you hear what you're saying? What do you think these guys are going to do behind you?
Mr. CAPLAN. I'll take a whack at that and say I think I can boil it down to at least three simple injunctions. One is let's make sure that veterans get the benefit of the doubt with respect to disability claims.
Secondly, we do need to make sure that we have the kind of monitoring and health surveillance that we don't for these veterans because, Congressman, we may not have heard the last of the health complaints. We haven't heard about long-term effects. And we need that infrastructure set in.
And, third, as I tried to suggest when I was giving my testimony, it is very important that we have the health infrastructure for pre-deployment, physicals for troops, to take health assessments, to monitor what's going on, and to have the appropriate chemical and biological weapons detectors be in place. If we deploy tomorrow, right now, we may be sitting here 2 years from now having this discussion.
Mr. QUINN. Yes. Thank you, Dr. Caplan, Dr. Mattison, and Dr. Blazer. Unfortunately, we're going to have to break for a vote now.
Mr. FILNER. Are we going to keep them here?
Mr. QUINN. They're going to stay, but we have 10 minutes to get to a vote.
Mr. FILNER. I have one question when we come back.
Mr. QUINN. Absolutely. We'll recess and be back in about 15 to 20 minutes.
Dr. COOKSEY (presiding). If everyone will be seated, we'll get started. Mr. Filner, did you have a question?
Page 26 PREV PAGE TOP OF DOC Mr. FILNER. Yes, Mr. Chairman. Thank you very much. I'll try to be brief.
We apologize for this delay. I think that was the last vote. So we'll try to have some degree of efficiency here.
I think all of us and probably you all, too, share the frustration that was voiced earlier by Mr. Kennedy. When we see first studies of first phases of studies to be in the year 2000, when we have people who are now very sick, some very, very sick,I have literally hundreds of constituents in San Diego who have some degree of illness from this, maybe thousandsand when we know, as I think, we are already inoculating our troops for possible deployment in the Gulf again, to say that studies might be available in 2000 does not help any of the current situation.
It seems to me that if I were in charge either of the Legislative or the Executive Branch, I would be looking at this with a lot more emotion and intensity and money and energy, what Dr. Caplan, your committee's report called bold action.
Mr. Kennedy was impressed with the amount of money budgeted. I'm very unimpressed. I don't think we have anywhere near the resources needed, given the problem and given the speed at which we have to do this.
I'm sure you would like to do your study faster. If you had more resources, you would do that. So, rather than getting frustrated at you, it's our job to give you the resources that you need to complete your task quickly.
I have seen evidenceand I don't know if you're the people to ask or maybe a later panelwhere at least some percentage of the cases could have been caused by the inoculations that we gave or tested. And here we are giving other inoculations. I mean, if I were in the armed forces, I would be scared to death to have my government inoculate me with anything, believe me.
Page 27 PREV PAGE TOP OF DOC We don't know what caused it. We don't know what we're doing. And we're proceeding again. Is that a fair fear that we ought to have, given what's going on?
Mr. CAPLAN. Well, unlike my colleagues on this panel, I'm not here to do further studies or request money for further studies. I'm kind of here from the look-see that this Presidential Advisory Committee took.
But I will say this, Congressman Filner, with respect to the vaccination issue, you don't need a study to understand that where we let down the troops who were over there before is not telling them that they were getting something new or untested and then not following them to see whether they became sick once they came back.
Mr. FILNER. Has that admission been in any public document from DOD or DVA?
Mr. CAPLAN. It's in our report.
Mr. FILNER. Your report, but has the Government of the United States ever said that?
Mr. CAPLAN. Sluggishly and grudgingly is the way I
Mr. FILNER. I mean, that would be an important statement to make
Mr. CAPLAN. And I think
Mr. FILNER (continuing). And deal with it if that's the case.
Mr. CAPLAN. I think it's important that we understand that were we to use new agents, investigational agents tomorrow morning through vaccination or for anti-chemical or anti-biological warfare, I'm not convinced that we're not facing the exact same lack of infrastructure to tell them and monitor them.
As one veteran of the Gulf told mehe said: Look, informed consent isn't the issue. If you tell me someone is going to shoot a big canister of poison gas at my head and you might have something that could help me fend it off, I'll give you my informed consent, and you can give me the vaccine. It's not a big issue. But to follow me and study me and make sure that then I didn't get sick as a result of that, that's what we
Page 28 PREV PAGE TOP OF DOC Mr. FILNER. But isn't it true that we do not have even the most basic vaccination records? I mean, were they not kept? Are they kept classified?
Mr. CAPLAN. They were kept sloppily.
Mr. FILNER. Do we have them but they have not been made public?
Mr. CAPLAN. No. I don't think they're kept in good order. They were not kept in good order.
Mr. FILNER. I mean, that's a pretty damning thing, and I would hope
Mr. CAPLAN. What I would say is this
Mr. FILNER (continuing). That we are doing it different this time around.
Mr. CAPLAN. We deployed
Mr. FILNER. I see Dr. Rostker shaking his head yes. That scares me to death that we didn't keep these kinds of records and are not even admitting it, as far as I can tell.
By the way, did your committee look at the experiences of other nations in this regard? Because this was a multilateral effort. Are other countries experiencing the same thing?
Mr. CAPLAN. There certainly are other countries who have had veterans who report Gulf War illness. Specifically what you're asking about, recordkeeping and disclosure and follow-up and so on, I think our deployment and our presence was of a dimension that just isn't comparable.
Mr. FILNER. Is it trueI have heard this, and I'll ask this. The French had about 25,000 troops in there. I am told that there is not one case of the illnesses reported among the French who were there. Is that true or not? Has anybody heard that?
Page 29 PREV PAGE TOP OF DOC Dr. BLAZER. I've not heard.
Mr. CAPLAN. I've heard that, but I also did have occasion to talk with a few veterans from France who served in the Gulf. And they told me that the system for reporting, the way information is collected is not the same.
Plus, many of those who went in the French forces are still on active service. And it's a bit more difficult to report these kinds of symptoms when you're still active, as opposed to when you're out.
Mr. FILNER. I'm sorry to say that that may be the case here, too.
The reason I asked is that I understand they had a protocol treatment before their troops were deployed, which is, in fact, not allowed among our own troops. And if that is the caseand, again, I would like to find out, and I'm warning the other panelists I'm going to ask this if the French had a protocol that prevented the illness and we are not allowing the use of that same protocol, that would seem to me rather a disservice to our troops.
Dr. COOKSEY. Mr. Snyder, any questions?
Dr. SNYDER. No.
Dr. COOKSEY. Dr. Caplan, Dr. Snyder and I are both physicians. Let me ask you. You have a Ph.D.? In what?
Mr. CAPLAN. In philosophy, bioethics.
Dr. COOKSEY. Philosophy. Okay.
Let me ask you a couple of questions. The GAO report, of course, caused a little controversy and seemed to contradict that report from previous experts that I assumed were trained in the scientific method, including the PAC, the President's Commission, and stated that ''A substantial body of research suggests that low-level exposure to chemical warfare agents or chemically related compounds is associated with delayed or long-term health effects.'' What's your assessment of that statement and the strength of the underlying scientific evidence?
Page 30 PREV PAGE TOP OF DOC Mr. CAPLAN. I would take issue with that statement, and I think it's not on a question of medical or scientific knowledge. It is actually on a question of logic and evidence.
What I think the GAO did was to say that you can't rule out chemical causes, chemical weapons causes, for these symptoms, as we tried to do in our report, saying that whatever was going on, all of the illnesses and all of the people who had them couldn't be explained by low-level chemical weapons exposure. And they said: Well, you can't be sure of that.
My response would be to say the evidence that's available, what is known about the pattern of disease does not support that as the single cause of all the different illness complaints that veterans have. And I think the GAO, while wanting to keep the door open, if you will, is not consistent with what the evidence says about a single cause, chemical or otherwise, for all of these illnesses.
Mr. FILNER. Would you yield for one second, Doctor?
Dr. COOKSEY. Sure.
Mr. FILNER. But why? I mean, I'm sorry to point out a logical flaw in a philosophy professor, but I have a Ph.D., too. So I guess I can do it.
I don't understand why you kept saying a single cause. Why should that be the assumption?
Mr. CAPLAN. It isn't. I didn't mean to
Mr. FILNER. If we were looking for a single cause and find no evidence of a ''single'' cause we should not conclude there are not multiple causes.
Mr. CAPLAN. I would prefer to call that an extension of what I said, rather than a contradiction. Yes, you are absolutely right. In fact, what the GAO was hinting toward was a single cause type of approach.
What we were trying to say again and again in this report is that low-level chemicals may have played a role in combinations of that, may have played a role in genetic differences. Plus, that may have played a role. But to simply say, ''Well, you can't rule out this single agent as causing everything,'' even with the evidence, does not square with the evidence.
Page 31 PREV PAGE TOP OF DOC Mr. FILNER. Okay. I'm sorry, Doctor.
Dr. COOKSEY. Good point.
The GAO report seemed to reply heavily on the work of Dr. Robert Haley. And Dr. Haley indicated that his studies suggested that there were some subtle neurological findings that he attributed possibly to chemicals and chemical exposures. Did you and your colleagues review his report, number one? What is Dr. Haley's background?
Mr. CAPLAN. Physician, very expert researcher. I believe he was at Texas.
Dr. COOKSEY. One of the medical schools?
Mr. CAPLAN. Yes.
Dr. COOKSEY. Okay. Thank you.
Mr. CAPLAN. And the article did appear in the Journal of the American Medical Association. So it was subjected to peer review and so forth. We looked at it.
If you asked me personally, my impression of what my fellow panelists and I thought about his work was that it was very interesting, very important, should be credible but just an early report of something that needed more investigation.
Dr. BLAZER. I might be able to add something regarding the deliberations of our committee on the CCEP. In fact, Dr. Haley's findings actually were published just days before our first report was released. But we did go back subsequently and look very carefully at this report.
One thing in reviewing the large literature that was evident to us is that there is very, very little data at the present time regarding the long-term effects of low-level exposure to toxins. That data is not there.
Dr. Haley's study may give us a beginning piece of that puzzle, but it's a puzzle that's far from complete. That study certainly should be replicated.
Page 32 PREV PAGE TOP OF DOC One person on our committee actually found a number of methodological flaws in the study. I think it was a good study. I think there are flaws. And I think you cannot jump to conclusions regarding that study, but I think it does reflect how little we know about long-term effects from some of these toxins that people may been exposed to in the Gulf War.
