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House of Representatives,
Committee on Veterans' Affairs,
Washington, DC.
    The committee met, pursuant to call, at 1 p.m., in room 334, Cannon House Office Building, Hon. Bob Stump (chairman of the committee), presiding.
    Present: Representatives Stump, Smith of New Jersey, Bilirakis, Everett, Quinn, Bachus, Stearns, Moran, Cooksey, Hutchinson, Chenoweth, Evans, Kennedy, Filner, Gutierrez, Bishop, Mascara, Peterson, Reyes, and Snyder.


    The CHAIRMAN. The meeting will please come to order. Let me say before we start today that we have urged all members not to take their time in offering a 5-minute opening remark. If you do have a statement you would like to make, please do so at the time you ask questions.
    We'll allow that at the end of each panel. But we will abide by the 5-minute rule. We have a very, very long agenda, and I know that there's a big dinner tonight at the VFW that most people would like to attend.
    Today's hearing on health concerns of Persian Gulf veterans is our 11th such hearing and far from our last on this subject. We won't get all the answers or resolve all the issues today, but we will follow these issues wherever it takes us. If additional legislation is needed, we will take it up and move it very swiftly.
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    This afternoon we will hear testimony from scientists, government officials, and spokesmen for our veterans' organizations. Testimony from individual veterans will also remind us of the importance of providing empathetic care, timely benefits, and ultimately, real answers.
    Finding answers has been slow and elusive. Hopefully these hearings will help us understand the limitations as well as importance to these issues of scientific inquiry.
    Concerns regarding Persian Gulf veterans' illnesses have sparked many theories regarding both cause and cure. We will not help our veterans, however, by substituting our own judgment for that of the experts in determining the most fruitful avenues for further research. And we must not let our frustrations regarding the search for answers overtake our responsibility for judicious decisionmaking.
    In that regard, the Presidential Advisory Committee on Gulf War veterans' illnesses has accomplished important work, as has the Institute of Medicine. I hope the work of these expert panels will help us agree on where we go from here.
    At this time I'm happy to recognize the ranking member, Lane Evans.


    Mr. EVANS. Thank you, Mr. Chairman. I appreciate you holding the hearing today. We have some important witnesses before us. So I'll keep my remarks very short.
    I commend President Clinton for establishing the advisory committee and its members and staff for all the important services they have provided to our country. By all accounts, their work has been thorough, competent, effective, and candid. I hope future government advisory committees will conduct the people's business in the same manner in carrying out their mandate as well.
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    Mr. Chairman, I anticipate some members of the Committee may have additional questions for some of the witnesses following the conclusion of this hearing. I request all members be given the opportunity to submit questions in writing to witnesses and those questions and their responses to them would be included in today's hearing record.
    The CHAIRMAN. Without objection and also encouraged.
    Mr. EVANS. I appreciate your holding the hearing, Mr. Chairman. Thank you.
    The CHAIRMAN. Thank you, Lane.
    Our first panel today will be Major Marguerite Knox, a member of the Presidential Advisory Committee on Gulf War Illnesses who also served during the Gulf War; and Dr. Russell, a member of the Institute of Medicine Committee which reviewed these issues. Major Knox, if you'd like to lead off?
    And let me say to the members we are not discriminating against the members. We'd also ask the witnesses to try to hold their remarks to 5 minutes, please, each, if you would. Ms. Knox.
    Ms. KNOX. Good afternoon. How are you all?


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    Ms. KNOX. Mr. Chairman, members of the Committee, thank you for this opportunity to appear before you today. We have submitted written testimony for the record. As you requested, I will now summarize this material.
    First, there should be no question that the Presidential Advisory Committee on Gulf War Veterans' Illnesses recognizes that many veterans are experiencing medical problems connected to their service in the Gulf.
    In the near term, the Government needs to fine-tune some specific efforts in follow-up clinical care and risk communication. Overall, the advisory committee found that the Government had learned some lessons from our experience with Vietnam in responding to the range of health-related problems experienced by Gulf War veterans.
    Regarding research, the committee found that the current research portfolio is for the most part appropriately balanced. Clearly, the broad array of ongoing studies will improve our understanding of Gulf War veterans' illnesses.
    To close the gaps in the current knowledge base, we recommended additional research in three specific areas: number one, on the long-term health effects of low-level exposures to chemical warfare agents; number two, on the synergistic effects of pyridostigmine bromide with other Gulf War risk factors; and, number three, on the body's physical response to stress.
    In addition, the committee noted the importance of continuing to ensure that resources are devoted to mortality studies since some health effects, such as cancer, would not be expected to appear until a decade or more after the end of the Gulf War.
    In reviewing the data available for our December 1996 report, the advisory committee was able to reach some conclusions about the nature of Gulf War veterans' illnesses. In this regard, we have three findings as well.
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    First, as I noted earlier, many veterans have illnesses connected to their service in the Gulf.
    Next, the committee conducted a comprehensive review based on results subjected to peer review of the health effects of pesticides, chemical warfare agents, biological warfare agents, vaccines, pyridostigmine bromide, infectious illnesses, and depleted uranium, oil well fire/smoke, and petroleum products. Current scientific evidence does not support a causal link between the symptoms and illnesses that veterans report today and exposures to any environmental risk factor of the commonly suspected Gulf War hazards that we assessed.
    And, finally, stress which is known to affect the brain, the immune system, cardiovascular system, and various hormonal responses is likely to be an important contributing factor to Gulf War veterans' illnesses.
    As I just noted, prudence requires further research in this area as well as on the synergistic effects of PB and long-term health effects of low-level exposure to chemical warfare agents.
    As you know, the advisory committee had one significant caveat about the Government's performance related to Gulf War veterans' health concerns. We took strong issue with the Department of Defense's efforts to assess possible exposures of U.S. troops to chemical warfare agents in the Gulf. An atmosphere of government mistrust now surrounds every aspect of Gulf War veterans' illnesses because of DOD's mishandling of this issue. This atmosphere of mistrust is regrettable.
    Our investigation of DOD's efforts in this area led us to conclude the department's early efforts were superficial and lacked credibility. We found substantial evidence of site-specific low-level exposures to chemical warfare agents. Moreover, we found DOD's investigations had been superficial and were unlikely to provide credible answers to veteran's and public's questions.
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    The advisory committee also noted that DOD's failure to seriously investigate these issues also adversely affected decisions related to funding research and to possible health effects of low-level exposures to chemical warfare agents. DOD's intransigence in refusing to fund such research until late last year has done veterans and the public a disservice.
    Before concluding my oral remarks, I do want to mention that during the course of the advisory committee's deliberations on Gulf War veterans' illnesses, we judged that the Government could do a better job in the future of avoiding post-conflict health concerns. Thus, we made several recommendations to address the need for better communication, better data collection, and better services.
    I would be happy to discuss these recommendations in greater detail should you have questions, but I especially want to note a strong need to improve data collection and handling. The Government has a significant amount of ground to recover with Gulf War veterans and the American public because they have come to question whether a lack of data—for example, on the possible exposures, on the pre- and post-deployment health of veterans, or on the location of troops in theatre—actually indicates a lack of commitment to veterans' health.
    Mr. Chairman and members of the Committee, the Nation has just begun to pay its debt to Gulf War veterans in many important ways. It is essential now to move swiftly toward resolving their principal remaining concerns.
    Thank you again for the opportunity to review the committee's work with you. I or committee staff members Holly Gwin or Mark Brown would be happy to answer questions about our work.
    On a personal note, however, I would like to add that I hope DOD and VA will respond quickly and compassionately and sincerely in providing the state-of-the-art health care that any veteran seeks in any institution within DOD and VA. Veterans need timely health care and timely receipt of benefits and compensation. I am pleased that the President supported Secretary Brown's reexamination of the presumptive period for undiagnosed illnesses. And I hope this review will be completed as soon as possible.
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    Finally, to quote fellow committee member Dr. Philip Landrigan in his recent editorial in the Journal of American Medical Association, he states, ''Despite the limitations of current epidemiological studies and clinical investigations and regardless of the unanswered questions surrounding the hazards of potential exposures during the Persian Gulf War, these veterans will need all the resources and all of the care that they are owed by this Nation that they have so generously and gallantly served.''
    Thank you. We'll be glad to address any questions.
    [The prepared statement of Major Knox appears on p. 316.]
    The CHAIRMAN. Thank you, Major Knox.
    Now we'll hear from Dr. Russell, who was a committee member on the committee to review the health consequence of service during the Persian Gulf War for the Institute of Medicine. Is that correct, Doctor?