Dr. COOKSEY. Mr. Gutierrez.
Mr. GUTIERREZ. Thank you, Mr. Chairman.
Dr. Caplan, I'd like to read you a recommendation from Page 23 of the PAC special report and ask you to comment. It says, quote, ''The Committee envisions legislation that directs VA to contract with an organization with the appropriate scientific expertise for a periodic review for benefits and future research purposes of the available scientific evidence regarding associations between illnesses and Gulf War service. The object of such an analysis would be to determine statistical association between service in the Gulf, morbidity and mortality, while also considering whether a plausible biological mechanism exists, whether research results are capable of replication and of clinical significance, and whether the data withstand peer review.'' Based on the external evaluation, the Secretary of Veterans Affairs would make a presumption of Service connection for positive associations or published reasons for not doing so.
I think that it's extremely important for the committee to make sure that we understand both the intent and the rationale for this recommendation. Does this recommendation mean that the PAC believes that symptoms that have a greater prevalence in the veterans' population deployed in the Gulf than in the non-deployed veteran population can provide a scientific basis for Service connection? And if not, please explain to us.
Mr. CAPLAN. I think it does. And I think that what we were trying to indicate there in my view was to try and lower the barriers that people have to claiming disability, what I was talking about in some earlier comments of mine. And I think it may be up to Congress to work with these agencies to create a program that they're satisfied does, in fact, lower those barriers.
Page 33 PREV PAGE TOP OF DOC But it is what we were saying. In the face of uncertainty, give the veteran the benefit of the doubt. In the face of uncertainty, it is the veteran who I think should in the end be the object of our empathy and compassion and that that recommendation is specifically targeted right to that goal.
I think even the message that those manning the gates, doctors doing the disability benefits, yield in the face of, other things being equal, to the presumption of the veteran is still not a message that has percolated from these chambers out through the medical system.
Mr. GUTIERREZ. Do you know if the Secretary of Veterans Affairs or Department of Veterans Affairs say they're going to publish such a report or a recommendation in response to this report?
Mr. CAPLAN. I believe there was a contract
Dr. MATTISON. Can I comment on that?
Mr. GUTIERREZ. Sure.
Dr. MATTISON. The study that I described as the proposed study that would be followed by the Institute of Medicine is, I think, a direct reflection of the Department of Veterans Affairs' response to this particular recommendation.
So I believe at least one component, the periodic review and the establishment of firm, credible scientific linkage between exposures and disease, will be specifically explored in that study. So at least that one component of that recommendation has been followed.
Mr. GUTIERREZ. So maybe what we should be doing as a Committee is making sure when the Veterans Affairs Department comes, make sure that that presumption is being given now as we continue testing because we're going to test ourselves to death herewell, actually, the veterans to death here, quite figuratively speaking and literally speaking, if we don't start giving them some presumption of the illness because it always seems to me that it's such a contradiction.
Page 34 PREV PAGE TOP OF DOC So I'm happy to hear Dr. Caplan's words and members of the committee, those members of the panel testify because, if my memory serves me correctly, we had the President of the United States of America, President Bush, and every member of Congress and senator talking about the brave, the intelligent, and the worthy men and women of this Nation, our best and our finest that were going off to fight and defend our Nation. And then they came back.
I was sitting here. I was elected in 1992. So I came here. And one of my first hearings was the people from actually the Department of Defense coming here and saying: Well, we think there's some malingering going on here and some people looking for pensions. Those were certainly the allegations that were made, and that's the only conclusion you could arrive at. They said: Well, you know, these guys are making up some strange stuff here, these men and women.
So I just want to make sure that we record for history that this just never happens again, that they are the finest, they are carrying out their duty, they are brave, they are everything we say they are, during war and after war, when they come back here.
You can't go to a bunch of parades all over the country, take photo ops, put them in your campaign literature, and then sit here in this Congress and say, ''Well, you know, I'm sorry, but there might have been a malingerer in that parade with me that I was celebrating that day.''
So I'm really happy and excited to hear your explanation to this answer, Dr. Caplan, because I think we've come a long way. Unfortunately, it has taken us 5 years to get here. And I think we have to make sure that we have that presumption. I think all veterans should have that presumption.
It's kind of like sayingyou know what it reminds me of, Mrs. Chenoweth? It reminds me of thatyou ever buy something and then you call up an 800 number and they said everything was covered but that? I'm sure everybody in this audience has. Everything was covered but that.
Page 35 PREV PAGE TOP OF DOC That's the way I would feel if I were a veteran. Everything was covered but this. You know, everything is covered is everything is covered. We should keep our bond to our word.
Thank you very much.
Mrs. CHENOWETH (presiding). I thank the gentleman from Illinois.
Does the gentleman from California have anything to add?
Mr. FILNER. Just briefly. By the way, I would take your analogy, Mr. Gutierrez, and say the 800 number generally doesn't answer and that is the real frustration. (Laughter.)
Mr. Kennedy before you were here, Madam Chair, voiced a lot of frustration and was asking for some more direct help.
We're all in professions, whether we're professors or doctors or bureaucrats or Congress people, in which we talk in a certain language and a certain format. And the format of these hearings adds to that. We talk in an understated, subdued way.
I want some emotion. I want you to tell us, ''I don't have enough money. I'm angry. I'm frustrated. I'm saddened.''
When I see the people in my district who are sick, I'm angry, but I'm trying to get them help. And I'm getting frustrated. I want some emotion in all of this, as opposed to these bureaucratic kinds of things that we're all involved in.
I see Dr. Rostker sitting in the front row just waiting to get here. I think part of the reason he was chosen for this job is he brings some of that emotion. Unfortunately, I think he's using his great skills still to cover up what the reality is.
But we need some of that emotion in this and not just bland statements, ''In the year 2000, we're going to do the first phase.'' I mean, we've got real people here who are dying. We're sending them off to war again, and we don't know what the hell happened.
Page 36 PREV PAGE TOP OF DOC I want some action, and I think that's what we all have to talk about and get the kind of intensity here that lay behind the Manhattan Project and that kind of commitment of a Nation toward saving these young men and women.
Mrs. CHENOWETH. I thank you, Mr. Filner. Very well-stated.
I want to thank this panel very much for their valuable time and information. And, again, you know that you can supplement the record for a short period of time. And I want to thank you on behalf of the committee for your excellent participation.
Mrs. CHENOWETH. And the Chair will recognize the second panel now. The second panel consists of: Dr. Kenneth W. Kizer, M.D., the VA's Under Secretary for Health; Dr. Bernard Rostker, Special Assistant to the Deputy Secretary of Defense for Gulf War Illnesses, who is accompanied by Mr. Gary Christopherson, Acting Principal Deputy Assistant Secretary for Health Affairs at Department of Defense; and Dr. Donna Heivilin, Director of Planning and Reporting of the National Security and International Affairs Division at the U.S. General Accounting Office, who is accompanied by Dr. Kwai Chan, Director of Special Studies and Evaluation of the National Security and International Affairs Division at GAO.
Welcome to all of you. And I know that you are experienced in offering your testimony and that you know for the record your testimony should be given in 5 minutes. And then you will be asked a series of questions by the committee.
The Chair would like to recognize Dr. Kizer first for his testimony.
Dr. KIZER. Thank you, Madam Chairman.
STATEMENTS OF KENNETH W. KIZER, M.D., M.P.H., UNDER SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY: FRANCES MURPHY, M.D., M.P.H., DIRECTOR, ENVIRONMENTAL AGENTS SERVICE, CHIEF CONSULTANT, OCCUPATIONAL AND ENVIRONMENTAL HEALTH; JOHN F. FEUSSNER, M.D., CHIEF RESEARCH OFFICER, DEPARTMENT OF VETERANS AFFAIRS; BERNARD ROSTKER, Ph.D., SPECIAL ASSISTANT TO THE DEPUTY SECRETARY OF DEFENSE FOR GULF WAR ILLNESSES, DEPARTMENT OF DEFENSE; GARY CHRISTOPHERSON, ACTING PRINCIPAL DEPUTY ASSISTANT SECRETARY FOR HEALTH AFFAIRS, DEPARTMENT OF DEFENSE; DONNA HEIVILIN, Ph.D., DIRECTOR OF PLANNING AND REPORTING, NATIONAL SECURITY AND INTERNATIONAL AFFAIRS DIVISION, U.S. GENERAL ACCOUNTING OFFICE, ACCOMPANIED BY KWAI CHAN, DIRECTOR, SPECIAL STUDIES AND EVALUATION, NATIONAL SECURITY AND INTERNATIONAL AFFAIRS DIVISION, U.S. GENERAL ACCOUNTING OFFICE
Page 37 PREV PAGE TOP OF DOC
STATEMENT OF KENNETH KIZER
Dr. KIZER. Let me introduce to you, for the record, the two other individuals who accompany me today: Dr. Jack Feussner, the Chief of Research and Development for the Veterans Health Administration; and Dr. Fran Murphy, who is in charge of the Occupational and Environmental Strategic Health Care Group.
Mrs. CHENOWETH. Welcome, Doctors.
Dr. KIZER. I thank you for this opportunity to continue our discussion of the health problems of Gulf War veterans. I have previously provided the committee a formal statement. That statement provides a much more complete review of VHA's efforts to provide health services to Gulf War veterans and our research efforts to finds answers to the very complex medical and scientific questions related to Gulf War service than this brief opening statement, some of those difficult questions were touched upon by the last panel.
Before mentioning a few specific things, I think it is useful to note the context in which VA's response to the problems experienced by Gulf War veterans has developed.
No two wars in American history have been alike. The geography where the conflicts have occurred, the military tactics and weapons used; the ambient political, social, and cultural climate in which they occurred; the prevailing health technology at the time; and many other factors have been significantly different for each war in our history. Just as the Vietnam War differed from World War II, which was different from World War I, the environment of the Gulf War was unique. And, while it may be pointing out the obvious, I think it is often overlooked that much of what we are dealing with in Gulf War veterans is a medical frontier.
There is no model or standard formula about how to best respond to post-war health effects in general or Gulf War effects in particular. There simply is no textbook or standard reference that you can go to to find out what the best practices are to deal with the problem.
Page 38 PREV PAGE TOP OF DOC Indeed, when you consider the various environmental, technological, psychological, and other factors that collectively impact the soldiers who have fought the wars, and the state of the medical science at that time, it should be obvious that when you combine these factors this with the countless ways in which the human body can respond to those various stimuli, I think it should be clear how complex it is to determine cause and effect and the most effective medical interventions.
Because of these things, from the beginning of its response to Gulf War veteran problems, VA has sought broad scientific and other input to help inform us about the best course of action. As we have gained knowledge and information, we have continued to consult the best scientists available to help focus our efforts. Various groups, including the GAO; the congressional committees, such as this; the Presidential Advisory Committee; veterans themselves; and focus groups and other forums have reviewed our strategy and course of action. Those groups have provided their opinions and advice, and we have welcomed their opinions. We have tried to incorporate many changes in what we do, both in our health care programs and our research strategy based on that input.
Now, let me review a few things. And I am cognizant of the clock, so I am going to abbreviate much of what I was going to say.
Regarding VA's health programs, to date, almost 65,000 Gulf War veterans have completed registry examinations. More than 2,500,000 million ambulatory care visits have been provided to over 220,000 Gulf War veterans. More than 22,000 Gulf War veterans have been hospitalized at VA medical facilities for service-connected and non-service connected conditions. And more than 83,000 of these veterans have been counseled at our vet centers.
As we have discussed before at other forums such as this, Gulf War veterans participating in the Registry examination program have commonly reported that they suffer from a diverse array of symptoms, including fatigue and skin rash, muscle and joint pains, headache, memory problems, shortness of breath, sleep disturbances, diarrhea and other gastrointestinal symptoms, and chest pain. And the list of symptoms goes on considerably.
Page 39 PREV PAGE TOP OF DOC The diagnoses of our registry participants do not cluster in one organ system or disease category but, instead, thus span a wide range of illnesses and diagnostic categories.
A large majority of the veterans who have these symptoms and illnesses have been diagnosed and successfully treated. However, depending on the specific medical nomenclature that is used, somewhere between 10 and 25 percent of the veterans from the Registry who have been examined have unexplained illnesses.
I think it is useful in the way of context to again note that this frequency of unexplained symptoms among Gulf War veterans appears to be about the same as in a general medical practice outside of the VA or outside of a military setting.
It is important to note, however, that the medical scientists who are looking at this are far from completing their studies of these unexplained conditions. There continues to be considerable uncertainty about the character, natural history and potential causes of these conditions. It is essential if we are going to find effective treatments that this research continue into the underlying causes and the natural history and other aspects of these various conditions.
In the way of treatment, I think it's worthwhile to note that we have initiated clinical demonstration projects for multidisciplinary clinical care for Gulf War veterans as well as markedly expanding our case management efforts.
Case management as a routine clinical strategy for Gulf War veterans has already been implemented at 20I think it is over 20 nowVA medical centers as part of a major initiative underway throughout the department. Indeed, as one of the Fiscal Year 1998 performance measures for our network directors, this has been targeted. They are focused specifically on this.
Likewise, in the area of compensation and pension examinationsand I know that there is another panel that will specifically address some of these issues laterbut let me just say that we have been working with VBA, particularly with regard to clarifying the terminology and the protocols and the manner in which these examinations, particularly examinations for individuals with undiagnosed illnesses, would be conducted. We have developed some clear guidelines, which are being disseminated to the field, to help improve this effort. We expect that this will be an iterative process, and these will probably need to be refined over time as well, as just about everything else in this regard.
Page 40 PREV PAGE TOP OF DOC We are continuing our effort to expand health care education for our clinicians and care-givers. We have discussed our efforts in this regard at other forums like this, particularly for the registry physicians and those in Gulf War program per se, but we think that all of our clinicians should have a basic understanding of this. One step in that regard is a recently completed continuing medical education program that will be mailed and sent to every VA physician.
As an aside, I would also note that we will make this available for non-VA personnel at cost, as well.
In the interest of time, I am not going to discuss research programs per se other than to note that there is, as was commented before, a large number of research projects these underway and that a number of significant studies that are underway have reached critical points and are producing information that will be helpful as we move forward.
I think in my statement we also discuss in more detail our responses to the Presidential Advisory Committee's special report. I would note that many of the recommendations of that report have been implemented and are underway.
And, to respond to a question that Mr. Gutierrez asked before, we have indeed effected the contract with the National Academy of Sciences. As far as that specific recommendation which he asked about, the part that VA can do is completed.
I suspect there may be further discussion as far as the GAO report's recommendation, but in a very few words I would note that while we recognize the legitimacy of the recommendations and the inherent obviousness of what is recommended, this is a good example of how well-intentioned advice may be exceedingly difficult to complete.
There was some discussion before about efforts that are already underway with the Institute of Medicine to try to define health outcomes in a manner in which this can be tracked. I would go back to what I said very early in these comments, in that this is an area that certainly would be characterized as being on the frontier of medical science.
Page 41 PREV PAGE TOP OF DOC Let me just close by saying that there are some very real scientific conundrums which need to be worked out with Gulf War veteran issues. We are working with the National Academy of Sciences and others in trying to do this.
I think that we have made substantial progress in both furthering the understanding of Gulf War health issues and providing care for persons having health problems related to their service in the Gulf War. But, as I have testified at prior hearings, and I will reiterate today, that while we believe that our programs have been well-designed based on the current best available information, we also know that they are neither uniformly delivered nor perfect.
We also recognize that some of our veterans have not always received the kind of reception or the care at our VA medical facilities that we strive for, but I think we certainly have improved this, and we will continue to further improve in the future.
We are working diligently to improve the consistency and the predictability of care provided everywhere in this enormous system known as the veterans' health care system.
With that, let me close. I will be happy to try to answer your questions or respond to your comments as we move forward.
[The prepared statement of Dr. Kizer appears on p. 100.]
Mrs. CHENOWETH. Thank you, Dr. Kizer, for that very interesting testimony.
The Chair recognizes Bernard Rostker.
Mr. ROSTKER. Thank you, Madam Chairman, for the opportunity to appear before the committee today. With your permission, I would like to submit my written testimony for the record and provide the committee with brief remarks.
Page 42 PREV PAGE TOP OF DOC Mrs. CHENOWETH. Without objection, so ordered.
STATEMENT OF BERNARD ROSTKER
Mr. ROSTKER. Madam Chairman, members of the committee, you asked for a discussion of the Presidential Advisory Committee's special report. As you may know, the intergovernmental response is in the final stages of coordination. However, let me briefly comment in those aspects which fall under my purview.
In most respects, we agree with the PAC's findings. We concur with the recommendation to improve chemical warfare detection. And, in fact, the President's budget has an extra billion dollars to be spent over 6 years for chemical agent detection and protective equipment.
We agree that an objective standard that needs to be applied to all investigations and we strongly agree that independent oversight would dispel concerns regarding bias.
We disagree with two recommendations. First, at this time, we do not believe a low-level chemical exposure doctrine is needed, although we are funding research on what that doctrine would be. And the department will be announcing within the next 30 days the full-scale development of a fourth generation of chemical detector, which will include for the first time the ability to detect low levels of chemical agents.
Secondly, we disagree that notification of all personnel within the 300-mile radius of Khamisiyah is needed. We have already notified those people whom we believe may have been exposed. And, as our research continues, we will make further adjustments to that notification.
Let me also recognize the PAC. The members provided an invaluable service to our veterans and the American public. We appreciate their many constructive and relevant recommendations.
Page 43 PREV PAGE TOP OF DOC You also asked for my comments on the second report that the Committee has highlighted, the Committee on Government Reform and Oversight Subcommittee on Human Resources.
In testimony and response to requests for information, I provided that committee with a great deal of material. Needless to say, we were surprised and disappointed that the report published this past November included little of the information we provided.
Let me be more specific. The DOD has published 13 case narratives and information papers which were virtually ignored by the report. And we have for the Committee's inspection the 13 case narratives and information papers.
Several of these case narratives deal directly with issues raised by the committee and charges made by witnesses called before the committee. Our narratives were built upon the testimony of scores of Gulf War veterans. By ignoring facts presented in the case narratives, I believe that the committee's report is misleading about what happened in the Gulf.
Finally, in regard to the General Accounting Office report, I have included a copy of my response for the record. Virtually all of the facts and conclusions presented in that report were duplicates of previous reviews.
If it had been published a year earlier, the report would have been more accurate. As written, however, it does not present timely or accurate portrayals of work being performed by the Department of Defense.
And we have provided for the members' reviewand I would ask that it be put in the recordthe annual report from my office which covers the activities that have occurred since the office was established in November of 1996.
Looking ahead, this next year we will continue to investigate specific events concerning chemical agents. Our main focus will be on environmental issues, however. We will complete separate reports on pesticides, depleted uranium, and oil well fires. We look forward to working with Congress and our oversight agencies and remain committed to our veterans.
Page 44 PREV PAGE TOP OF DOC I would like to add one additional thing. I thank Congressman Filner for recognizing my passion. Part of that passion has been a willingness to go out and meet with veterans in town hall meetings, including in San Diego.
And it was at the town hall meeting in San Diego that I met the Dudleys. They discussed with me their concerns and particularly their concern that the government had stifled some of its premier researchers from looking at or positively reacting to the work of the Nicholsons.
I immediately came back to Washington and had a meeting at Walter Reed. In fact, Mr. Christopherson joined me at that pointwhere we reviewed with the researcher that the Dudleys asked us to as well as the Walter Reed staff the work that had gone on.
And based upon our review, we found that the protocols that we were establishing with the Nicholsons were correct in design but not adequately resourced and that we ordered additional resources and priorities be placed upon that effort. And at the committee's request, we're prepared to provide a complete report on our current status with the Nicholsons.
We take the veterans' concerns very seriously, both those concerns that come to us through our 800 hotline number as well as those that we gain in face-to-face contacts with the veterans. And this particular case is one where the Dudleys made certain representations which were very serious, and we took them very seriously.
So I thank the Chair for allowing me to make these comments.
[The prepared statement of Mr. Rostker, with attachments, appears on p. 114.]
Dr. COOKSEY (presiding). Mr. Rostker, what is your Ph.D. in?
Mr. ROSTKER. I'm an economist.
Dr. COOKSEY. Oh, that's good, statistics and economy.
Page 45 PREV PAGE TOP OF DOC Mr. ROSTKER. Statistics is one of the fields that I have a specialty in.