    Dr. RUSSELL. Mr. Chairman, members of the Committee, thank you for the opportunity to discuss some aspects of the health problems faced by veterans of Desert Shield and Desert Storm. I'm here in place of Dr. John Bailar, the chair of the IOM Committee to review the health consequences of service during the Persian Gulf War.
    Dr. Bailar's formal statement has been submitted earlier, and I fully support his statement and am very happy to speak on behalf of the committee and answer questions about the statement.
    The charge to our committee was to assess the actions taken by the Secretary of Veterans Affairs and the Secretary of Defense to collect and maintain information and generate databases useful for addressing the health consequences of service in the Gulf.
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    Another charge was to recommend means to improve collection and maintenance of relevant information and to determine whether there is a sound basis for epidemiologic studies of the health consequences of service in the Gulf and make recommendations regarding the studies.
    Our committee met 16 times over a period of 3 years and received information from a wide variety of sources, including veterans, physicians, epidemiologists, research scientists, and military experts.
    Forty-five recommendations from our committee are contained in the two published reports. Our recommendations emphasize the urgent need for improved medical record systems and compatible medical databases in the armed services and the Department of Veterans Affairs.
    We made a series of recommendations directed at improving ongoing research programs, and we emphasized the need for additional efforts in several areas, including stress management in military operations, stress-related disorders, excess accident mortality in veterans, and longitudinal studies of veterans' health and causes of morbidity and mortality.
    We made several recommendations aimed at improving the capability of the armed forces to relate experiences and potential environmental exposures during deployment to medical outcomes.
    We supported the continuation of ongoing epidemiologic and toxicologic research, including studies of the long-term effects of chemical warfare agents.
    In the course of our studies, we reviewed information in 14 different hypotheses, which have been put forward as possible explanations for illnesses in veterans of the Gulf War or causes of the Gulf War Syndrome.
    We found no convincing evidence to support any of the proposed explanations. Our committee found no convincing evidence for a definable or unique new medical condition among Gulf War veterans and no direct evidence for environmental exposures causing adverse physical or physiologic consequences.
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    More recent information regarding potential exposures to chemical weapons from destruction of captured munitions raises questions about documenting exposure and defines a population deserving further study. However, it does not alter our conclusions or recommendations. Our conclusions and recommendations were based on an assumption that low-level exposure was a possibility that had not been excluded and may never be adequately determined.
    The Presidential Advisory Committee on Gulf War Illnesses addressed several of the same issues as the Institute of Medicine committee. In those areas, there's almost complete agreement. Differences are really very minor and a matter of emphasis and perspective, matter of tone.
    Both committees recognized the profound impact that service in the Gulf War had on the health of the deployed military population. Although battle injuries and infectious disease casualties were low, stress-related illnesses and ill-defined symptoms and symptom complexes has created a serious disease burden.
    Access to care problems and adverse determinations regarding service-connected illnesses created serious social and medical consequences as well as confounding early epidemiologic consequences.
    Both committees as well as earlier groups which addressed the problem came to the same conclusion regarding the lack of convincing evidence for a causative role for the suspected environmental toxins, oil fire/smoke, petroleum products, depleted uranium, chemical and biologic weapons, vaccines, medications, repellents, and insecticides.
    In closing, let me say that I have become very doubtful that after almost 6 years of intense study, investigation, and debate, we will ever come to a conclusion about the existence of Gulf War Syndrome or that we will ever find convincing evidence of long-term health effects resulting from exposure to a specific causative agent or combination of agents. There are still very important areas for additional study and research, but I have very little optimism that we will find definitive answers or agree on the answers.
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    The most important actions in my view are in the areas of assuring optimal medical care and support for this group of veterans and for veterans of future conflicts. We should give high priority to developing epidemiologically sound medical record systems and accurate deployment records. We should strengthen the capability of the armed forces to rapidly and thoroughly investigate all medical problems related to future deployment.
    Thank you very much for the opportunity to be here.
    [The statement of Dr. John Bailar appears on p. 322.]
    The CHAIRMAN. Thank you, Doctor.
    I have one quick question of either of you or maybe both. A report suggesting that Persian Gulf veterans' family members have been getting sick and that their offspring have had birth defects has been alarming. Does the available research offer any reassurance on this? Would either of you care to?
    Dr. RUSSELL. The studies that were available to our committee were in early stages of their producing results, but the data that we saw did not indicate any excess problems of birth defects within the population. There are ongoing studies that will continue to address this.
    The CHAIRMAN. Thank you.
    Ms. KNOX. Our conclusion was essentially the same about both of those.
    The CHAIRMAN. Thank you. Mr. Evans.
    Mr. EVANS. Thank you, Mr. Chairman.
    I'd like to ask the panel about stress. Stress has been cited repeatedly as a possible factor in the continuing health problems of our Persian Gulf veterans. Is stress considered a leading cause because knowledge of other possible causes is lacking?
    Ms. KNOX. I don't think that's so at all. I think that stress is definitely a contributing factor to anybody who participates in war. And, having been there, it's a very stressful environment. Just like we know that many people have hypertension due to stress-related complications in their lives, stress can cause, may not be the only cause, but it's a contributing factor to certain disease processes.
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    Do you want to add something?
    Dr. RUSSELL. Stress casualties are an expected outcome of war. They have been since we have been keeping medical records of casualties during wartime.
    The Gulf War was a very stressful war, and it wasn't a short war for most of the deployed troops. They were there for many months. The stress levels were very high on a continuous basis. And it was expected that we would have stress casualties from that kind of an operation. Management of stress is a continued, ongoing problem for military leadership and military medical support.
    I think we were led to underestimate the impact of stress because the casualties due to hostile fire were low, the casualties due to infectious diseases were unexpectedly low. But the stress casualties were not mitigated.
    Mr. EVANS. What could the military do to best reduce stress symptoms in the future?
    Dr. RUSSELL. It's a complex problem. Some of the best ways of reducing stress are to prepare the troops for the environment and the hazards they have to face. Leadership is incredibly important. Unit cohesion is incredibly important in avoiding stress casualties. The better leadership, the better trained the organization, the lower the stress casualties.
    Mr. EVANS. All right. Thank you, Mr. Chairman.
    The CHAIRMAN. Thank you, Lane.
    The gentleman from Alabama, Mr. Everett.
    Mr. EVERETT. Thank you, Mr. Chairman.
    Major Knox and Dr. Russell, our veterans seem to be asking two questions, basically, ''What caused me to get sick?'' and ''How can I be cured?'' Are these two separate research areas?
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    Dr. RUSSELL. I would say so, yes, sir. The search for etiology may involve the toxicology, epidemiology, may involve other disciplines. Treatment of illness may involve dealing with the patients' total problems and medical management. They are two entirely different problems.
    Mr. EVERETT. I notice from the testimony submitted that a lot of research is indicated. How are we going to ensure that the research and what happened do not interfere with us treating our veterans and trying to get a cure to them or can we do that? And how long are we talking about here?
    Ms. KNOX. You know, it may be impossible to ever find a cure since veterans were exposed to so many different risk factors during the Gulf War. Just finding out about low-level chemical exposure is 5 years after the fact, so research has been delayed. So until that time, legislation will have to approve recommendations for veterans to get the care that they deserve in the VA.
    Mr. EVERETT. I'm sorry, Major Knox. Did you want to add something else?
    Ms. KNOX. I'm going to let Holly Gwin add to that.
    Ms. GWIN. One thing that the committee found is that neither DOD nor VA is waiting until we know the precise cause or a particular cure for undiagnosed illness before they're treating the veterans. There are extensive clinical programs in place to diagnose and to treat veterans who complain of symptoms related to the Gulf War.
    Mr. EVERETT. Dr. Russell, speaking of the 4-year delay, what loss has that caused us in the ability to find out exactly what happened?
    Dr. RUSSELL. I think the problem is not the delay. It's that we've been at it for so many years and have exhausted—we've intensively investigated multiple proposed hypotheses. And each one of them proved not to have sufficient evidence to be a convincing candidate for suspect etiology.
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    I think also as time goes on, the ability to relate symptoms and illness to something in the remote past becomes more and more difficult from a medical and epidemiologic basis.
    Mr. EVERETT. Could you say that DOD's inaction for 4 years on this and not allowing funding to go through at the level that it should have has caused any effect on it?
    Dr. RUSSELL. We probably did not start early enough and vigorously enough with our epidemiologic investigations. Yes, sir.
    Mr. EVERETT. Let me ask you a final question, please. Dr. Bailar's testimony raises a question of whether the frequency of diminished symptoms in some very serious diseases is higher for Gulf War veterans and their non-deployed counterparts. Have you found any evidence of an increase of such frequency?
    Dr. RUSSELL. I haven't. I've reviewed the same data that Dr. Bailar has. And there is evidence of increased illnesses of several types among Gulf War veterans compared to their colleagues that did not deploy. There's evidence of increased mortality due to automobile accidents.
    That still doesn't help us very much in determining exactly what the cause of these illnesses is.
    Mr. EVERETT. Thank you. Thank you, Mr. Chairman.
    The CHAIRMAN. Thank you.
    The gentleman from California, Mr. Filner.


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    Mr. FILNER. Thank you, Mr. Chairman. And thank you for holding these hearings.
    I appreciate, Major Knox, your comments. I, too, was disturbed at some of the early reactions, the defensiveness of the Defense Department. I guess Defense Department doesn't mean you have to be defensive on these kinds of issues and on administration and reluctance to admit either error or wrongdoing or even ignorance, which is part of our condition and seemingly to focus on, ''Well, since we can't pinpoint an exact cause, therefore, there is no responsibility here.'' I found those statements very disconcerting, as I think you indicated.
    And, of course, now I think, as most of the questions preceding me I think were pointing to, that, regardless of whether we have that answer, it is our responsibility to assure that the health care is provided and also compensation to those individuals whose health problems are associated with this service.
    Obviously we have to continue that research, but I don't think we should wait for all this complex science involved with this to come forward with a national responsibility toward our fighting men and women in the Persian Gulf. So I don't think they can wait any longer. We have to accept that responsibility and move forward, even if we never find a, quote, ''exact'' cause.
    I'm still disturbed by people who seem to think that that's what this issue is all about since they can't find the one or because they can't find anybody at fault or we didn't do it on purpose. I mean, I saw General Schwartzkopf say, ''Well, we didn't do it on purpose.'' Well, nobody ever said that that was.
    Obviously that's not the issue here. The issue is we have thousands and thousands of people suffering. And we need to deal with that.
    I read with some interest another study—I think it followed yours—by the University of Texas.
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    Ms. KNOX. Right.
    Mr. FILNER. Are you familiar with that one, which seemed to—I mean, it took away some of the concentration on stress and looked at other syndromes that involved brain and nerve damage caused by exposure? Did you look at that and is that— —
    Ms. KNOX. You are speaking of Dr. Robert Haley's study out of Southwest Texas?
    Mr. FILNER. I think so, yes.
    Ms. KNOX. Yes. In fact, one of our members, Philip Landrigan, did the editorial on that particular issue. I think that was a good study that Dr. Haley did. And I think more studies need to be done to find out what the effects of low-level chemical exposure could have been.
    However, his study still does not show a cause and effect relationship. He did a multivariate statistical analysis. And he actually wrote three articles in that particular journal, but it still does not show a cause and effect on low-level chemical exposure.
    Did you want to add to that, Dr. Russell?
    Dr. RUSSELL. Yes. I fully agree with Dr. Landrigan's analysis of those studies. They were ambitious, sophisticated. They raised questions, but they had substantial epidemiologic and methodologic weaknesses and limitations of the study population. They raised interesting and worthy questions, but they're not conclusive.
    One of the conclusions that was drawn in the study was that the neurologists and the investigators who were blinded to the subject whether they were cases or controls could not differentiate on the basis of clinical laboratory findings between the cases and the controls. The findings were nonspecific and not sufficient to diagnose a known syndrome or in any subgroup.
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    So it is useful research, but it doesn't provide us with definitive answers.
    Ms. KNOX. However, we welcome further research on that area because we just don't have the answers regarding low-level chemical exposures.
    Mr. FILNER. You used a few interesting words in your opening statement, including ''superficial'' and some other ones, which I agreed with, as I said. Has the DOD been responsive to that critique? I mean, have they accepted that or are they still trying to defend what they were doing? I mean, are they on a new path in your view that— —
    Ms. KNOX. I think so. I think that Secretary John White was very sincere in his last remarks to our committee. I think the biggest problem that DOD has had is in their communication. Risk communication has been very poor.
    I am still employed by DOD. And I would like to think that it acts in the best interests of our veterans. And it is a big organization. So there have been problems.
    Mr. FILNER. Thank you. I just hope that your findings, your statement can get us on the path of a constructive dealing with some real human problems. And honesty about what we did or didn't do I think has to be there because I don't care where the chips fall. If we have done something wrong or something stupid or something out of ignorance, we need to know it. I mean, it's in our national interest to be honest here and not to— —
    Ms. KNOX. I agree.
    Mr. FILNER (continuing). Hide or cover up, be defensive or superficial. I mean, that's what national security to me means in the future: to be honest about what happens here. And I think your report has helped us.
    Thank you.
    The CHAIRMAN. The gentleman from New York, Mr. Quinn.
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    Mr. QUINN. Thank you, Mr. Chairman. I want to thank you, Chairman, and the Ranking Member Evans for your interest in holding today's hearing. I'm looking forward to this Committee becoming more and more involved in this issue as we hear testimony today, both from this panel and other members on panels later this afternoon.
    I also want to thank the commission for their work in responding to us, not only as members of the U.S. Congress, but also as we try to respond to constituents back home in our states and cities and districts all across the country.

    Mr. Chairman, I have a statement that I would like included in the record for later.
    The CHAIRMAN. Without objection.
    [The prepared statement of Congressman Quinn follows:]

Prepared statement of Hon. Jack Quinn
    Mr. Chairman, thank you for holding this important hearing on the illnesses that are facing some our Gulf War veterans. I congratulate the Advisory Commission on their work and I am pleased they will continue their service to America's veterans for several more months.
    Mr. Chairman, I approach this issue with an open mind on almost every aspect except the way the Department of Defense has handled the issue.
    Veterans are sick. There is no doubt about that. The issue before this committee is to determine how VA is now taking care of sick veterans and what VA is doing in terms of research and how VA is compensating veterans for their service-connected disabilities.
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    The Commission makes several interesting recommendations regarding record keeping at DOD and VA. As Chairman of the Subcommittee on Benefits, I am very interested in VA and DOD standardizing medical and personnel records to ensure the most seamless handoff between DOD and VA possible. In addition to easing the data collection in cases like this, it will make VA's job easier in all future benefts cases.
    Mr. Chairman, I am also concerned about how VA is handling compensation claims. I understand that VA is in the process of re-evaluating several thousand claims at this time to determine whether VA had processed the claims properly. I urge VA to complete the project as quickly as possible. I am also aware that Secretary Brown is considering adjusting the two year presumptive period for compensation claims. I know that he has been pressed hard by some members of the other body to take an immediate administrative active to lengthen the presumptive period and that he has stated that he needs to see the data before he takes action. I support that approach, and I am pleased that Secretary Brown will make his decision based on available data, not emotional appeal.
    To determine how VA has been handling Persian Gulf compensation cases, I will schedule a hearing in the spring. That will allow time for VA to accumulate data from its re-evaluation project to give us a good picture of how veterans are being served. If necessary, I intend to hold an additional hearing this fall on the issue.
    Mr. Chairman, that concludes my remarks.

    Mr. QUINN. Major Knox, you talked about one of the recommendations that the committee saw fit to include was to talk about better communications. And, clearly, that's one of the things I think we have to work on with the Department of Defense, for example, when we talk about communications and asking questions and receiving straightforward answers and so on and so forth.
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    Can you briefly state what recommendations you make in terms of communications, between whom and with whom and how it might be helpful, or are you not able to do that at this time?
    Ms. KNOX. I'll let Holly Gwin speak to that since she's deputy counsel.
    Ms. GWIN. We made a number of recommendations about communication. The two most forward-looking ones have to do with—well, the first one is DOD and VA need to get together and develop a risk communication plan to explain to veterans, in advance as well as after the fact, to their best ability what are the risks that they face in a wartime situation and what are the possible health consequences of those risks.
    Mr. QUINN. I understand.
    Ms. GWIN. That seems to be a basic area of misunderstanding right now.
    Another area where we thought there needed to be vastly improved communication is in the area of drugs, investigational drugs, that are approved for use under an interim waiver of conformed consent now available from FDA. Drugs like pyridostigmine bromide, although they're approved for one use, are not approved for the use in which they were employed during the war.
    We figured there needed to be much better communication, not only to the service members about what they were taking, but a broader public dialogue about whether that is an appropriate use of drugs in this society.
    Mr. QUINN. Thank you, Ms. Gwin. Those are both very helpful.
    Would it be possible for you to sort of get for me and for the Committee other areas of communication that you looked at? For example, is there any discussion about communication between the various departments and this Committee?
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    Now that the event is over, we have a tough time getting some information sometimes. Is that area of communication addressed at all in the report?
    Ms. GWIN. No.
    Mr. QUINN. Then I'd to suggest to our Committee, the chairman and the ranking member, that maybe after today's discussion that we look into that area of communication.
    My other question was for Ms. Gwin as well. You talked in answer to a previous question about some ongoing treatment that's taking place right now, even though we're not going to wait for the culprit or the reason. Extensive treatment everywhere throughout the country? All veterans? Some veterans? Different areas?
    Ms. GWIN. The VA Persian Gulf health registry is available to any veteran of the Gulf War who is no longer on active duty. DOD's comprehensive clinical evaluation protocol is available to all active duty members. These provide comprehensive diagnosis and treatment programs for veterans of the war who believe that they have service-connected symptoms.
    Mr. QUINN. All across the country?
    Ms. GWIN. All across the country. There are hierarchies of care. There is your entrance-level exam and treatment.
    Mr. QUINN. That's one of the problems the veterans have, the hierarchy and the bureaucracy, et cetera, not directed at you, but that they have experienced throughout this. And that's what I'm trying to get at.
    Ms. GWIN. We did hear a lot in our public hearings from veterans who had experienced lots of difficulties in acquiring care, both initially and in follow-up.
    We conducted a series of site visits in 1995 and 1996, which is several years after those programs were initiated. We evaluated those programs at the time. We looked at them as being excellent. That is not to deny that many people had problems with those programs in the beginning.
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    Mr. QUINN. Very well. And part of that is mentioned in the report. Thank you. I appreciate that very much.
    Dr. Russell, you talked about stress. This is probably more a comment than a question before I finish up. And a couple of the other members, Lane talked about stress and others have. I would just submit to the Committee and to the panel that if you think that stress was a factor in all of this while our veterans served, we ought to consider the stress they're under now not having answers, not being able to access the system once in a while, and the stress on their families and other members of their immediate home situations, so the stress when this whole thing happened, as you point out correctly. And that's a newer problem for us. But I also want to point out that there's a lot of other stress that's going on here.
    Lastly—I know my time is up. I have some more questions further, Mr. Chairman. This is housekeeping maybe for the major. We say that the Presidential Advisory Committee on Gulf War Illnesses has been extended through October of 1997 to oversee exposure and implementations and recommendations.
    Ms. KNOX. That's correct.
    Mr. QUINN. I am not exactly sure about the funding of that until—I mean, that's only a few short, 6 or 7 months away. You're funded and operating up until then?
    Ms. KNOX. Yes.
    Ms. GWIN. We operate under an executive order.
    Mr. QUINN. Right.
    Ms. GWIN. The new order extending our life through October as far as producing work and then another 30 days for closeout was just issued.
    Mr. QUINN. Okay. Thanks very much. I appreciate your answers. Thank you, Mr. Chairman.
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    The CHAIRMAN. The gentleman from Texas, Mr. Reyes, is recognized.


    Mr. REYES. Thank you, Mr. Chairman. I, too, would like to submit a written statement for the record.
    The CHAIRMAN. Yes, sir.
    [The prepared statement of Congressman Reyes appears on p. 313.]
    Mr. REYES. In the interest of saving time, I represent a district with approximately 60,000 veterans. And there is a deep sense of frustration that I think speaks to part of—as my colleague said, what's interesting to the language that you used, ''superficial'' and ''lacked credibility,'' I think in the context of what we're seeing that's coming out in the Gulf War Syndrome ailments, I guess would be the best way to describe it, and the interrelation to stress, all of these issues I think compound the feeing and the sense of frustration that veterans are feeling because they feel betrayed by their own government.
    And, being a veteran myself, I know that combat is very stressful, but you place your trust in the leadership, in the ability of your commanders to provide the information to you. And part of the frustration that I think we're all feeling is the fact that subsequent to the stonewalling that has now come out, we feel that, even now, it's been a situation where it's like pulling teeth from DOD and in some cases from the VA.
    I think that one question that I would like to ask, Ms. Knox, is: Do you believe that we will ever have accurate data on the wide range of exposures that our servicemen were exposed to in the Persian War? Is that something that is feasible or possible given what you know about— —
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    Ms. KNOX. I don't think so. I don't think we had enough pre-deployment data in order to compare post-deployment relationships. Because we didn't collect that data prior to their service and then again afterwards, it's an epidemiological nightmare. You cannot go back and re-create that situation.
    And, in comparison with Vietnam, that just dealt with one agent, Agent Orange, we have multiple risk factors that are involved.
    Dr. RUSSELL. I agree with that. I don't think we're going to be able to relate environmental exposure in any precise manner to illnesses.
    I might add that the stress of wartime doesn't end when the war is over. The stresses of demobilization and reentry into civilian life can be equally as devastating as the stress of combat.
    If you add to that a lack of realization of the relationship between the stress-related illnesses and the service and access to care issues, then we have additional stress placed on this population. So we have a buildup of combat stress, post-deployment stress, and then issues revolving around access to health care and the issues of whether this is or is not related to service.
    I feel that if we took more comprehensive, better care of the post-deployed population without attempting to determine up front whether they had a service-connected disability or not but just recognize that they were going to have illnesses post-deployment and deal with those illnesses and with whatever the state-of-the-art medicine is at the time, that we would mitigate a lot of these kinds of problems.
    Mr. EVANS. Would the gentleman yield? Would the gentleman from Texas yield?
    Mr. REYES. Yes.
    Mr. EVANS. Ms. Knox, you said that there was a lack of pre-deployment data?
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    Ms. KNOX. Right.
    Mr. EVANS. For future deployments, what kind of data should we be collecting during the pre-deployment period?
    Ms. KNOX. I think in defense of DOD, they have done some of that pre-deployment data collection in Bosnia. They have done some environmental testing in the area that troops were deployed, and they have also done a better job of collecting, say, for instance, serum specimens prior to their service. And troops can be checked again following their service for any type of exposures.
    Mr. EVANS. Thank the gentleman for yielding. Thank you.
    Mr. REYES. Just as a matter of a follow-up and I think in the context of what we're doing here today and what has occurred before in these types of hearings, one of the comments we heard this morning from Commander Nier from the VFW this morning was an expressed desire that in issues that affect our veterans, that we err on the side of the veteran, instead of against them.
    As a result of the information that you have been able to secure as a result of the committee findings, are you in a position to make a formal recommendation that we do that as a matter of practical policy in treatment and dealing with our veterans? Because I think that's a very important issue in the context of how our veterans, including those that are serving in the military now that are keeping us free as a nation—that's something in a way of reassurance to repair I think the damage that has been done by virtually what we have since found out regarding the Gulf War Syndrome.
    Ms. KNOX. I am going to refer to Holly Gwin on that. I don't think that's in our charter.
    Ms. GWIN. Well, in our final report, the committee does not make a specific recommendation that you err on the side of the veteran. But I think that if you look at our work, you will find that the staff as well as the committee approached all of the issues like that and emphasized the importance of providing care, even in the absence of knowledge about the cause. And in our presumptions that we made about chemical warfare exposure, we always thought that you should err on the side of the veteran.
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    Mr. REYES. Thank you, Mr. Chairman.
    The CHAIRMAN. Thank you, sir.
    The gentleman from Louisiana, Dr. Cooksey, is recognized.


    Dr. COOKSEY. I can't help but notice that there has been more exposure to more chemicals in this war. Do you think it's related, number one, to the fact that we have more ability to find chemicals than we did in my era, in the Vietnam War era? Number two, when did veterans first come forward with these symptoms? My third question:—and you can divide these up as you see fit—How many deaths have been attributed to this syndrome or have there been any? First, the chemicals; second, the earliest symptoms; and, third, the number of deaths.
    Dr. RUSSELL. I think the environmental exposures are not different in this war except for the nerve agents and the pyridostigmine bromide. Otherwise, I think the exposure in our era, sir, was equally great.
    I'm sorry. I've forgotten— —
    Dr. COOKSEY. When did veterans first come forward with these symptoms?
    Dr. RUSSELL. I think the 93rd ARCOM study was the first one. That was about 6 months after the— —
    Ms. GWIN. Nineteen ninety-two.
    Dr. RUSSELL. Yes.
    Ms. GWIN. Spring of 1992.
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    Dr. COOKSEY. And the third questions: deaths. How many deaths can you attribute to this?
    Dr. RUSSELL. Since we can't define the syndrome, since there is no definition of a Gulf War syndrome, there are no deaths due to it. And the studies of mortality in the veterans population show equivalent mortality to a controlled population except for accidental deaths, which are elevated, which is true of all military post-deployment populations.
    Dr. COOKSEY. Thank you, Mr. Chairman.
    The CHAIRMAN. Thank you, Doctor.
    The gentleman from Arkansas, Dr. Snyder.


    Mr. SNYDER. Thank you, Mr. Chairman.
    Could we talk a little more about the Haley study? Are you all dismissing it or is it leading to ask further questions? What's the next step for research? I guess is what I'm saying. And what direction is that going on right now?
    Dr. RUSSELL. We are not dismissing that. I don't believe anybody is. That's a very serious study. And these are good scientists, good physicians.
    Mr. SNYDER. If I were a Gulf War veteran and I were having problems and I read that study, I think I would kind of get the sense of ''Thank God. Somebody is finally getting on to something.'' So that's why— —
    Dr. RUSSELL. The problem is that the findings in the epidemiologic part of the study are based on subjective data and not objective data. And they're subject to serious problems with the population, series of—I'm not an epidemiologist. So I can't critique it in detail, but it does have epidemiologic— —
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    Mr. SNYDER. If I can interrupt now, of course, this kind of study with those types of—I can't say the word either—those kinds of problems, a lot of times that's a funding problem in terms of being able to track down enough people from the unit, the ones that just didn't self-report, but kind of track down everybody. Is that what you're getting at?
    Dr. RUSSELL. Well, I think there are very large epidemiologic studies ongoing. I think the other side of the issue is the toxicologic and neurophysiologic abnormalities that are found at a very low level.
    Further studies of neurophysiology and following low-level exposure to the agents, argon phosphorus and similar agents, are definitely indicated. And there is a variety of experimental and medical ways of following up on these studies.
    Mr. SNYDER. Are those ongoing now?
    Dr. RUSSELL. I can't answer that.
    Mr. SNYDER. Is funding adequate for that?
    Dr. RUSSELL. I don't know. Probably.
    Ms. KNOX. DOD has given a great deal of funding for that since they recognized that veterans were exposed to chemical munitions at Khamisiyah. Do you know the amount right off? I don't know.
    Dr. BROWN. Yes. There are a number of studies that DOD has funded and is just starting to fund in the next fiscal year that are looking at this. I think, just to say again what Major Knox mentioned, the committee made a finding, a recommendation, that to answer some of the questions about low-level exposure and the combination of exposures from different agents, particularly the pyridostigmine bromide and chemical agents, for example, that there should be further studies done on this issue.
    Mr. SNYDER. When I read your report— —
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    Dr. BROWN. Haley's study is just the first, I think. I think there is going to be a whole slew of studies coming down the pipeline.
    Mr. SNYDER. Probably with some dead ends along the way. When I read your report earlier today and you made that reference, was that your reference to the Haley study? Is that kind of an acknowledgment of that type of interest, the type of things that that study looked at and need to look at laundry detergents and insect repellents and flea collars and— —
    Ms. KNOX. Actually, Haley's report was not published until after we had completed our final report.
    Mr. SNYDER. I got you. And just a couple of things that you all or one thing that you all said there, you said that you were only dealing with one agent in Vietnam. And you made the comment that you thought there were several and that somebody remembers slapping on insect repellent. And God knows what our clothes were washed in.
    I'm just wondering. Was there a little bit of disagreement between the two of you? I guess we didn't take antimalarial medicines and parasitic diseases were present. Was there a little disagreement between the two of you on Vietnam? I don't think that Vietnam was a controlled study with only one agent, I guess.
    Ms. KNOX. No, it wasn't.
    Dr. RUSSELL. No, it was not.
    Ms. KNOX. Well, I think the veterans' complaint, though, was about Agent Orange during that era.
    Mr. SNYDER. It was complaining about one chemical.
    Ms. KNOX. Yes.
    Mr. SNYDER. Thank you, Mr. Chairman.
    The CHAIRMAN. Thank you.
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    Mr. Mascara, the gentleman from Pennsylvania, is recognized.