Dr. COOKSEY. Good. Thank you. Thank you very much.
Dr. Filner, another Ph.D.
Mr. FILNER. At least there's a 50 percent chance that that occurred; right?
Dr. COOKSEY. I'm sorry. I'm sorry. We have another witness first, two more. So, if you could
Mr. FILNER. I'm sorry.
Dr. COOKSEY. Mr. Christopherson is next. Thank you.
STATEMENT OF GARY CHRISTOPHERSON
Mr. CHRISTOPHERSON. Mr. Chairman, let me be very brief. I know time is short for the committee.
A couple of quick things. One is that let us be very clear from the point of view of the medical side of life that our concern here has been and will continue to be even more so taking care of our beneficiaries, the troops that come back from the Gulf War. It is our point as well to do the best research we can to try and understand what's going on. This is not an easy problem, as has been indicated by the previous panel.
What is important also to understand is from out of the Gulf War experience, there is no doubt that mistakes were made. We learned a lot from the Gulf War. Recordkeeping was not what it should have been. Tracking of vaccinations was not what it should have been. A lot of the monitoring and surveillance we did at that time was not what it should have been as well. Again, we learned a lot from it. We are paying some prices, in fact, for not having those things in place. A lot of those things are now being moved forward.
Page 46 PREV PAGE TOP OF DOC If you look at the current experience and what we're doing there, Bosnia is kind of the case there. Bosnia is a case of making significant progress, but we're still not all the way home yet.
Some classic cases there are if you look at, for example, surveillance. We are doing a tremendous amount of surveillance in the environment, other kinds of hazards or the troops that are there to make sure we understand what went on there and after the fact, if necessary, to be the case figuring out what happened there.
It is also true that we have those things in place so that if something does come up, we are in a position as well to treat to take care of there. If you look, for example, at the experience with Bosnia, it is one of the lowest disease non-battle injury rates we have ever had.
And, again, a lot of it is because a lot of public health is in place. A lot of lessons have been learned again out of the Gulf War. Records have gotten better. We have introduced automated record systems in the Bosnia situation, again, not perfect but, again, a lot of progress over that there, a lot of lessons learned out of Bosnia.
The final thing I guess I would come back to is obviously the concern here we have, including taking care of the troops, taking care of our Gulf War veterans, which we are doing, is: What are we doing for the future?
A lot of things I think for the future come down to a number. One, it is clear that when there are real threats out there, we need to prepare to provide the right kinds of protective measures, preferably licensed, most acceptably that we can possibly do out there.
And, secondly, we need good recordkeeping. We need to know exactly who got what and what happened with that so, again, we can trace back; if something pops up again the next time, we are in position and ready to do so.
It is also very important that we have in place surveillance plans so we can see what's going on in the environment in future deployments again so that we again can know what happened after the fact.
Page 47 PREV PAGE TOP OF DOC Better record systems. We're to put into place new computerized patient record systems there, which will be deployed in future deployments, personal information carriers. There's a way to track information all the way to the front. All of those things are in place.
Better research. Again, a need to do more in those areas there. We're working very closely with Veterans Affairs to do that. That's all, again, very important to trying to do what we need to do.
A lot more collaboration. I think what you've seen, especially in the last several years, in the VA and HHS is a lot of collaboration because no one agency can essentially do this all by themselves. It's a collaborative kind of effort.
Again, our commitment is to take care of the troops. And we're trying to do our best to do that. We'll do more in the future, our best to understand what's going on and more research, more epidemiological kind of work, all part of trying to make this better for our troops.
Dr. COOKSEY. Thank you, Mr. Christopherson.
Dr. Heivilin, if I could ask, what is your Ph.D. in?
Ms. HEIVILIN. I have a doctorate in public administration.
Dr. COOKSEY. Okay. Thank you. Proceed.
Ms. HEIVILIN. Thank you, Mr. Chairman, members of the committee.
STATEMENT OF DONNA HEIVILIN
Ms. HEIVILIN. I am pleased to be here today to discuss two reports that were put out last summer. In the first one, we reported on the government's clinical care and medical research programs relating to Gulf War illnesses. In the second, we assessed the medical surveillance of the military personnel in Bosnia.
Page 48 PREV PAGE TOP OF DOC Our reports covered four issues: the adequacy of the mechanisms used by DOD and VA to monitor the quality, appropriateness, and effectiveness of Gulf War veterans' care and to follow up on their clinical progress over time; two, the government's research strategy for studying Gulf War veterans' illnesses and the methodological problems posed in the studies; three, the consistency of key official conclusions with available data on the causes of Gulf War veterans illnesses; and, four, the extent to which the DOD's efforts in Bosnia were successful in overcoming the medical surveillance problems that were seen in the Gulf War.
I'd like to mention that we are currently working on several related studies requested by other congressional committees and will be happy to share the results of this work once it is completed.
In one, we are looking at the incidence of tumors among Gulf War veterans. In a second study, we're looking at the possible presence of antibodies for synthetic squalene in blood samples of Gulf War veterans. In the third study, we're looking at the processes, methods, and criteria used by the Persian Gulf Veteran's Coordinating Board, DOD, and VA to approve or disapprove research protocols. And in a fourth study, we're looking at the extent to which ongoing research is likely to provide information on what caused Gulf War veterans' illnesses.
In our report on the Gulf War veterans' illnesses, we noted that while DOD and VA had provided care to eligible Gulf War veterans, they had no system for following up on their health to determine the effectiveness of the care after initial treatment. Also, because of the methodological problems and incomplete medical records on the veterans, research has not come close to providing conclusive answers on the causes of the illnesses. Given the data needed versus what is available, which is primarily anecdotal, we believe it will be very difficult, if not impossible, to determine the causes of the illnesses.
And, finally, the support for some official conclusions regarding stress, leishmaniasis, and exposure to chemical agents was weak or subject to other interpretations.
Page 49 PREV PAGE TOP OF DOC Regarding our report on the medical surveillance of Servicemen deployed to Bosnia, although we found that DOD had improved its capability to monitor and assess the effects of deployments on the Servicemen's health since the Gulf War, certain problems still remained. One, the database containing deployment information was inaccurate. Not all the troops received post-deployment medical assessments. Many of the medical records we reviewed were incomplete.
In the first report, the one on Gulf War illnesses, we recommended that the Secretary of Defense and Secretary of Veterans Affairs set up a plan for monitoring the clinical progress of Gulf War veterans to help promote effective treatment and better direct the research agenda. And we ask that they give greater priority to research on effective treatment for ill veterans and on low-level exposures to chemicals and their interactive effects and less priority to further epidemiological studies.
I think in the earlier panel, they said that we said that it was a single cause. We did not say that. We said that it was a possible, one of the possible causes, and that there should be research in this area. To back that up, we had looked at 16 different studies which supported the fact that low-level effects are possible causes for symptoms which are similar to those which are being seen in the Gulf War veterans.
We also recommended that the Secretaries of Defense and Veterans Affairs refine the current approaches of the clinical and research programs for diagnosing posttraumatic stress disorder consistent with suggestions recently made by the Institute of Medicine. The Institute had noted the need for improved documentation of screening procedures and patient histories and the importance of ruling out alternative causes of impairment.
Since our report, the agencies involved have taken a number of actions related to our recommendations. In December of 1997, DOD and VA asked the Institute of Medicine to establish a committee to assess the appropriate methodology for monitoring the health outcomes and treatment for Gulf War veterans.
Page 50 PREV PAGE TOP OF DOC Recently the coordinating board informed us that it had initiated a joint program with DOD to conduct multi-center treatment trials for fibromyalgia and chronic fatigue syndrome in Gulf War veterans. It is anticipated that the protocol will begin in late 1998 or early 1999.
As of January of this year, 23 studies had been added to the research portfolio, including research on the toxicology of low-level exposures to neurotoxins such as pyridostigmine bromide, insecticides, and chemical warfare nerve agents, with an emphasis on interactions among them.
In our report on the deployment and medical records for Service members deployed to Bosnia, we recommended that the Secretary of Defense ensure that a DOD-wide policy be expeditiously implemented on medical surveillance using lessons learned from Bosnia and the Gulf War.
We also recommended they have procedures developed to ensure that medical surveillance policies are implemented and also that they have procedures developed for providing accurate and complete medical assessment information to the centralized database.
In response to our recommendation, DOD established a new policy and implementing guidance in August of 1997. And we are told that they have plans to emphasize this to the field commanders, to emphasize to them the importance of this system.
Mr. Chairman, that concludes my summary. I will be happy to answer any questions you may have and provide the full statement for the record.
[The prepared statement of Ms. Heivilin appears on p. 134.]
Dr. COOKSEY. Thank you, Dr. Heivilin.
Mr. CHAN. It's Mister.
Page 51 PREV PAGE TOP OF DOC Dr. COOKSEY. And, just to be equal with everybody, what is your Ph.D. in?
Mr. CHAN. I don't have a Ph.D. I have a Master's degree in mathematics and statistics.
Dr. COOKSEY. Statistics. I had a tough time in statistics when I went through my M.B.A. program. I'm anxious to hear from you. Go ahead.
Mr. CHAN. I don't have a statement to make, sir. Thanks.
Dr. COOKSEY. Oh, you have no testimony?
Mr. CHAN. No.
Dr. COOKSEY. Okay. Dr. Filner?
Mr. FILNER. Dr. Cooksey? Doctor, doctor, doctor, doctor, doctor. Thank you.
I would ask unanimous consent, Mr. Chairman, that all members of the committee may submit additional statements and questions for the record.
Dr. COOKSEY. So ordered.
Mr. FILNER. Dr. Kizer, are there any treatments that had been suggested for this illness that are not allowed to be delivered at the VA hospitals? Are there any banned treatments?
Dr. KIZER. I do not know of any that are banned. The reason I am hesitating a little, is that I was trying to interpret what you mean by ''banned''?
Mr. FILNER. I have talked to doctors within the VA system and have seen some written memos that suggest that no doctor can deliver the antibiotic treatment that was developed by the researchers that Dr. Rostker mentioned earlier, the Nicholsons, that they are forbidden from providing their treatment. Is that the case or not?
Dr. KIZER. Well, I do not know of any such memo. My colleagues to my right tell me that there is no such thing. But I recognize that in a system as large as this, there may be pieces of paper that we do not know about. So if you do have in your possession or know of such, I would like to have a copy.
Page 52 PREV PAGE TOP OF DOC Mr. FILNER. If we had testimony by doctors in the VA system that they were, in fact, given orders not to give that antibiotic treatment, would you be surprised by that?
Dr. KIZER. I would be surprised, but also I think you raise a real interesting question. And it is one that you spoke to earlier today in your comments, as did a number of other members of the committee. Some very impassioned statements were made that it is absolutely essential that troops, and I take by extension veterans, not be given vaccines or other medications that are not approved for those uses; i.e., approved by FDA for those uses. To get that approval, they need a scientific evidentiary base to support their use.
The issue that you raise is whether we should apply that same standard to treatments or not. Should we require that the treatment that is given to our patients have some evidentiary base or justification in the medical literature that would be accepted, at least by a significant number of practitioners, or should we encourage any type of treatment? I raise this merely as
Mr. FILNER. Well, certainly the initial inoculations and testing from the DOD did not live up to that standard, unfortunately. I understand what you're saying, but you're also justifying a whole infrastructure, I'll have to say, the words that you're using, ''evidentiary'' this and ''supported by'' that, et cetera.
If, for example, there was a built-in bias against certain kinds of treatment by the very doctors who are making decisions on this, by the very ones who are testing out certain standards, your very infrastructure would end up leading to a conclusion that they are not worthy of use.
That is, if the whole system is biased against a certain protocol or a certain kind of evidenceand we have seen that in this situation. We have seen it with Agent Orange. We have seen it again and again.
Page 53 PREV PAGE TOP OF DOC The Chairman didn't ask what field my Ph.D. is in. I happen to be an historian and philosopher of science. Science is merely what most people who are called scientists say is science. It has nothing to do absolutely with truth. I see at least Dr. Rostker is agreeing with me. It has to do with what people think is the truth at a given set of time.
And if everybody in VA thinks, who have all those M.D.'s and Ph.D.'s beside their name, that a certain treatment is wrong, their whole methodology will end up proving that. And so the VA will end up with a very credentialed and very trustworthy, in their own view, system which has ended up being so biased that it precludes certain treatments that are out of the given mainstream.
Dr. KIZER. I am not sure that I would agree with that. I understand what you are saying, and I think that is a statement about the practice of medicine in general, not VA in particular.
Mr. FILNER. Right.
Dr. KIZER. But I think that one of the points that has been made at a number of forums like this that if we are going to pursue things that are not accepted by the prevailing scientific view, that the appropriate way to do that is through some sort of investigative protocol so that we have some clear understanding of what the outcomes are.
Mr. FILNER. I agree if you could do that fast enough to deal with the people who are dying or potentially dying. That is, you've got to do something. And, as we know with certain cancers and other treatments, if people are terminal, they're willing to take anything that has seemed to work by anecdotal evidence. And we have documented many cases of those working. Your whole system is set up to preclude certain ways of dealing with this issue.
Dr. KIZER. Could I just finish what I was going to say? The direction that the Congress has given the VAand we are a public agency that is governed by the Congressis that our treatments and the modalities that we utilize have to meet certain standards.
Page 54 PREV PAGE TOP OF DOC As a matter of public policy, if the Congress should espouse that we should not be taking that approach, then I think it needs to say so.
Mr. FILNER. Do you know who Dr. Lo is in the Defense Department?
Dr. KIZER. I don't personally know him, but Dr. Murphy does.
Dr. MURPHY. Dr. Shi Lo is a researcher at the Armed Forces Institute of Pathology
Mr. FILNER. Right. Is he in a position to decide yes or no on certain research protocols? I mean, would he have that influence within the bureaucracy to do that?
Dr. MURPHY. No, not to my knowledge.
Mr. CHRISTOPHERSON. No.
Dr. MURPHY. Mr. Christopherson may be able to answer that.
Mr. CHRISTOPHERSON. I think that's correct. I mean, again, all of the research that is done in either organization has to go underneath a certain amount of peer review, partly to protect the troops and the veterans that we're talking about there.
On the other hand, they're encouraged, obviously, to look for new and innovative ways to try and deal with very difficult issues, this being clearly one of those.
Mr. ROSTKER. Sir, if I might, Dr. Lo was, in fact, the doctor who was cited by the Dudleys, whom Mr. Christopherson and I spent a full day with. He educated us on it. We reviewed with him
Mr. FILNER. I'm sorry. Dr. Lo did or
Mr. ROSTKER. Dr. Lo. We presented to him the statements that had been presented to me about the protocols. He said they did not represent his view, that he was in full accordance with the progress we were making, the approach we were making to take several hundred random blood samples and submit them to a number of laboratories. He is a world-class researcher in the area of mycoplasma, and he has been fully on board.
Page 55 PREV PAGE TOP OF DOC To the best of my knowledge,and I have asked him directlywhat we are doing is in line with what his recommendations are.
Mr. FILNER. Yes, that's the problem.
Dr. Cooksey, my time is up. I would
Dr. COOKSEY. I will have some latitude. I'm not a tough
Mr. FILNER. Thank you, Mr. Chairman.
By the way, Dr. Rostker, I appreciate your confronting directly in your testimony the issue of the Nicholsons. You said that if the committee requested, you would give a more full report on that. I would so request.
Mr. ROSTKER. Okay.
Mr. FILNER. When did that change or the new support for that research take place?
Mr. ROSTKER. We had the meeting last spring. And within I would guess a week of coming back from San Diego, Mr. Christopherson and I and members of our staff, our physicians went to Walter Reed, met with Dr. Lo, met with the physicians there, directed that any question of financial priority be put aside, and that this took the highest priority, and to push forward.
Mr. FILNER. So is he being funded at a
Mr. ROSTKER. Yes.
Mr. FILNER (continuing). Level that he sees as sufficient? I don't know.
Mr. ROSTKER. Well, the agreed-upon task, with the involvement of the National Institutes of Health, was to test out his techniques for identifying the mycoplasma.
Page 56 PREV PAGE TOP OF DOC I would be happy to have Colonel Riddle provide you right now with an update on where we are.
Mr. FILNER. I'll get back to that in a second. What I heard in my initial round of questions was that we are all open to this, we're doing this, we're doing everything we can. It just is in conflict with all the anecdotes or many anecdotes that we hear across the country.
So we have to figure out why that is the case, why you feeland I don't dispute that you're honestthat your systems are open and honest and subject to peer review and all of that when we all know from history and from experience that any bureaucracyI don't care if it's big or small; I don't care if it's VA, Defense, or my own officehas built-in biases and turfs and jealousies that the upper people might not be aware of. And I think that's a possibility here, but that's something that we're not going to figure out today.
Let me just ask you, Dr. Rostker: It's fair to assume, I think, that this Nation has stores of chemical and biological weapons. I mean, we are yelling at Saddam Hussein, but it would be unlikely to assume that we would not have such weapons?
Mr. ROSTKER. We are a signator of the chemical treaty. And we have been in the process for years of destroying those weapons.
Mr. FILNER. But obviously we have research into those weapons. We have tested those weapons, I suspect. We have tested antidotes to those weapons.
Mr. ROSTKER. Yes, sir.
Mr. FILNER. Would you find it unlikely or impossible that that very production, development, testing of weaponry and its antidotes could have caused some of this illness? I mean, is that a possibility that you would exclude?
Mr. ROSTKER. We have looked very hard. It's really been the major function of my office compared to our colleagues, whom we have worked with consistently, to understand what happened in the Gulf.
Page 57 PREV PAGE TOP OF DOC And we are all aware of the events at Khamisiyah. We have spent a great deal of effort.
Mr. FILNER. I asked you about our own. Friendly fire is what I'm talking about.
Mr. ROSTKER. To the best of my knowledge, we had no chemical weapons in the Gulf.
Mr. FILNER. I'm not talking about the Gulf. You're purposely narrowing my question. I asked: Is it possible that any of our troops could have gotten what we call Persian Gulf illness from our own inoculations, from our own testing, from our own development of these kinds of weapons, in the Gulf or elsewhere?
Mr. ROSTKER. No, sir.
Mr. FILNER. You don't think that's a possibility?
Mr. ROSTKER. I have absolutely no facts before me that would lead me in any way to that conclusion.
Mr. FILNER. All right. In terms of possibilities here, is it possible that some percentage of what we call Gulf War illness is contagious?
Mr. ROSTKER. I'm not a physician, and there's no way I would be able to make
Mr. FILNER. Would you exclude that, as a statistical expert, as a possibility?
Mr. ROSTKER. To the best of my knowledge, there was no biological agent that our troops were exposed to. Whether there were other things in the Gulf, I can't tell you, but we
Mr. FILNER. Well, why do family members seem to be able to come down with this or pets seem to come down with it? How would you explain that?
Page 58 PREV PAGE TOP OF DOC Mr. ROSTKER. I have no explanation, sir.
Mr. FILNER. It seems to me that contagion is a possibility there. Dr. Kizer?
Dr. MURPHY. Yes. We've looked at this issue very carefully. It is a concern to us, especially since the Gulf War veterans brought the concern to VA shortly after leaving the Gulf, that they felt that their family members were suffering from similar symptoms.
We've looked. We've found no current rigorous scientific evidence that supports a contagious or an infectious illness being transmitted either to family members or to the general population.
Mr. FILNER. Let me just tell youDr. Cooksey, I'll end with thisthe history of dealing with this issue, as the history with Agent Orange and some other incidents in this Nation, every time somebody made a suggestion such as I had just done7 years ago when someone said there is an illness, someone up there testified there is no evidence that there is such an illness.
When the evidence built up that there was some possibility of an illness, somebody like me asked: Is it possible they were exposed to chemical or biological weapons in the Gulf? And someone like you said: There is no possibility. There is no evidence that that occurred.
Then knowledge that somebody had about Khamisiyah and other such incidents occurred. I said: Well, how many people were exposed? Could it have been thousands? And someone like you said: There is no evidence that more than a few hundred people were exposed to this. Now we know 100,000.
At every stage in this thingthis is what gets me most angry. At every stage in our inquiry, the public's inquiry, people have said with the credentials that you have, with the positions that you have, that there is no evidence for what someone who has acquired that evidence from anecdotal means, from testimony, from conversationsyou know, Congress people are not dumb.