    Mr. MASCARA. Thank you, Mr. Chairman.
    I happen to have been touched personally by this problem. A constituent of mine by the name of Mary Rhoads came to me. And we had quite an extensive conversation about her problems. They were very real. In the final analysis, we were able to get her 100 percent disability, but she's still out there fighting for others who have similar symptoms.
    I'll just read here for a moment. She was 39 years old and served with the 14th Quartermaster Detachment in Greensburg, Pennsylvania, a community that I represent. She survived an Iraqi scud missile attack on her barracks which killed 13 members of her unit.
    Since coming home, she has undergone a hysterectomy. She had her gallbladder removed. She has lesions from time to time that separate her from 12-year-old. She has vaginal bleeding, vomiting, and chest pains. She has a swollen stomach. In fact, I came to Washington, DC to introduce her to the President's commission. She testified here in Washington, DC.
    I'm disturbed by the findings. The only thing you can find is psychosomatic, a stress syndrome that causes these diseases. I'm not a doctor. So I can't say that that is the case or not and how important that is to the issue before us.
    The prior gentleman who asked you about the mortality rate among those people who served in the Gulf, I think your response was that nobody has died from that because you really don't know what the Gulf War Syndrome is. So you have no fatalities.
    My question is it's my understanding that three individuals, all in the age 30 bracket, have died from myocardial infarctions. One 60-year-old died. Is the Department of Defense tracking those veterans who served in the Gulf War to see if there's any clustering of deaths in order to assist you in coming up with an answer?
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    I mean, 30-year-olds dying from heart attacks is not usual. So it's unique. Is the DOD tracking all 690-some thousand veterans to see who's dying, what they're dying from?
    Dr. RUSSELL. There have been two published reports on follow-up mortality in this population. And I assume that this population will be followed very carefully from the point of view of excess mortality. So far with the exception of the accidental deaths, the mortality is not greater than a non-deployed similar population.
    Mr. MASCARA. There is no concern about the three people serving in the Gulf who died from heart attack?
    Dr. RUSSELL. I don't know. The heart attacks in young people are rare, but they do occur in all populations. And whether it's a statistically significant difference, I can't say.
    The problem we have is—and your constituent is one of the problems—a 39-year-old person deployed will have post-deployment the expected illnesses of a 39 or 40-year-old person plus whatever exacerbation might be due to the stresses of the deployment.
    Obviously she was in a very stressful situation. She may also have had some other medically important events occur in the Gulf, but they're very hard to separate from what happens in an ordinary population. It's a challenge of epidemiology.
    Mr. MASCARA. It's not ordinary for me to be asked to help somebody in Florida but because Mary Rhoads had been given 100 percent disability, the Congress person from that district asked me if our staff would look into it. This woman suffered from similar kinds of problems. She eventually received 100 percent disability, a young lady from Florida.
    I have one more question—perhaps Ms. Knox might be able to answer it—about the question of funding for the ongoing research and tracking of problems associated with the Gulf War Syndrome. Is the Department of Defense spending at a level that you feel is sufficient to do the job? And have there been instances where the money was available and the Department of Defense did not spend that money? And is there presently a commitment by the DOD to spend and to ask for whatever it takes so that we can maybe bring this thing to closure.
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    Ms. KNOX. Just a couple of things to comment on your previous discussion with Dr. Russell. We do appreciate you appearing in Arlington October of last year. I particularly remember Mary's testimony because she is also a nurse.
    And I think, if I remember correctly, Mary had difficulty right at the time that she took the pyridostigmine bromide tablets. So our committee has recommended that further research be done on pyridostigmine bromide and their synergistic effects. And there are already studies that have looked at the synergistic effects of PB and stress, the Israeli study and then PB and DEET. Dr. Abou Donia out of Duke did that study. So I hope that that will answer some of those unanswered questions that we have about what the cause is.
    As far as the appropriate amount of money to spend on this condition, I don't know if it's adequate to— —
    Dr. BROWN. Well, the committee found that, as Major Knox mentioned, the Federal Government does have a good mixture of studies ongoing and planned looking at Gulf War health issues and that the mix of studies includes the right studies on epidemiology; that is to say, looking at Gulf War veterans to see if there are illnesses or other problems at a greater rate than they should be and also an emphasis on stress, looking at the long-term health effects, not just the psychosomatic effects, but the real physical health effects of stress. So I think the committee was very encouraged with the overall federal research portfolio on Gulf War veterans' illnesses.
    In addition, just recently the Department of Defense released, recently within the last couple of months, a new request for proposals which, depending on how you add it up, has more than $10 million attached to it. I guess I think overall the committee would not fault the amount of research, the emphasis on research that's going on now.
    Mr. MASCARA. I see my time has run out, Mr. Chairman, but I hope we're not going down the same path as we did with Agent Orange.
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    Thank you, Mr. Chairman.
    The CHAIRMAN. Thank you, sir.
    The Chair recognizes the gentleman from Minnesota, Mr. Peterson.


    Mr. PETERSON. Thank you, Mr. Chairman.
    I'm kind of new to all of this. So I may ask some dumb questions here, but I'd just like to make a comment first that I think that I've got a lot of folks in my office, I have a hospital in my district. And I think that most people out there wish that you'd spend more time studying why people feel like they're not getting adequate care, rather than studying whether they're compared to some other group or not.
    I mean, is anybody doing that? Is anybody actually spending time figuring out why so many veterans feel like they're not getting this problem addressed? Has any time been spent on that?
    Ms. KNOX. We looked at that a great deal, particularly early on in 1995. In September we held a meeting in Charlotte to look at the care that veterans were receiving, both in DOD and in the VA system, and examined the comprehensive clinical evaluation program that DOD provides for the soldiers and also the physicals that the VA is giving.
    And, as Holly stated earlier, we were not able to do that right at the beginning, when they were in their biggest influx of veterans that came into the system. But when we did look at that in 1995 and 1996, we found it to be adequate.
    Mr. PETERSON. Well, I can tell you there are still people coming to my office who are not getting the kind of care that they think they ought to get.
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    Ms. KNOX. Well, I think— —
    Mr. PETERSON. I think that more work needs to be done looking into that.
    Ms. KNOX. I think maybe examining that presumptive period, veterans who are now experiencing illness that is beyond the 2-year limit, is an issue as well.
    Mr. PETERSON. I'm trying to get a handle on just exactly what these commissions were supposed to do. This testimony here by Dr. Bailar, in here you say that, ''You will note that the charge of our committee did not include the study of the so-called Gulf War Syndrome.''
    Dr. RUSSELL. Correct.
    Mr. PETERSON. What do you mean by that? It looks like every other place in the study you go in— —
    Dr. RUSSELL. We were unable to avoid looking at the Gulf War Syndrome and the science surrounding it, but the Institute of Medicine committees have very narrow charges usually. Ours was convened very early in response principally to the oil well fires.
    So our charge was to determine whether the Department of Defense's and the Department of Veterans Affairs' ability to collect and maintain information and generate databases was going to be adequate to study the effects of the oil well fires and, by extension, the effects of health consequences from any environmental— —
    Mr. PETERSON. Did it actually say that you are not to study the Gulf War Syndrome in your charge?
    Dr. RUSSELL. No. It didn't have any negative in it, but our recommendations were aimed at epidemiologic databases, information systems, epidemiologic investigations, and the quality of the research.
    Mr. PETERSON. What confused me, I mean, I read that, and then I went on to read some of your other statements, where it looks like you have.
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    Dr. RUSSELL. We could not avoid it. It was impossible to carry out the charge without evaluating the hypotheses that were being put forward as explanations. And they came one after another about—I think there are about 16 different hypotheses now that had—and then we had to look at the quality of the investigations that pertained to those hypotheses, the research quality.
    Mr. PETERSON. Well, I'm not a doctor. I have a hard time following all of this stuff. Again, I just would associate myself with some of the comments of my colleagues and just tell you that I think we still have a lot of work to do out there. There are people that I don't think are getting the kind of care.
    And we ought to not just worry so much about why this all happened but get focused on getting help to the people who need it.
    Ms. KNOX. If I could add, that is one of our recommendations, to look at the clinical follow-up of these veterans. And so the President has given us the authority to do that, to see if our recommendations are being followed.
    Mr. PETERSON. Good. Thank you, Mr. Chairman.
    The CHAIRMAN. Thank you, sir.
    The gentleman from Florida, Mr. Stearns, is recognized.


    Mr. STEARNS. Thank you, Mr. Chairman. And let me compliment you for having this hearing on the Gulf War Syndrome.
    One of the first casualties of this syndrome was a Michael Adcock from my congressional district in Ocala, Florida. He was a 22-year-old young man in prime of health before he went there. He came back. He had played football in high school. And he suffered from nausea, skin rashes, aching joints, hair loss, bleeding gums, blurred vision, lack of energy. And he eventually died of a brain tumor at a very young age. So Mrs. Adcock has been up here.
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    Some of my concerns are—is either one of you a scientist?
    Dr. RUSSELL. Here.
    Mr. STEARNS. Because you mentioned earlier that the immune system—do you have a pretty good detailed background in the immune system and— —
    Dr. RUSSELL. I am an internist. And I've spent my career in infectious disease research.
    Mr. STEARNS. It seems like some witnesses and people have said that the Presidential Advisory Commission did not have enough scientists on it. I think some of the witnesses today are coming in or have said that they relied too much on government-provided information and not enough scientific studies. Would you care to comment on that?
    Dr. RUSSELL. I think the vast bulk of the scientific information we have available is from highly reputable scientists, whether in or out of the Government.
    Mr. STEARNS. Weren't most of them in the Government?
    Dr. RUSSELL. I don't believe so. I think, for example, that Dr. Haley's study from Texas is. And there's a substantial amount of work that's been done on government contract. There's a spectrum of scientific research capability within the Government that's very highly credible in the Department of Veterans Affairs and within the Department of Defense. And their colleagues in the academic community are contributing I think probably to an equal extent.
    Mr. STEARNS. For example, did they check on the veterans coming in for hepatitis C?
    Dr. RUSSELL. The issue with hepatitis C has— —
    Mr. STEARNS. Every veteran who complained about this, did he or she get an exam for hepatitis C? Can you be assured of that
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    Dr. RUSSELL. I can't be certain of that. I know that hepatitis C is being extensively investigated by the DOD.
    Mr. STEARNS. It's not just hepatitis C. There's A, B, C, D, E, F, G, and I think they're finding more.
    Let me just change— —
    Dr. RUSSELL. C is a specific problem because of the gammaglobulin.
    Mr. STEARNS. Yes, right. How much money is being spent by DOD presently devoted to the research funding for the Persian Gulf
    Dr. RUSSELL. I have no idea. I can't give you a number on that.
    Ms. KNOX. Mark can give us that.
    Mr. STEARNS. We have been told that it's approximately $30 million. Do you have any way to know about it?
    Dr. BROWN. It is something that we have tracked. I think it depends a little bit on how you define research. If you define research the way I define it, which is investigations of health effects and so forth, it's something in the neighborhood of $15 million in fiscal years 1996 and 1997.
    Mr. STEARNS. Shouldn't you folks or the VA be involved with this and not just DOD? Shouldn't there be a cross-pollination here or something? Have you been asked anything, the advisory council, asked anything by DOD about how to spend this money or anything?
    Dr. BROWN. The group that's overseeing research is not DOD specifically. It's the research working group of the Coordinating Board, which has members at the cabinet level from VA and DOD and HHS. So there is an interagency oversight of this research program now.
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    Mr. STEARNS. So you feel that there's enough cross-pollination between DOD and the VA in dealing with the people who are actually coming into the hospitals? I mean, is there feedback from the veterans' hospitals so that DOD knows where to address things?
    Dr. BROWN. I guess the best way I can answer that is to say that the research working group of the Coordinating Board has representation from VA and DOD.
    Mr. STEARNS. Okay. One last question: Has there been a study of either the British, French, or Canadian particularly soldiers that went over there? Did they suffer the same thing? Has there been a similar type of phenomena of a syndrome?
    Dr. RUSSELL. I understand there's an ongoing study in the British forces.
    Mr. STEARNS. After all this time, there's no real conclusion that they have the same type of thing or not? From the advisory council, you haven't found that out?
    Ms. GWIN. Our report includes information from the British and the Canadian clinical evaluation programs. And, in fact, the early data from those programs is very much like the data from our clinical programs with the same types of symptoms being reported by their veterans.
    But the British have just gotten their epidemiologic studies underway. So it will be quite a while before we have any results from those.
    Mr. STEARNS. And the French?
    Ms. GWIN. We have been trying to get information from the French since we started working for this committee. And it's been— —
    Mr. STEARNS. To no avail?
    Ms. GWIN (continuing). Slow to come.
    Mr. STEARNS. So the French won't give you anything. The British is just starting. And Canada has a similar phenomenon, a syndrome of this type. Is that fair to say?
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    Ms. GWIN. I don't know if it's fair to say they have a syndrome. They have reported clinical data that looks very much like the U.S. clinical data.
    Mr. STEARNS. Okay. Thank you, Mr. Chairman.
    The CHAIRMAN. Thank you, Mr. Stearns.
    The gentleman from Massachusetts, Mr. Kennedy, is recognized.


    Mr. KENNEDY. Thank you very much, Mr. Chairman. I want to thank you very much for hosting this hearing today and let you know how much we appreciate it and look forward to many more in the future, Mr. Chairman.
    I want to just deal with what I think is sort of an underlying concern that many of the veterans that I think we hear from on a regular basis have about how this whole process has developed.
    First of all, I wonder if you could comment, Ms. Knox, on why you feel that this took 6 years for the Government to acknowledge. And, more specifically, I wonder if you might tell us about the extent to which you feel that you have really covered any possible coverup that could occur by the Government with regard to potential chemical or biological exposures.
    We have heard about the Khamisiyah exposures that, as I understand it, did not come through your particular organization but, rather, came about as a result of some CIA documentation.
    I've been contacted. A number of us have been contacted over the years with regard to sort of incidental kinds of occurrences that took place that have I think created a general atmosphere of mistrust between the veterans and the government.
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    And I wonder if you can just address directly whether or not you feel that you have gotten a handle on the extent to which these illnesses could possibly be caused by something other than stress.
    Ms. KNOX. To answer your first question, we are not the first committee to look at Gulf War veterans' illnesses. Actually, we are the fifth committee to look at Gulf War veterans' illnesses. Dr. Russell worked with the IOM committee. So it has been studied a great deal.
    I do agree that DOD's failure to come forward with chemical exposure at Khamisiyah definitely causes an area of mistrust in the veterans. In addition to that, one of the things that we had tried to find out from the Persian Gulf investigation team was where troops were located so that we could look at the realm of veterans that could have been exposed.
    So along with that lack of data as to where troops were located and what chemicals were there and to what degree they were exposed, we cannot answer that.
    Mr. KENNEDY. I appreciate your response, Ms. Knox, because I was going to get through and I asked the staff here if they could—you know, you say that it's a number of different committees that you are aware of. There have been more different sort of fits and stops on behalf of the Congress and a number of others that have sort of looked at this whole issue.
    I remember going back to a point where we had the fellow who actually did the Agent Orange study, the first fellow who ever came before this Committee to talk about it, said there was absolutely nothing to this whatsoever and that it is just—''malingers'' is a word that he used in terms of describing what the problem was.
    I think that if you look at just the whole series, whether it's the group, the symptom of the Pennsylvania Air National Guard or you look at the birth defects in Mississippi, if you look at the individuals who have contacted almost every member of this Committee with a series of complaints, and then you were told that we're supposed to sort of characterize this in general terms as sort of stress-related, it just seems to me that—I don't know if anybody had ever mentioned to you any of the people who fought in War World II and the like that had to land on the beaches in Normandy and all the rest of it, whether or not there were any similar kinds of stress-related problems.
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    I mean, I think we're all sort of aware of PTSD and other issues that came as a result of the Vietnam War, but I'm wondering whether or not we ever saw anything like the degree to which we see these kinds of issues just in this particular conflict.
    Ms. KNOX. I just want to reiterate that we say stress is a contributing factor. We don't think it's the cause of Gulf War veterans' illnesses. And we recommend that further study needs to be done on the physiological response to stress.
    Mr. KENNEDY. I don't mean to cut you off, and I know that Dr. Russell has got something to say. But because my time is running out, what I do want to suggest is that when you are running a presidential commission on this issue, it has the weight of the entire Federal Government and the responsibility to sort of be almost the sort of final say in what has occurred.
    And I think that this is an issue that if you are not feeling that you have your arms around every possibly explanation, including whatever secret documents might be available, including every possible lead that should be run down to make the determination as to whether or not there is some kind of cause that has not been fully exposed to all of the veterans and to the American people, there's a responsibility that I think rests squarely on your shoulders. And anything that we can do to help you get that information, I think you should feel like you should come to us and ask for it. And this is an opportunity for you to do that.
    So I really want you to make sure that you answer the question whether or not you feel that you have at this time exhausted and have a full sort of accounting of everything that could possibly have contributed to this and whether or not we're at least in a process of having that be completely aired.
    Ms. KNOX. Well, I don't think we can ever have a full account of what occurred. Just as it took until 1996, to hear about Khamisiyah, I would think that there might be other things that might evolve or come about that we might discover at a later time. Hopefully we'll discover that before the end of our charge.
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    Holly, you might want to add to that. I don't— —
    Mr. KENNEDY. Well, Mr. Chairman, I'll finish up.
    But I just don't think it's acceptable that we have a circumstance where the presidential commission is not coming in and reporting back to the Congress as to the full extent of what this has been about.
    We've spent millions and millions of dollars. We still don't know what's going on. And here's the chairwoman of the committee saying that we're going to hear more and more about this in the future. I just think that this should not be as difficult a job as it seems to be coming across.
    The CHAIRMAN. I thank the gentleman.
    Dr. Cooksey, did you have a quick question?
    Dr. COOKSEY. Mr. Chairman, I know I've already had a question. Just a comment from someone who's older and been around a little bit longer and also is a physician.
    Some of us here are old enough to remember the days of polio. There were a lot of unanswered questions about polio. And when I was a kid, my parents did a lot of crazy things to protect me from polio. And we later found out the answers.
    I personally feel that veterans, particularly the Persian Gulf veterans, should have everything that they're entitled to in the way of a disability claim. But as physicians, we don't always know the answers to these questions. And I think that needs to be brought into perspective.
    Mr. KENNEDY. If the gentleman would yield just briefly?
    Dr. COOKSEY. And sometimes it takes the time to get the answers to these questions.
    Yes, I will yield.
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    The CHAIRMAN. If the gentleman has a direct response very quickly.
    Mr. KENNEDY. Yes, very briefly. You've been around on Earth a lot longer than I have, Doctor, but I have been around here long enough to know sometimes it's hard to get straight answers from people who come before this Committee and a lot of other committees. And it's good to keep your left hand high when you're dealing with them.
    Dr. COOKSEY. I've been here 10 years longer.
    The CHAIRMAN. The gentleman from Alabama, Mr. Bachus, is recognized.


    Mr. BACHUS. Thank you, Mr. Chairman. I do want to compliment you on holding this hearing. And I appreciate the panelists.
    I have a statement, but I don't want to take time on my views. I just want to get right to what y'all think, ''y'all'' being an Alabama express.
    Now, we had an ammunition dump that blew up in Iraq in March of 1991. And almost immediately when the Gulf War veterans returned, we had 40 or 50 thousand of them who were sick. And people started asking the question: Was there chemical exposure? And until June of 1996 we were told no. So you're talking about from March of 1991.
    There's now been a recognition by the Pentagon last June that as many as 20,000 of our troops were exposed to chemical exposure in the March 1991 incident.
    My question is this. Maybe I'll direct it to Major Knox. I want to commend the presidential committee on really coming to the conclusion that the Pentagon knew before June that there had been this exposure but they didn't say anything until June.
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    My first question would be to you. This was a concealment for some period of time. Does this constitute a coverup? I know that's a tough question.
    [The prepared statement of Congressman Bachus appears on p. 297.]
    Ms. KNOX. Well, I certainly think it generated mistrust on both the public and the veterans' view. The CIA was helpful as was UNSCOM in coming to that finding and bringing it to us. So certainly that's one of the biggest issues that has created this atmosphere of mistrust.
    Mr. BACHUS. But there was a concealment at the Pentagon of this chemical exposure.
    Ms. GWIN. We were able to pull together enough information for the committee to reach a conclusion that there was only a superficial effort, at best, to disclose the information.
    Mr. BACHUS. Well, that's a concealment.
    Ms. GWIN. Well, we did not go so far as to say there was any attempt to conceal.
    Mr. BACHUS. Well, wasn't their foot dragging? I mean, we were constantly asking: Were they exposed chemically? I mean, there was a concealment. What kind of military thinking led to a concealment like this or a coverup?
    Let me just ask you personally. Do you think there was a coverup?
    Ms. KNOX. Not personally, I don't.
    Mr. BACHUS. Do you think there was a concealment?
    Ms. KNOX. I think it was ineptness.
    Mr. BACHUS. Was what? Ineptness?
    Ms. KNOX. Yes.
    Mr. BACHUS. Over a major issue that was being debated in this country with 40 or 50 thousand sick veterans, there was just an ineptness?
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    Ms. KNOX. That's really difficult for me to answer.
    Mr. BACHUS. I can understand I'm putting you in an embarrassing situation, but can you see how we would conclude that there's been a coverup or concealment?
    Ms. KNOX. Yes, sir, I understand.
    Mr. BACHUS. And now let me move beyond that. Well, let me ask you this: What kind of military thinking led to this ineptness? Is the Pentagon inept?
    Ms. KNOX. I just said they were.
    Mr. BACHUS. All right. [Laughter.]
    Dr. Russell.
    Dr. RUSSELL. I have no knowledge of how the information was transmitted from the CIA, the origin of the information, at what level in the civil establishment we call the Defense Department. And I don't know where the fault lies.
    I must say our committee was very unhappy about having been kept in the dark.
    Mr. BACHUS. Right. Kept in the dark, foot dragging, concealment, coverup, whatever it was, what institutional changes do you think can be made at the Pentagon to see that this doesn't happen again?
    Ms. GWIN. This Committee has been extended in part to oversee the activities that DOD has put in place now. They have expanded their investigative team substantially, I guess almost tenfold. They have devoted much more money to the investigative effort as well as— —
    Mr. BACHUS. So you're sort of monitoring them and investigating the investigators or— —
    Ms. GWIN. We are overseeing their activities as well as trying to conduct some of our independent investigations so that we can make sure— —
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    Mr. BACHUS. Okay. Thank you.
    Let me ask another question. Now that we've got the chemical exposure and there's proven chemical exposure, now there's a question of the link between that and the illnesses that our veterans have. The University of Texas study that's come out recently appears, at least my thought is, that that conclusively provides a link between some of this exposure and some of these illnesses. Dr. Russell, is that?
    Dr. RUSSELL. I don't believe there—what has been proven is a release of chemical agent into the atmosphere when the munitions dumps were destroyed. Whether there was any true exposure or not has yet to be determined.
    Whether that population that was exposed has medical outcomes any different than the rest of the population that was in the Gulf anywhere near those dumps, I don't know the relationship between the patients that Dr. Haley studied and that monition dump. But I think I know that they weren't anywhere near there. So we can't draw any cause and effect relationship. No, sir.
    Mr. BACHUS. Would you agree that that was a significant study?
    Dr. RUSSELL. I think it was a significant study. It will require extensive follow-up and replication by other scientists.
    Mr. BACHUS. Thank you.
    And, finally, this is my last question. There have been reports that VA doctors who have studied the Gulf War Syndrome have been fired from the VA system. You all may have heard of those reports. They say that this was retaliation. Would you all make any comment? Are you aware of those reports?
    Ms. GWIN. We are aware of the reports. We have not reviewed as a committee the basis for them.
    Mr. BACHUS. Don't you think that should be done? And who should do that?
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    Ms. GWIN. The committee hasn't reached a conclusion about that.
    Mr. BACHUS. Would you take a look at that? Thank you.
    The CHAIRMAN. The gentleman from New Jersey, Mr. Smith, is recognized.