Page 59 PREV PAGE TOP OF DOC And just because we're not scientists, although I happen to have a degree there, doesn't mean that what we come up with is not truth. Our antennae are out there with talking to people, with testimony, with anecdotes, with letters, with calls, with all of this evidence. We were the first ones who said there was an illness when everybody there said there wasn't any.
So I just have trouble with your saying there is absolutely no evidence and no possibility or nothing of this
Dr. MURPHY. If I could continue for just a moment? Because I think it's important that you hear the rest of my statement. In the past, I've been on the front lines taking care of Gulf War veterans. I've seen their pain. I've talked with their family members. And I can be as passionate about this as you are. I also have lots of anecdotes. But our job now is to look at all Gulf War veterans and how we can help them.
VA has taken the issue of contagiousness very seriously. DOD has begun to do the scientific work that will answer the specific questions that you have asked in a non-anecdotal way. And, in addition, VA is evaluating carefully the Gulf War veterans' illnesses and any potential association association with the illnesses of their families. We're beginning the physical examination phase of the national survey, which will allow us to address the scientific questions that you're asking.
Mr. FILNER. I'm going to tell you now that, again, I have been in the homes. I have seen the pets. I will tell you that it's a fact. Three years from now someone there is going to say, ''Oh, yeah. Now we know that it's contagious.''
Given the lack of knowledge that you all seem to have about thisyou know, we're inoculating troops today against anthrax or something. I don't know what it is that we're inoculating troops against. Why are we doing something that nobody can tell me what it actually is, the impact it has, or what effect it's going to have there?
Page 60 PREV PAGE TOP OF DOC Mr. ROSTKER. Let me first say that you know that as many as 100,000 troops may have been exposed because the Department of Defense did the work that developed that
Mr. FILNER. How many years after they knew it?
Mr. ROSTKER. We did the work to develop that
Mr. FILNER. Because you couldn't cover it up, because somebody leaked it basically.
Mr. ROSTKER. We did the work. We have not been satisfied. We pushed back the frontiers of knowledge. And as we pushed back the frontiers of knowledge and we bring that information to you, we're accused of a coverup or: Why have you changed your mind?
We are not static. We see the same people that you see. We work in their behalf just as much as members of the Congress. And we are trying as hard as we can to push back the frontiers of knowledge, whether it be on the medical side or whether it be to uncover what happened in the Gulf.
And you know this information because they're contained in this stack of reports that examine this and are answering the questions that people are asking.
Mr. CHRISTOPHERSON. Let me also pick up on that because you opened up a line of avenue I think we need to talk about for a second here: the issue of vaccination. And we all have to be very careful. We walk a very fine line here between protecting people from, in quotes, in terms of ''consequences'' of something and protecting them from real threats in real wartime situations here.
When you're looking, for exampleand the issue obviously that's in the back of your mind is the issue of anthrax vaccination. Let me be very clear. On anthrax vaccination, we have a fully licensed vaccine that's safe and effective against what can be a very real threat that kills people.
Page 61 PREV PAGE TOP OF DOC We would be irresponsible were we not to use these things. At the same time, which is also our responsibility, is the need to track what happens, to make sure that we understand that there are other consequences there, even though it's fully licensed, safe, used for many years, and this kind of thing.
The commitment of the Department of Defense is that for those kinds of measures, which we do need to use because we have this Hobson's choice between, in quotes, ''doing or not doing'' there, we have to step forward and provide those things.
At the same time, the lessons learned from the Gulf War, which are applied now, is to better understand if something comes out of that that nobody expects. But we would be irresponsible not to protect our troops in those kinds of situations.
Mr. FILNER. And, finallyand I appreciate your patience, Dr. Cooksey. this conversation can go on for a long, long time. Several reports, the Shays Committee report, to some degree the PAC report, said: Look, basically all of this has to be put in the hands of an independent group.
I would go further: not contracted by the VA, not contracted by the DOD. SomeoneI hate to say this because I don't like the independent counsel legislationwho has the authority to delve into both bureaucracies and come up with things that bureaucratic inertia or turf battles or cautiousness or whatever you want to call it is not able to come to grips with. And that's what I would recommend to the Congress of the United States.
Mr. ROSTKER. I would just point out that your colleagues in the Senate have a special investigative committee looking exactly at that. And we have had the pleasure of jointly going overseas. I had a number of trips overseas to the countries you were talking about and many more. And we invited members of congressional committees' staffers to join us, and we had members from the Senate investigative committee of the Veterans Committee. So we have done that.
Page 62 PREV PAGE TOP OF DOC And I would only add to the extensive GAO reviews that GAO is living with us. They're in the process of reviewing all of our work in great detail. And we offer that to anyone who wants to come in.
We believe oversight is an important part of the process. So does the administration. And that's why they're standing up a new oversight board, which will have full access to everything we're doing.
Mr. FILNER. I don't want oversight. I want insight.
Mr. CHRISTOPHERSON. Let me go back because I think what you need to remember, by the waygo back to the previous panel. The Institute of Medicine is not here on their own. They came here because we contracted with them to provide oversight, independent review, the best science minds in this country here to do exactly what you're asking to do.
We agree that independent oversight and the outside reviews is very critical not only in terms of trying to get the right answers but, going back to the early discussion on, about trust.
And we've got to try and get the best minds working with us to understand these things who can step back from where we are standing at a given moment in time and tell us what's best clinically, what's best in terms of research.
Mr. FILNER. Why don't you give them enough money to do it in 3 months, instead of 5 years, though?
Dr. COOKSEY. I have some questions of my own, but I think it's interesting to observe that we are all sitting here today because of one man, one demagogue, one dictator, who is not elected. He got where he is at the end of a gun barrel. He is a coward. He hid during the Gulf War. He hides at night. He kills people with his own handgun but when he's surrounded by people.
Page 63 PREV PAGE TOP OF DOC And I understand Mr. Filner's frustration because as congressmen, we do have people that come to us and say, ''I've got symptoms.'' As a physician, I think I get more of them than the average congressman. And it is frustrating.
A few questions. Of 700,000 vets that were in the Gulf War, how many have come forward with symptoms that have been categorized as Gulf War illness? Dr. Murphy, if I could ask you? You're an internist, Dr. Murphy?
Dr. MURPHY. I'm a neurologist, sir.
Dr. COOKSEY. A neurologist?
Dr. MURPHY. Yes.
Dr. COOKSEY. Great.
Dr. MURPHY. Approximately 100,000 veterans have come either to the DOD CCEP program or to the VA Registry program. We have approximately 12 to 15 percent over time who have come in with no symptoms. They're feeling well. They just want the examination. And they want to be able to talk to a physician about their concerns. Of those
Dr. COOKSEY. Can I clarify that? You're saying about 12 percent of the 700,000 have no symptoms?
Dr. MURPHY. No. I'm sorry. Of the 66,000 that VA has examined, about 12 percent have come in with no symptoms.
Dr. COOKSEY. Okay. That's a significant number.
Dr. MURPHY. Yes. And I think it speaks to some of the confidence that the veterans, at least some of them, have in the VA system to provide answers.
Of the symptomatic veterans, we have not been able to find a diagnosis in anywhere from 10 to 25 percent depending on how you determine what an unexplained illness is. And we have used two different methods depending on whether it was our original registry program or the revised.
Page 64 PREV PAGE TOP OF DOC DOD has approximately the same number of individuals who have a category of conditions which, in the International Classification of Diseases, is called: Signs, Symptoms, and Ill-defined Conditions. These are not diagnoses so much as symptoms that have been described by the veterans.
So that's where we are with unexplained illnesses among the people that we have examined.
Dr. COOKSEY. Okay. Mr. Christopherson?
Mr. CHRISTOPHERSON. Yes, Mr. Chairman?
Dr. COOKSEY. What do you think, and just very briefly, what are the five lessons that you think we have learned or should have learned from this experience, the Gulf War illness and the symptoms of the war, the symptoms, the complaints?
Mr. CHRISTOPHERSON. That's a good question to be putting. One is clearly medical records. We've got to do a much better job of keeping track of records of what's going on health-wise there.
Second is clearly surveillance, knowing what's going on in the environment around the troops as they are deployed out there, and understanding that part of it as well.
Third is clearly education, the need to risk communication, other kinds of education of the troops, so they know better what they're getting into and are better abler to handle it when the time comes.
Fourth is clearly the institution very early on of a clinical evaluation and treatment program so that if something does appear in this thing, we can quickly figure out what it is, especially when it's fresh in people's minds, they understand what's going on. When you ask them what may have happened to them in the Gulf, there's a better chance of getting an accurate answer.
The final thing is the need for some clear research to be done on things we do not understand as well. Clearly in the area of chemical and biological, there's a lot of work that needs to be done there. There are certain other kinds of environmental hazards. Research still needs to be done as well.
Page 65 PREV PAGE TOP OF DOC But on a rough count, I'd say that's probably the five I would put forward as lessons learned and lessons being applied.
Dr. COOKSEY. Good. That's a good brief answer.
You know, one of our warfare installations was in Pine Bluff, Arkansas. Was that chemical or biological? I think it's closed now, but
Mr. CHRISTOPHERSON. I'm not sure.
Dr. COOKSEY (continuing). One of them was there because I live not too far. I'm not an Arkansan. Don't label me with that. I'm from Louisiana. But there was one of them that's in Pine Bluff.
Mr. CHRISTOPHERSON. The consensus, by the way, seems to be chemical is what we believe.
Dr. COOKSEY. Chemical? Okay. I know it's been closed.
Let me ask you this: What do you think is the most serious deficiency that still is not addressed?
Mr. CHRISTOPHERSON. Serious deficiency? I probably have a few candidates, actually, for that, but I think very honestly the one that we are probably wrestling with the mostand it kind of goes back to your opening remarks about certain persons in certain other parts of the worldhas to do probably with the chemical and biological area.
There's just a number of things we need to understand better, both in terms of preventive measures, protective measures for the troops there, better detectors. It sort of all glums around that issue of trying to do it. It's the one we spent the least time figuring out, but there's a lot of research now committed to trying to figure this out.
Dr. COOKSEY. Dr. Kizer, do you know: Have we had any exchange of research with some of our former enemies, like the Soviet Union?
Dr. KIZER. If I might just defer that for one second because I'd like to also respond to your former question if that's agreeable.
Page 66 PREV PAGE TOP OF DOC Dr. COOKSEY. Sure, sure.