    Mr. SMITH of New Jersey. Thank you very much, Mr. Chairman.
    A couple of questions. And many of the more important questions have been asked already. And I appreciate my colleagues zeroing in on those questions. Major Knox, one of our witnesses today, Mr. Ford, will make the comment that a majority of the funded Gulf War studies and nearly half of those completed that were related to stress, that ''It's not surprising,'' to use his words, ''that the Presidential Advisory Committee found stress to be an important contributing factor.''
    And also in testimony today the commander-in-chief of the Veterans of Foreign Wars, Mr. Nier, states, ''We, the VFW, find it unfathomable as well as counterproductive to insist that stress is the predominant cause. These elements are nothing more than, in the veterans' heads, an insult.'' And then it goes on to develop that theme.
    How do you respond to that?
    Ms. KNOX. Well, again, in our report we state that we need to look at stress in more detail, the physiological effects of stress. And that was one of the largest areas of funding that DOD did. Of course, the results of that are not in.
    But that was one of the three findings that we made that stress was a contributing factor. We do need to look at PB and the synergistic effects and also low-level chemical exposure.
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    Mr. SMITH of New Jersey. Again, Mr. Ford raises a question today—and, again, looking at their testimony, they do raise some questions that ought to be highlighted here—that ''The Presidential Advisory Committee's findings are questionable because it included individuals who are not scientists and because it relied heavily on government-provided information.''
    How do you respond to that, particularly the latter part of that?
    Ms. KNOX. As I said in my opening statement, all of the panels that we heard had peer-reviewed research included. Our committee includes scientists.
    Mr. SMITH of New Jersey. So you believe you had sufficient resources to do the job?
    Ms. KNOX. I think we did.
    Mr. SMITH of New Jersey. Let me ask one final question. Your committee recommends that the VA should seek statutory authority to treat veterans and their families for reproductive problems caused by their service connection. You don't include abortion in this list of services, do you?
    Ms. KNOX. I'll have to refer— —
    Ms. GWIN. The service we specifically identify is genetic counseling.
    Mr. SMITH of New Jersey. Okay. But what about abortion?
    Ms. GWIN. The committee did not consider abortion. We specifically recommended that genetic counseling be included in this.
    Mr. SMITH of New Jersey. Okay. Thank you. I yield back the balance of my time.
    The CHAIRMAN. Thank you, sir.
    The gentle lady from Idaho, Ms. Chenoweth, is recognized for 5 minutes.
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    Mrs. CHENOWETH. I won't be using my 5 minutes. I just have one question. But I do have a statement that, with your permission, I'd like to enter into the record.
    The CHAIRMAN. Certainly will.
    [The prepared statement of Congresswoman Chenoweth appears on p. 314.]
    Mrs. CHENOWETH. Thank you, Mr. Chairman.
    My question is this to Ms. Knox: Can you foresee that any of the records involving this subject in the Pentagon would be considered classified or would have any other kind of classification on them so that people would hesitate to send them to either us or to people who have been suffering from Gulf War Syndrome, their own records with regard to medical records?
    Ms. KNOX. Is your question: Would the medical records be classified?
    Mrs. CHENOWETH. Either medical records or procedures that this Committee may want with regards to how things are handled.
    Ms. KNOX. Not that I'm aware of.
    Ms. GWIN. The only medical records that we came into contact with that had at one time been classified were the records of the vaccines, Anthrax and botulin toxoid vaccines, that were given to the troops.
    Mrs. CHENOWETH. Ms. Gwin, do you see any problem with that now? Is it the policy of the Pentagon and the Department of Defense to make sure that any patient who requests medical records or who requests information with regards to procedures or vaccinations or anything be afforded that information?
    Ms. GWIN. We believe the policy of DOD and VA is to make medical records available to the individuals to whom those records apply.
    Mrs. CHENOWETH. Mr. Chairman, I do have records here that have been stamped that read, ''These documents or records or information contained herein are deemed confidential and privileged under provisions of 38 USC 3305 and VA Regulation 6500 through 6540, which provides for fines up to $22,000 per violation.'' This material shall not be transferred to anyone without proper consent or authorization as provided for by law or regulation.
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    And I know that the Committee through the subpoena process can probably eventually get what we need. But I am also concerned that the process is not set up in DOD or the Pentagon. So our veterans cannot get all the records that they need to— —
    Ms. GWIN. I am not absolutely sure, but I think that citation is to a Privacy Act concern, not to classification.
    Mrs. CHENOWETH. Thirty-eight USC 3305?
    The CHAIRMAN. The Chair I think can answer that, I think there's a statute that prevents the VA from releasing these records. It's kind of like the Privacy Act—it does not prohibit the individual from seeing it, but the VA cannot release those records to other people.
    Mrs. CHENOWETH. Okay. Mr. Chairman, my concern is that the victims of Gulf War Syndrome had a very difficult time in getting their own records or because this was stamped on their records. And people who would have otherwise issued them didn't want to be fined $20,000.
    The CHAIRMAN. In my understanding, that should not be the case for the individual to get his records. He is certainly eligible to get those records.
    Mrs. CHENOWETH. Well, Mr. Chairman, that's the reason that I wanted to be sure and bring that up now— —
    The CHAIRMAN. Thank you.
    Mrs. CHENOWETH (continuing). So that it won't happen in the future.
    Mr. EVANS. Mr. Chairman, I also understand, at least during my time, the service said you had all your medical records that you took with you from command to command and when you were discharged, they hold onto them. But you can easily obtain those. If that's a problem, individuals should see their local member of Congress.
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    Mrs. CHENOWETH. Thank you. And, Mr. Chairman, I will be entering this also in the record later.
    The CHAIRMAN. Thank you.
    The CHAIRMAN. Mr. Bachus, you got here just in time to be the last one on this panel. Thank you, sir.
    Dr. Russell and Major Knox, Ms. Knox, and Ms. Gwin and Mr. Brown, we thank you for your time this afternoon. There will probably be questions from members and staff of the Committee. We would appreciate a rapid response, if you would, please. And thank you very much.
    Dr. RUSSELL. Certainly.
    Ms. KNOX. Thank you, sir.
    The CHAIRMAN. Our next witness is Commander Nier. And while he's coming up, let me remind the members that this first panel has taken a little over an hour and a half. If you could, please refrain from asking other members to yield so as to not use their time. It would be appreciated if we move very rapidly through this. We have four panels to go.
    Commander Nier is the Commander-in-Chief of the Veterans of the Foreign Wars. We're happy to have you with us, Commander. And, if you care to introduce anyone or if you want to proceed, your entire statement will be made a part of the record. If you can summarize, it would be appreciated.
    Mr. NIER. Thank you, Mr. Chairman, and members— —
    The CHAIRMAN. Let me just give it one second for these members so as not to be interrupted.
    Go ahead, sir.
    Mr. NIER. Thank you, Mr. Chairman, members of the Committee.
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    Mr. NIER. Yes, I would like to introduce the two gentlemen who are with me. On my left and your right, Mr. Ken Steadman, the Executive Director of our Washington office; and on my right and your left, Mr. John Gwizdak, my legislative chairman from the great State of Georgia.
    The CHAIRMAN. Thank you, sir.
    Mr. NIER. As you are aware, it was my privilege earlier today to express the views of the Veterans of Foreign Wars before a joint hearing on the Committees on Veterans' Affairs regarding veterans programs and entitlements. It is now my honor to come before this Committee on behalf of a very special segment of the veteran population: those brave young men and women who served so honorably and well in the Persian Gulf.
    A number of these individuals are suffering from as-yet-undiagnosed disabilities collectively known as Gulf War Syndrome. The VFW is unalterably committed to seeing this Nation spare no effort in coming to the aid of these veterans. We insist that Persian Gulf veterans receive all the health care and compensation that is there due.
    Yesterday afternoon the VFW hosted a major forum within the context of our Washington conference addressing Gulf War Syndrome held at the Sheraton Washington Hotel and facilitated by VFW staff. senior representatives from the President's advisory committee, DOD, the VA, Centers for Disease Control, and concerned VSOs took part. I can tell you that this forum was an enormous success. And we fully intend to continue in this vein.
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    The VFW has for some time pushed for the extension of the life of the President's Advisory Committee on Gulf War Veterans' Illnesses, which has served so ably in overseeing and coordinating the effort to resolve this issue. We are highly gratified that the President has heeded our request by extending the committee's operation another 9 months.
    While Gulf War Syndrome is now fully recognized in the scientific and medical communities as a legitimate disease, its cause and cure have continued to remain elusive. One serious obstacle to properly resolving this issue has been its far-from-adequate handling by the Department of Defense.
    At least early on, DOD simply refused to give Gulf War veterans' own reports of ill health symptoms and possible toxics exposure episodes the credence they deserved. Further, DOD's failure to come forward in a timely manner with information showing that a large number of our troops in the Gulf may have come into contact with chemical and biological agents has surely impaired relevant scientific research.
    Perhaps even more detrimental, however, is the climate of uncertainty and even distrust this has created among Gulf veterans themselves. Many perceive themselves to have been deliberately deceived and will call will into question almost information that COD now provides. This has rendered an already troublesome issue much more difficult and indeed represents an affront to the sacrifice and service of all of this Nation's veterans.
    The VFW demands that all relevant data on the Gulf War experience be provided to the appropriate scientific and public entities as soon as it comes to light.
    The VFW is also deeply concerned over the high denial rate for Gulf veterans seeking VA compensation for undiagnosed illnesses. While it is our understanding that some of these veterans now receive compensation for diagnosed disabilities, the 95 disallowance rate for undiagnosed illness claims strikes us as implausibly high.
    We insist that no Gulf veteran in need be left out in the cold because of our as-yet inadequate understanding of Persian Gulf Syndrome. An important step in this regard would be the expansion of the current 2-year presumptive period in which Gulf War Syndrome must manifest in order for a veteran to receive VA compensation. In light of the medical, scientific, and factual uncertainty surrounding this issue, this manifestation period is both overly restrictive and scientifically unsound.
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    The VFW urges the immediate establishment of an open-ended presumptive period for Gulf War Syndrome. The VFW also supports the establishment of a case definition for Gulf War Syndrome. This would, at the very least, allow veterans benefit administration to take individual symptoms associated with service of the Gulf under consideration collectively.
    Whereas, when taken individually these disabilities may not fall within their assigned manifestation periods, taken together they may represent a compensable manifestation of Gulf War illness. Further, this would compel VA doctors to more thoroughly assess the etiology of Gulf veterans' disabilities, thereby improving the rating process.
    Mr. Chairman, it would be remiss of me if I did not at this time commend the strong bipartisan effort of the Congress as well as the administration in addressing this issue. Standing in stark contrast to the handling of Agent Orange many years ago, this Nation's lawmakers have been swift and vigorous in working to provide veterans suffering from Gulf War Syndrome the care and compensation they need and they deserve.
    I thank and congratulate you for your accomplishments thus far. Be assured the Veterans of Foreign Wars will continue to work together with you and will not relent until the Persian Gulf issue is fully resolved.
    Thank you very much.
    [The prepared statement of Mr. Nier appears on p. 326.]
    The CHAIRMAN. Commander, thank you for your statement. We look forward to working with you and your membership.
    Do any members have questions? Mr. Evans?
    Mr. EVANS. No, Mr. Chairman.
    I appreciate the commander's insistence that we extend the filing date. That's very important. I hope we'll work on that in this Congress.
    Thank you, Mr. Chairman.
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    The CHAIRMAN. Mr. Quinn, I'm just going to bounce back and forth. I don't know. Any questions of the commander?
    Mr. QUINN. Thank you, Mr. Chairman.
    No questions at this time. We heard your testimony this morning at the hearing, Mr. Commander. We appreciate your time very, very much.
    Mr. NIER. Thank you very much, sir.
    The CHAIRMAN. Mr. Kennedy.
    Mr. KENNEDY. Thank you, Mr. Chairman.
    Commander, first of all, I wanted to just apologize for not being able to be with you this morning. I was at a meeting at the White House. And I apologize for not being there, but I look forward to having an opportunity to read your testimony.
    Further, I just wanted to ask one brief question, which is whether or not your current sense of the health care that is being provided to the veterans that are a part of your organization that have this particular syndrome is, in fact, being dealt with adequately by the VA.
    Mr. NIER. No, sir, we do not. We think it's inadequate. It's our goal to ensure that these veterans receive the care and compensation they deserve. And right now we're not happy with the 95 percent disallowance rate.
    Mr. KENNEDY. Can you just explain a little bit more about what you feel the implications of that 95 percent rate are? In other words, why are they being turned down? Is your sense that there is still an attitude by the VA itself of not recognizing this as a legitimate illness or what is your sense of why people are not getting properly cared for?
    Mr. NIER. It's my sense, sir, that it's the presumptive period. That's why we want it extended.
    Mr. KENNEDY. But the presumptive period because Mr. Evans and I and the Chairman worked on this last year would only cover, as I understand that issue—Mr. Chairman, maybe you can help me if I'm wrong about this, but I thought that that only dealt with those individuals who would be coming forward now who had not previously felt that they had illnesses that related to their service in the Gulf. Is that really the only category of veterans that you're suggesting are not being properly cared for or are there, in fact, others who are just going in and are feeling like they're not getting—you know, they go in and they say, ''Listen, I've got these complaints,'' that they did, in fact, register but they're just not getting the proper care?
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    Mr. NIER. Yes. Our concern is, Senator, that it could be when the— —
    Mr. KENNEDY. My uncle would not be pleased with that one, Mr.— —
    Mr. NIER. I'm sorry.
    Mr. KENNEDY. The Chairman probably would be just as happy to have me move out, but anyway.
    Mr. NIER. Sorry. The coming forth of the veterans with individual symptoms may not have been granted the compensation. We feel that they now should be looked at with collective symptoms. And perhaps they would be eligible for the compensation and care.
    Mr. KENNEDY. I could pretend I understood what you just meant by that. Can you just explain that for a second, please?
    Mr. NIER. Well, they could have come forth early on with a symptom that was not recognized as compensable by the VA.
    Mr. KENNEDY. I see.
    Mr. NIER. Later they may have come forth with more symptoms that looked at collectively may— —
    Mr. KENNEDY. I see. But it is really the category of veterans that have the requirement or the need to actually declare themselves victims of the syndrome at this stage, rather than people who have been treated in the past who have declared themselves to be victims of the syndrome. You're feeling that those veterans, which I think would be the vast majority of the ones that are being cared for by the VA, are getting adequate care? I'm just trying to get an understanding of what you're suggesting.
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    Mr. NIER. I think so, yes, sir.

    [The information follows:]
    To date, approximately 2000 Guard/Reserve members have completed diagnostic evaluations through the CCEP; however, the number of individuals who may be in need of follow-up care is unknown. Guard/Reserve personnel have limited entitlement to follow-up treatment within the MHSS unless they have a medical condition which can be shown to be service connected according to strict criteria. Provisions of Public Law entitle any Persian Gulf veterans who may have been exposed to a toxic substance or environmental hazard to receive follow-up care through the VA. The Department will be working with VA to make certain that Guard /Reserve personnel evaluated through the CCEP are aware that they may apply for follow-up care through the VA system.

    Mr. KENNEDY. Yes.
    Mr. NIER. Right.
    Mr. KENNEDY. Okay. Thank you very much.
    The CHAIRMAN. Dr. Cooksey, do you have questions?
    Dr. COOKSEY. No, no questions. Thank you.
    The CHAIRMAN. Thank you, sir.
    Mr. Peterson, no questions? Who's next? Mr. Bilirakis, do you have a statement?
    Mr. BILIRAKIS. Just one, Mr. Chairman. I guess it's more a follow-up to Mr. Kennedy's.
    Is it your feeling, your strong feeling—I know you referred to the study, the presumptive period. But is it your strong feeling that if that were extended, that it would probably pick up an awful lot of the disallowances— —
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    Mr. NIER. Yes, sir.
    Mr. BILIRAKIS (continuing). By the problems?
    Mr. NIER. Yes, sir.
    Mr. BILIRAKIS. Do you have any feeling as a result of your own research and whatnot as to what that period should be?
    Mr. NIER. Yes. We have our own Gulf War registry. And we are really pursuing this issue within our organization.
    Mr. BILIRAKIS. Okay. But you have no recommendation to this Congress in terms of whether it should be 3 years, 4 years, or——
    Mr. NIER. Open-ended. Yes, sir, we do.
    Mr. BILIRAKIS. Open-ended?
    Mr. NIER. Open-ended. Yes, sir.
    Mr. BILIRAKIS. I see.
    Mr. NIER. That's our recommendation.
    Mr. BILIRAKIS. All right. Thank you. Thank you, Mr. Chairman.
    The CHAIRMAN. Dr. Snyder? No questions. Mr. Peterson? No questions. Bob Filner?
    Mr. FILNER. Thank you, Mr. Chairman.
    I apologize for missing your statement. I heard you this morning. So I'm sure I agree with everything you said. But let me tell you why I missed your statement. And I'd like to have some advice on this because it seems to exemplify the problems that people are dealing with or having with the establishment, as it were, the folks who are supposed to be helping us out of this.
    I was meeting with a couple of your members from California, very serious people, looked to me very credible,—they had one of your hats on; so I assume they were very credible—explaining to me that a set of doctors that they knew working both in Texas and in California had because of relatives who had come down with these symptoms got very personally involved with the research, et cetera, and had developed some laboratory tests that involve tests that most doctors wouldn't either know about or how to do. They have to do with white cell testing, DNA prints, and claim to have been able to diagnose the set of symptoms in some very precise ways and then treat them in very successful ways. And they have case studies now up to 6,000. The way they relayed it to me they have not been able to get an official hearing on what exactly they're doing and the success they've had.
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    Now, does that sound credible to you, that story? and what is the problem with people who are seeming to make gains in this not getting a respectful hearing about things that might help thousands and thousands and thousands of people? Does this story sound at all credible?
    And what should we do about it? I'd like to ask both you and the Chair: If there is something to this, how do we get these stories out here?
    Mr. NIER. I do not know. I can't respond to the credibility. I would think it is, sir, if it came from VFW members. Who were they asking for the hearing with? I'm not quite sure.
    Mr. FILNER. I didn't have time to go over the full story because I want to come back and talk to you. But they were explaining their studies had been submitted to the Pentagon and to the commissions. And people were just not paying any attention because these were not doctors within the normal network or the normal establishment, as it were.
    Mr. NIER. I am just being told that we have encouraged the VA to look into this. It's a Mr. Garth Nicholson, I believe you said, a microbiologist?
    Mr. FILNER. I think so.
    Mr. NIER. So that story is, in fact, credible. And we are encouraging the VA to meet with them, sir.
    Mr. FILNER. I hope we as a Committee or as a group could encourage that. It sounded to me to be very real. The response that they have encountered sounded to me typical of some of the defensiveness and inability to accept things outside the normal chain of command but might have success. At least it's worthy given what we are dealing with as a nation of some interest.
    The CHAIRMAN. Mr. Filner, we have members of the VA here today. And you can ask them that question.
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    Mr. FILNER. Thank you very much. I appreciate it.
    I yield to Mr. Evans, please.
    The CHAIRMAN. Mr. Evans.
    Mr. EVANS. I understand Garth Nicholson's concerns are being. investigated by the United States Army at this point, not the VA, that they're looking into it.
    Mr. FILNER. I am not certain this is the right name or not, frankly, but we— —
    Mr. EVANS. Is that the name?
    Mr. FILNER. I'm not sure. That's what they think they— —
    Mr. NIER. It is one of several, sir.
    Mr. EVANS. The VA is also funding some studies. I think you can direct your questions to them when they come up— —
    Mr. FILNER. Fine. Thank you.
    Mr. EVANS (continuing). About some studies that they are going to fund in the next fiscal year.
    The CHAIRMAN. Are there other questions? Mrs. Chenoweth? Mr. Bachus? Spencer?
    Mr. BACHUS. Thank you.
    Commander, this 95 percent that we hear, is this of all disability benefits or these are just the mysterious illnesses, undiagnosed, or is this all of them?
    Mr. NIER. All of them, sir.
    Mr. BACHUS. But that's the total of— —
    Mr. NIER. That's correct.
    Mr. BACHUS (continuing). Over what? Over 7,000. And we've only had about 400 of them honored?
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    Mr. NIER. Right.
    Mr. BACHUS. Are you familiar that the GAO took a look at that, the reasons for these denials? Have you all reviewed the GAO's—do you all have any comment maybe on the GAO study?
    Mr. NIER. Go ahead, Mr. Steadman.
    Mr. STEADMAN. Sir, we are familiar with that. Our staff is reviewing that currently, taking a look at what GAO had to say about it.
    Mr. BACHUS. How does this 95 percent figure, say, correlate to earlier wars and disability claims under those wars, say Vietnam?
    Mr. NIER. We think it's inordinate, but I would suggest you ask the VA that, sir.
    Mr. BACHUS. Okay. I think it would be important to— —
    Mr. NIER. Yes, sir.
    Mr. BACHUS (continuing). Take a look at how it varied.
    Also, we did note that a lot of the veterans were never told that they had to give evidence that this manifested itself within 2 years, which we have now extended. Do you think this played a big factor? Do you think— —
    Mr. NIER. Yes, definitely.
    Mr. STEADMAN. One of the Presidential Advisory Committee's interim findings was that both DOD and VA needed to expand their outreach efforts.
    Mr. BACHUS. Thank you.
    The CHAIRMAN. Thank you, sir.
    Mr. Bishop, did you have any questions? You're the last one on this panel or we'll go to the next panel if you don't.
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    Mr. BISHOP. No, no. I'll pass.
    The CHAIRMAN. Thank you, sir. Gentlemen, thank you. Commander, we hope to see you later on this evening.
    Mr. NIER. Thank you, Mr. Chairman.
    The CHAIRMAN. If we could have the third panel, then, please, to come up? Dr. Garthwaite, the Deputy Under Secretary of Health, Department of Veterans Affairs;—this may be the appropriate time to ask that question you just asked, Spencer—Dr. Rostker, special assistant to the Deputy Secretary of Defense for Gulf War Illnesses from the Department of Defense; and Dr. Jackson at the National Center for Environmental Health, Centers for Disease Control and Prevention, Department of HHS.
    Gentlemen, your entire statements will be submitted for the record and will be printed in the record in full. We would appreciate it you could summarize within the 5-minute time limit. Dr. Garthwaite.