Dr. KIZER. It occurs to me as one looking at a system that is taking care of people at the tail end, after all of this has happened, that one of the biggest problems we see in dealing with problems post-service, is: What was the extent of health or illness pre-service, and we need a more complete assessment of what the individual status was before?
And I know that efforts are underway towards this, but I just want to underscore that it would be critically important in the future to better know what people started off with when you end up trying to figure out what they have at that later time, and especially with regard to what the conditions may be due to.
Also, I would underscore a point that I have made at quite a number of other hearings in this regard, and that is the importance of a very concerted effort to look at the effects of chemical warfare agents and the fact that those problems are the same issues that are being wrestled with in other committeese.g., in individuals who live near toxic waste dumps or Superfund sites and the questions of low-level chemical exposure from environmental contamination. The same is true from an occupational safety point of view. Whether they are farm workers in California or people who work in factories, they are the same generic issue in a number of forums.
And the one, of course, on the horizon is what happens if there should be a terrorist incident in this country that affects a small or large number of civilians. Are we going to have the information to address their concerns at that time?
I would again underscore the point that I have made on a number of prior occasions that if we are going to do this, if we are going to have those answers, it will take a very large and concerted effort with substantial funding needs.
To try to best respond to your question, I would ask if you would repeat it.
Page 67 PREV PAGE TOP OF DOC Dr. COOKSEY. Okay. My question is: Has our government been able to obtain any information from our former enemies or even allies that have done research on chemical warfare and biological warfare that maybe we could either have already exchanged information that's been done or could we do it in the future that would help answer some of these questions?
Dr. KIZER. Let me answer that in three ways or a three-part answer in brief. And others I think will probably also shed some light on it. One, I don't know a specific incident of exchange of information from former adversaries or at least potential adversaries. That may well be occurring that I'm unaware of.
Secondly, we are working with some other foreign governments on incidents and the evaluation of those; for example, a joint research project with the Japanese is looking at the Tokyo subway incident involving sarin and the effects of that.
And, third, I am aware from my pre-federal government life of some efforts to work with the former Soviet Union countries on issues having to do with nuclear materials.
Mr. ROSTKER. The answer is yes in all counts. My team has not been to Russia, but we have been to Prague, France, England, Kuwait, Saudi Arabia, Egypt, and Israel and have compared notes both on health effects to the indigenous population, on health effects among troops who were in the Persian Gulf, as well as basic research on chemical agents, pesticides, and pyridostigmine bromide, and a whole range of factors which may impact the central nervous system in ways that are of interest to this topic.
We have been again joined in that research by members of the Senate, staff from the Senate investigative committee.
Mr. FILNER. Can you comment on the French situation that I asked about earlier?
Mr. ROSTKER. Sure. We know of no protocol that the French used. I think the best comment was the senior French colonel on the general's staff, who said: We are most interested in what you are doing because, as far as we're concerned, there but for the grace of God go we.
Page 68 PREV PAGE TOP OF DOC They have no idea and no hypothesis of why their troops have not made claims except that their whole health bureaucracy and health insurance system is quite different and their general relationship of the population to the government and these kinds of claims are different.
We explored with them the theory that they did not take PB, which had been presented. It was widely understood. And they dispelled that, that elements of their force did, in fact, take PB. And, as one French colonel said: PB? I took it every day for a month, and no problem.
So we have explored with the French all aspects of their program, and they have no hypotheses as to why they may not have reporting veterans.
Mr. FEUSSNER. Dr. Cooksey?
Dr. COOKSEY. Yes, sure.
Mr. FEUSSNER. If I might follow on that, in March of last year, the VA sponsored in collaboration with the Society of Toxicology an international symposium in Cincinnati. During that meeting, the investigators from Japan, the investigators who were involved in the sarin subway episode, a number of European investigators, Israeli investigators attended the meeting.
In addition to that, this past summer, we sent the director of our environmental epidemiology center in Boston to Europe for a 6-month period of time. We have been collaborating with the British, the Danish. And on the research working group, there is official and consistent representation with a British person and a Canadian person.
Dr. COOKSEY. Good. That's very good. The British do some very good work. They've come up with some great medications and solutions to problems.
Believe it or not, the great plague of my youth was polio. Dr. Kizer fortunately, is young enough. He assured me yesterday he was in high school when I was in medical school. Of course, Dr. Salk and Dr. Sabin found the solution for that.
Page 69 PREV PAGE TOP OF DOC And the great plague of this period is AIDS. And the protease inhibitors are beginning to save lives. I know this comes as a shock to some of you in this room, but trial lawyers did not find the solutions and politicians did not find the solutions.
Ms. Heivilin, a quick question: Do you know the incidence of Gulf War illness among the women veterans of the Gulf War/Persian War?
Ms. HEIVILIN. No, I do not.
Dr. COOKSEY. I don't either. Does anybody know? Dr. Murphy?
Dr. MURPHY. We actually looked at that jointly with DOD, and we have published an article in Military Medicine I'd be happy to provide you a copy.
In fact, it looks like the rates of illness are very similar in men and women. We found very few differences in the types of diseases that are being reported.
There is a slightly higher rate of genitourinary problems. That was reported while women were stationed in the Gulf and also after they returned. And that isn't terribly surprising, since GU problem among women patients.
Dr. COOKSEY. Sure. Dr. Heivilin, I noticed that in some of your previous work, you had disagreed with some of the experts, some of the scientists, these Ph.D.'s who had done some work and basically thrown off their work. And these were some people from the Institute of Medicine and the President's Advisory Committee.
Page 70 PREV PAGE TOP OF DOC With respect to your comments regarding the risk factors, it seems that you seemed to throw theirs off, their ideas off, and that you seemed to know better. Who peer-reviewed your work?
Ms. HEIVILIN. We have a very extensive quality assurance program, an internal peer review. We also show our work to outside experts when we're doing that, when we're going through that process.
Dr. COOKSEY. Who are your peer reviewers?
Ms. HEIVILIN. Who are our peer reviewers?
Dr. COOKSEY. Yes. What's their background?
Ms. HEIVILIN. What are their backgrounds? We had professors in pharmacology, epidemiology, toxicology, and neurology who peer-reviewed our work.
Dr. COOKSEY. Okay. That's good. Thank you.
I have no further questions of this panel. And so we appreciate your coming, and we'll hear the next panel.
Dr. COOKSEY. We'll now start with Panel 3. Mr. Thompson, Under Secretary of Benefits, DAV.
Mr. THOMPSON. Thank you, Mr. Chairman.
STATEMENTS OF JOSEPH THOMPSON, UNDER SECRETARY FOR BENEFITS, DEPARTMENT OF VETERANS AFFAIRS; STEPHEN BACKHUS, DIRECTOR, VETERANS' AFFAIRS AND MILITARY HEALTH CARE ISSUES, HEALTH, EDUCATION, AND HUMAN SERVICES DIVISION, U.S. GENERAL ACCOUNTING OFFICE; AND KRISTINE MOFFITT
STATEMENT OF JOSEPH THOMPSON
Page 71 PREV PAGE TOP OF DOC Mr. THOMPSON. I am pleased to provide a status report on the adjudication of Gulf War claims. I have submitted our full statement for the record, which I'd like to briefly summarize.
Dr. COOKSEY. Go ahead. Proceed.
Mr. THOMPSON. Regarding the redistribution of claims work from processing centers to regional offices, we were aware of concerns that the regional offices lack the expertise to handle these claims efficiently and accurately. Many members of Congress were anxious that we develop procedures to assist regional offices and monitor their progress. I'd like to summarize what we've done.
In May 1997, the Compensation and Pension Service conducted satellite broadcast training on Gulf War issues for our regional offices. This was followed by training sessions in June at the Cleveland Regional Office. Members of the Compensation and Pension Service also participated in several Gulf War workshops during the month of June.
The service established a rapid response team consisting of the most knowledgeable headquarters people to provide immediate assistance to regional offices with Gulf War claims when they had questions. The service also conducted weekly Gulf War conference callsthis has been going on since June of 1997where guidance is provided to regional offices who need to make a decision on these claims.
Every month each regional office is required to review a sample of Gulf War claims as part of its quality improvement program and to provide those reports to headquarters. These reviews provide the regional offices with a snapshot of the accuracy of what they're doing and identify areas for improvement.
The service has also conducted, in headquarters, a number of comprehensive reviews of Gulf War cases and will begin another one later this month. We use these cases to assess the current status of claims processing and give us some idea of what regional offices are doing.
Page 72 PREV PAGE TOP OF DOC Mr. Chairman, I am deeply committed to improving both the technical accuracy and the processing time for compensation and pension claims involving Gulf War. In pursuing this goal, I have established a special workgroup to study how we handle the workload issues in the regional offices today. I will use these findings to improve the accuracy of claims processing in general, and Gulf War claims in particular.
A major area of concern in Gulf War claims is the adequacy of medical exams. We have been working with VHA to produce guidelines for conducting the exams involving undiagnosed illnesses. These guidelines will ensure that all issues are fully addressed during the exam process. Implementation is imminent. To supplement this, a joint VBA-VHA satellite broadcast on Gulf War exams will take place early next month.
Since the redistribution of Gulf War claims, the regional offices have submitted weekly status reports on cases that have been adjudicated and readjudicated and or cases affected by the extension of the presumptive period for undiagnosed illnesses.
Last October, the Compensation and Pension Service asked the regional offices to make every effort to complete them by December 31. We did not do that. There are approximately 600 cases yet to be finalized. I have asked the service to provide me a monthly status report until all the cases are complete.
However, I believe the regional offices have done extremely well with these cases. They have worked very hard to get this done under very pressing workload conditions. And I commend them for their efforts.
An issue of continuing interest, of course, is how many Gulf War veterans receive compensation. Last summer, we discovered that some of the statistics we used to report on Gulf War business were not accurate. In response to these concerns, the Deputy Secretary asked the Office of Policy and Planning to coordinate all Gulf War information for the department. We have been working with that office to identify Gulf War veterans and ensure the information we provide is accurate. But I'll say at this point in time this is still a work in progress and the data still has an awful lot of areas that are shaky at best.
Page 73 PREV PAGE TOP OF DOC In my full testimony, I have provided the most recent numbers available, fully recognizing that the limitations of our information systems may impact on their accuracy. However, let me assure the Committee that we are working constantly to refine and improve them.
Mr. Chairman, that concludes my statement. I will be happy to answer any questions.
[The prepared statement of Mr. Thompson appears on p. 162.]
Dr. COOKSEY. Thank you, Mr. Thompson.
STATEMENT OF STEPHEN BACKHUS
Mr. BACKHUS. Good afternoon, Mr. Chairman, Mr. Filner. I'm pleased to be here today.
My statement focuses on two issues: first, VA's efforts to improve claims processing for Gulf War undiagnosed illnesses; and, second, the effect of these efforts on VA's reexamination of claims that they previously denied.
As you may know, back in May of 1996, we reported on deficiencies with the claims processing for these undiagnosed illness. And, as a result, VA is now readjudicating those denied claims. Our work is based on a statistical sample of the 11,000 denials as well as discussions with VA and VSO officials.
In summary, our examination indicates that VA has, in fact, taken a number of efforts to improve the processing of the Gulf War claims. And its reexamination has, in fact, followed its new procedures. As a result, more veterans have been granted compensation.
Specifically, the VA procedures call for the examiners to inform veterans of the types of evidence they need that can be used in adjudicating their claim. They seek out both medical and nonmedical evidence, and they use all of the evidence obtained, including lay statements, in their decisions.
Page 74 PREV PAGE TOP OF DOC You heard Mr. Thompson speak of the decentralization to their 58 regional offices. The purpose of that was to provide better customer service and faster processing, to spread the workload from 4 offices to 58.
It's too early for me to sit here and to tell you how well that's worked, but preliminarily based on the folks we've talked to, the results are mixed. There are more examiners, but there are potentially more inconsistencies as well with the decisions.
Considerable training has taken place, though, in the form of workshops, conference calls, teams of experts that are available to help the people adjudicate the claims, et cetera. The adjudicators we spoke with felt comfortable in when it came time to process these claims.
Turning to VA's reexamination of the denied claims, as I mentioned, VA followed its procedures and has granted benefits to 8 percent of the veterans who had previously been denied for undiagnosed illnesses. They're now receiving compensation and/or medical care. Another 5 percent, we estimate, are receiving benefits for diagnosed conditions. These were veterans who had made a claim under undiagnosed illness. When the case was reviewed, it was discovered they had a diagnosis and are now receiving benefits.
VA has provided veterans with information on the evidence they need to support their claims. A review of the files indicates they have, in fact, attempted to obtain all of the evidence that was necessary, and have considered all of the evidence in their decisions.
Two factors, though, still account for the majority of claimants being denied a second time. One-third of the claimants who reported an undiagnosed illness or thought it was undiagnosed wound up with a diagnosis. However, the diagnosis was either a noncompensable illness or had exceeded the presumptive period. Therefore, they were denied. And another third just lacked the evidence to sustain a claim.
That concludes my statement, Mr. Chairman. I will be glad to answer any questions you may have.
Page 75 PREV PAGE TOP OF DOC [The prepared statement of Mr. Backhus appears on p. 172.]
Dr. COOKSEY. Thank you, Mr. Backhus.
Ms. MOFFITT. Yes?
Dr. COOKSEY. Do you have a statement?
Ms. MOFFITT. No, I don't. I'll be happy to answer any questions you have.
Dr. COOKSEY. Okay. Mr. Filner.
Mr. FILNER. Thank you, Mr. Chairman.
Just briefly, you mentioned, Mr. Thompson, data problems that you are trying to correct now, but I couldn't tell from either your written or your oral testimony what kind of problem, what numbers were wrong, what kinds of things were we given wrong or you received wrong information on.
Mr. THOMPSON. Well, it's inconsistent information. Probably the best example is the number of undiagnosed illnesses we're actually compensating. If you look in our payment system, the benefits delivery network, it would show up as around 1,500 or so claims, 15 to 16 hundred claims.
The system is very old. It was designed strictly to pay claims, carries very little additional information, and has a number of limitations, which I won't bore you with, but it doesn't necessarily capture all of the information.
Another figure, which is from our tracker system, which we maintain in the local regional offices manually, would show 2,400 claims. There's roughly an 800-claim difference in the number paid. That is, again, a manual system handled by scores of people. And the data also could be in error.
Page 76 PREV PAGE TOP OF DOC Mr. FILNER. The Chairman had asked in the previous panel some questions of statistics, how many veterans, what percentage for this or that. And we had very precise answers. Were they subject to that same data problem? I mean, could they be in error?
Mr. THOMPSON. I would say any data that's extracted from our current computer systems is subject to misinterpretation.
Mr. FILNER. Why didn't they say that when they gave us the answers?
Mr. THOMPSON. Well, I'm not sure about the particular information they provided, but I'll give you an example. These systems were designed 30 to 40 years ago. And, again, they keep minimum information.
We limited the number of conditions that it will track to six. After six conditions, we start dropping the diagnostic codes. If the veteran has a zero percent rating for undiagnosed illness, that could well be dropped. You may have a record, but we would not know it.
These are longstanding problems that are related to our information technology infrastructure. And I don't want to make excuses for them, but I don't want to misrepresent the information.
Mr. FILNER. I appreciate that. I wish that when someone said that 12 percent, that is based on the data we have, in fact, and we are now in the process of checking out the accuracy of that data. I mean, somebody could say that.
That's the kind of thing that leads to the skepticism that I have been showing all day here. But I appreciate your openness about that, and I'll remember that when I ask similar questions in the future.
Thank you very much.
Dr. COOKSEY. Good news is that we are in the information age. Bad news is that the health profession, my profession, has not quite caught up. But there is technology out there.
Page 77 PREV PAGE TOP OF DOC So in the future when you go in to see your physician, you'll have a card. And on that card, you'll have a chip. And he or shemy associate is a woman. So I've learned to be politically correct. Anyway, they will have your full medical history. And you should be able to network this information. And it should transfer to military records, too.
A couple of questions. Mr. Thompson, could you give us your latest claims data?
Mr. THOMPSON. Yes, I can.
Dr. COOKSEY. How current is this?
Mr. THOMPSON. This morning.
Dr. COOKSEY. That's very good. Thank you.
Mr. THOMPSON. It has not been, let's say, scrubbed. So if I could put one codicil on that, it's subject to some change, but I think these are fairly accurate numbers.
There are three ways of looking at Gulf veterans we have: folks who are in the conflict, in the Gulf during the conflict; folks who were in the Gulf after the conflict; and then everyone who has been in the Gulf War era, which is from August 2, 1990 to the present.
Of the total number of veterans who have been in service from August 2, 1990, until the present, there are 3.3 million veterans. Approximately 10 percent, or 326,000, of those are receiving disability compensation.
Of the conflict, the folks who were actually in the Gulf during the war, 670,000 are veterans today. Approximately 77,000 of them are receiving benefits, so about 11 and a half percent.
Of the ones who were in the theater,they served after the war was over360,000 in number, about 5 percent of them, or 18,000, are receiving service-connected disability.
Page 78 PREV PAGE TOP OF DOC And of the erathese are the veterans who were not in the theater or in the conflict2.2 million, about 10 percent, or 231,000 of them received compensation.
Dr. COOKSEY. I was in the Air Force during the Vietnam period, 1967, 1968, 1969, and a little bit afterwards. How does the incidence of claims for the Gulf War compare with my generation's war or the Korean War or World War II?
Mr. THOMPSON. We're just starting to compile those statistics, but I would say that the number of claims being filed by veterans is on the increase. The number of conditions filed in each claim as well is on the increase.
I saw some very preliminary data yesterday that would suggest that from an original compensation claim, just slightly less than five conditions are claimed. That is very preliminary information. We hope within the next month or two to be able to tickle some more information out of that
But greater numbers file. And when they file, they have more issues at play.
Dr. COOKSEY. Let me ask you: Of those claims from the Gulf War, how many of them were claims for, say, combat injury, like a land mine, a bullet wound, the traditional wounds from weapons?
Mr. THOMPSON. I don't know what the number would be. Chris might have the number. It would be very low, though.
Ms. MOFFITT. We don't track what those issues come from. We don't track combat claims versus non-combat.
Dr. COOKSEY. Would DOD have that?
Ms. MOFFITT. I don't think they'd have a record of the claims filed with the Department of Veterans Affairs, no. I don't think so.
Mr. THOMPSON. We may be able to compare our records against DOD's. We could at least investigate that and get back to you.
Page 79 PREV PAGE TOP OF DOC Dr. COOKSEY. You know, in my congressional office, we really get a lot more claims from people that have non-combat-related injuries than we do people that had combat injuries.
I have treated patients with land mine injuries. This was after I was out of the military. It was when I was doing some mission work in East Africa, in Mozambique, at the end of that civil war. In the Air Force, we didn't see those injuries, but I had seen people who had injuries, eye injuries, from the Vietnam War.
And I feel like people who have an actual bullet wound, weapon type of injury should probably be paid twice or compensated twice or three times what they're being compensated. I at times get a little bit concerned that that's underdone.
Another quick question: What do you think you can do to improve your information technology, your information systems to avoid some of the problems we've gotten right now as to a person's previous medical history and wartime history and so forth and future history?
Mr. THOMPSON. Old Betsy has about seen the end of her service. It was initially built in the late 1950s and through much of the Vietnam era. It really can't be improved much beyond what it is doing today. It really needs to be replaced. We're in the process of attempting to do that.
Of course, as you well know, that's an extraordinary commitment for the agency. And, frankly, we have not been as successful as we could be.
Dr. COOKSEY. So these are trade computers or IBMs? They're surely not PCs?
Mr. THOMPSON. No. These are large mainframe batch systems. They're run primarily in Chicago and Austin. They have millions of lines of code in them, all COBOL programs. We need to get them in a modern database environment. That's part of the efforts that we're undertaking now, but that will not come quickly.
Page 80 PREV PAGE TOP OF DOC Dr. COOKSEY. Well, in closing, I feel that we are all very committed to the veterans. And I have just been in Congress a year now, a year and two or three weeks. I feel good about the things that were done in this time period for the veterans. As a veteran, I am very heavily committed to veterans. And, yet, if there's more that needs to be done, I want the veterans to know that this Committee is committed to them, as obvious by Mr. Filner's comments.
And I think that the whole Congress is committed to veterans. But we've got to base all of our decisions on facts as we find them from research data and find solutions that will be real solutions once we find the etiology of the illness.
I appreciate all of you coming today. It's been a long meeting, but we're always glad to hear from you. Thank you very much.
[Whereupon, at 4:13 p.m., the committee was adjourned.]