    Dr. GARTHWAITE. Thank you, Mr. Chairman and members of the Committee. I am pleased to have this opportunity to update you on VA's Persian Gulf War-related programs.
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    VA continues to improve and expand our efforts to meet the needs of Persian Gulf veterans using a four-pronged approach, including medical care, research, compensation, and education. Each of these areas also involves significant efforts at outreach to Persian Gulf War veterans. The department is on record regarding its accomplishments in each of these areas, and I would like to highlight our progress and note our recent initiatives and plans for the future in each area.
    With regard to medical care, the VA's clinical response to Gulf War veterans includes completed registry examinations on 63,000 Persian Gulf War veterans, 1.8 million outpatient visits for 191,000 veterans, hospitalizations of 19,000 veterans, comprehensive evaluation at Persian Gulf War referral centers for 350 veterans, and counseling for 74,000 veterans at VA Readjustment Counseling VET centers.
    The Presidential Advisory Committee agreed with the Institute of Medicine's conclusion that the clinical evaluation programs of the VA and Department of Defense are excellent for the evaluation and diagnosis of Gulf War veterans' illnesses. We believe, however, that we need to enhance the consistency of treatment of Persian Gulf War veterans and have implemented several initiatives aimed at improving care.
    First, we are about to release a self-study program for physicians which will serve as a supplement to our current educational efforts.
    Second, our customer feedback center is developing patient satisfaction surveys which will target Persian Gulf War veterans. The center has surveyed more than 200,000 veterans overall, and their data is a critical part of our expanding performance measurement system. We will focus this resource on Persian Gulf War veterans.
    Third, we have developed quality indicators and performance standards for Persian Gulf War examinations. The results of these ongoing assessments will guide additional program changes in our educational efforts.
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    Fourth, I am pleased to announce that we are establishing service evaluation and action teams in each of our 22 Veterans Integrated Service Networks (VISINs). These teams are being formed to improve communication with veterans and to improve the responsiveness of VA health care delivery. These initial teams will be piloted with Persian Gulf veterans.
    The teams will provide a mechanism for each network to continuously assess opportunities to enhance the effectiveness of VA clinical programs and respond to veterans' concerns. The teams, comprised of at least eight members representing a variety of disciplines and interests, including veterans, quality improvement specialists, patient representatives, and clinicians, will listen to and monitor trends in veterans' concerns about health care access, appropriateness of care and quality, and fulfillment of VA mandates. The information on reported concerns and recommendations for resolution will be referred to local medical center staff for action.
    With regard to research, VA, as lead agent for federally sponsored Persian Gulf War research programs, has already laid the foundation for a comprehensive research plan. Together with the Persian Gulf War Veterans Coordinating Board's Research Working Group, VA has developed a structured research portfolio of more than 80 projects to address the currently recognized highest priority medical and scientific issues.
    VA's own research program related to Persian Gulf War veterans' illnesses includes more than 30 individual projects being carried out nationwide by VA and university-affiliated investigators.
    With the potential of exposure of some troops to low-dose sarin and cyclosarin as a result of the demolition at Khamisiyah, the Coordinating Board has revised its action plan. The modified plan will address possible long-term health consequences of low-level exposure to chemical warfare, neurotoxins, and mustard gas.
    A recent review of the published scientific literature carried out by independent, nongovernment and government scientists suggests that readily identifiable long-term adverse health effects due to nerve agent exposures only occur in humans who show signs of acute toxicity or poisoning. However, research in this area is sparse and the absence of proof is not proof of absence.
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    In VA's judgment, this information does not preclude the possibility that clinically important adverse health effects occur in the setting of low-level neurotoxin exposures, especially if combined with other components or environmental stressors. The Coordinating Board has recommended that more research resources be allocated to address this question, and we strongly agree with this approach.
    Based on the Coordinating Board's recommendation, the newest recommendations from the Presidential Advisory Committee have been already incorporated into the Coordinating Board's latest research working plan, including investigation of the potential chronic health effects of low-level chemical warfare agent exposures, expanded research on the physiologic effects of non-traumatic and traumatic stress and investigations of the effects of pyridostigmine bromide in combination with other exposure agents.
    Funding for these new efforts will come from DOD's appropriation. And a copy of them has been provided to the Committee.
    In concert with the Coordinating Board's recommendations, VA's research service is developing a strategic plan for an environmental health research agenda that specifically focuses on low-level exposures. To enhance the scientific dialogue amongst researchers, VA has organized a symposium on exposure to neurotoxins which bridges both military and civilian incidents and related research. At this symposium next month, a multidisciplinary group of experts from around the world will meet to focus on finding innovative solutions to these perplexing problems.
    VA and DOD are partnering to expand their portfolios on stress-related research through the cooperative research program.
    With regard to compensation, Mr. Chairman, as you know, we have a special provision of law governing compensation of undiagnosed illnesses. VA strongly supported Public Law 103–446 to allow VA to pay compensation to any Persian Gulf veteran with a chronic disability resulting from an undiagnosed illness.
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    In the regulation implementing the statute, we establish a 2-year presumptive period. There have been growing concerns that the 2-year presumptive period for undiagnosed illness may no longer be appropriate. Some veterans are reporting even now that they are experiencing, for the first time, unexplained illnesses that they believe are related to their service in the Persian Gulf.
    Because of these concerns, the Secretary recommended to the President in early January that the issue of the presumptive period be revisited. On January 7, the President announced that he had approved this recommendation and asked Secretary Brown to report back to him in 60 days.
    During the 60-day period, the Secretary is gathering as much information as possible from veterans, veterans' service organizations, members of Congress, and VA officials. The Secretary will provide advice to the President with regard to extending the presumptive period by March 8, 1997.
    In the area of outreach and education, VA has a national training program for VA staff, including clinical meetings, satellite video conferences, teleconferences, printed fax sheets, and the planned self-study course I mentioned above. In addition, the Persian Gulf review is sent quarterly to a large mailing list, including all veterans on the Persian Gulf registry. The Persian Gulf hotline provides veterans and their families with a link to services and information available to Persian Gulf veterans.
    Risk communication will be an emphasis in both VA's education and outreach programs. Coordination with DOD will occur to the Persian Gulf Coordinating Board's clinical working group.
    VA vet centers, which were cited by the Presidential Advisory Committee as models for outreach, will be utilized in applying their time-proven strategies to risk communication and outreach to specific Persian Gulf populations.
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    In 1996, VA purchased satellite time to conduct one-on-one interviews with TV stations in top media markets for prime-time viewing. And we'll use this approach for future risk communication.
    In response to the Presidential Advisory Committee interim report, VA hired a media marketing firm to distribute to print, radio, and television public service announcements and to provide follow-up reports on market penetration. This will be continued in 1997.
    The Presidential Advisory Committee recommended that VA pay special attention to bilingual communications in areas with specific Latino populations. In 1996, VA published the first Spanish language version of ''Federal Benefits for Veterans and Dependents.'' VA will also conduct Spanish language print, radio, and television interviews targeting Persian Gulf veterans.
    The Presidential Advisory Committee also recommended special attention to women veterans. This has been a commitment of VA for many years. The VA women veterans' health programs have included Persian Gulf information in their national training program. Vet centers also include women veterans as a specific population for outreach related to readjustment counseling. This will continue.
    VA is also conducting a thorough review of its reproductive health policies, including genetic counseling, as part of our eligibility reform package or as part of our writing regulations for the eligibility reform package passed by this body. The Presidential Advisory Committee recommendation will receive serious consideration as part of this review process.
    In closing, I would like to thank the Presidential Advisory Committee for the thorough, in-depth review they provided to the complex issues of Persian Gulf veterans' illnesses and the thoughtful recommendations they have made to further address them. They have provided a significant service to the veterans of that war and to those responsible for caring for them.
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    That concludes my statement, be happy to answer your questions.
    [The prepared statement of Dr. Garthwaite appears on p. 329.]
    The CHAIRMAN. Thank you, Doctor. We'll continue on through the panel and then get to the questions.
    Dr. Joseph from Department of Defense.
    Dr. JOSEPH. Thank you, Mr. Chairman. It's a pleasure to be here.
    My statement is long and detailed. And, with your permission, I'd submit it in its entirety for the record and very, very briefly summarize and then come back to take your questions and comments.
    The CHAIRMAN. Thank you, sir. We appreciate it.


    Dr. JOSEPH. I am going to comment on four areas. The first is an overview, a history of the clinical and health research activities we have undertaken in the Department of Defense.
    Second, I will say a few words about research, although I think Mr. Garthwaite has covered that ground very thoroughly.
    Third, I want to make some comments about specific steps that we took on the medical side after learning of the Khamisiyah incident.
    And then, finally, I'll say something about changes we have made in the Department's medical force protection and surveillance activities. I will go into more detail on that if you want, although it may be a little peripheral to this Committee's specific hearing today. But, the question keeps coming up, and I'm sure you heard it earlier today from the Presidential Advisory Committee: What have we learned from the Gulf experience that we'll put into place to protect future deployments?
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    We began in the Spring of 1994, several weeks after I was confirmed, to build a health and medical research activity. We first began with what has become known as our Comprehensive Clinical Evaluation Program.
    At that time, the department had nothing in place. We began by working very closely with the model that the VA had begun developing somewhat earlier. Our first consideration was providing care to our people, taking care of the Persian Gulf veterans with symptoms and illnesses.
    We set up a hotline, and began the CCEP program, again, with close coordination with the VA. That program has grown into a program that now has had 38,000 people registered, almost 30,000 receiving very sophisticated medical evaluations. And, as was previously said, all the groups that have looked externally at the VA and our own clinical programs—the Presidential Advisory Committee, the Institute of Medicine, et cetera—have given us very high marks for those activities.
    We always say when we talk about them that these are not rigorous research programs. They were developed to take care of our people in the first instance. Second to use that experience, now a very large experience of some 60,000 people on the clinical side, to give us insights and signposts and guidelines in terms of the directions that we need to proceed in with regard to these symptoms and illnesses.
    You've heard earlier from the PAC—and you will hear it wherever you look—at the VA, at the DOD's clinical programs, at the Institute of Medicine, there is a very strong unanimity of findings coming out of the clinical program. The most important one is that there is no evidence for a single or unique illness. There is not a Gulf War Syndrome. Rather what there is, is a broad and large collection of symptoms and illnesses due to a variety of causes that do not fit a case definition. They certainly do not fit a single cause or etiology as the explanation for most, or any great part, of the illnesses.
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    As we set up this clinical evaluation program, we also had an external independent, highly credible person—the dean, at the time, of the Tulane School of Public Health—look at our plans for the program, we wanted him to look over our shoulder.
    At that same time we asked the Institute of Medicine of the National Academy of Sciences to set up a small committee—different from the larger research committee that they have set up to follow along with us—to look over our shoulder, critique our efforts, see whether they thought we were on the right road with our clinical evaluation protocol, itself, and also our conclusions. I believe that's probably been helpful to the VA as well.
    This is ongoing. And it's especially important since Khamisiyah. As I said, we now have about 38,000 people on the registry.
    With research, the only thing I would add to what Mr. Garthwaite has said is to stress again the importance of the Persian Gulf Veterans' Coordinating Board and the kind of research coordination that has enabled the agencies, principally VA and DOD but also HHS, to get a focus on where we're going and where the gaps are and to avoid duplication.
    The DOD will spend $27 million this year on Persian Gulf illnesses research, specifically focusing on the areas that Mr. Garthwaite mentioned.
    With Khamisiyah, the rules changed. Our awareness changed, and our concerns about whether or not there was probable evidence of exposure to chemical weapons changed. We immediately took a series of medical steps to go back and look at those people we already evaluated in the CCEP; those who belonged to units that we judged to have been in the Khamisiyah area to see if, with that different knowledge through hindsight, we might find different patterns. Patterns that we had overlooked before.
    To cut to the chase, in various other reviews and new listings of patients plus correlating CCEP participants with Khamisiyah, the only thing that I would say is: we see no pattern emerging that would show those people on our clinical register who were at Khamisiyah, or presumed to be at Khamisiyah, looking any differently in terms of their symptoms or their diagnosed illnesses.
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    Finally, about 2 years ago—and I wholeheartedly welcome the PAC statements on this issue—we began a change, in a very major way, the means by which we medically protect our people when they are going to deploy.
    Should you be interested, I'll go through the list of things that we now do pre-deployment: better education, better health assessments, personnel registers; during deployment: laboratories in the field for preventive medicine surveillance, environment surveillance, combat stress teams in the field; and then, post-deployment: health assessments, psychological questionnaire, and serum specimens in the bank, plus an enhanced level of electronic telemedicine capability to watch people's health during deployments.
    We have implemented this during Bosnia. The Bosnia deployment is very different, in terms of force protection from a medical point of view, than previous deployments have been.
    And, by the way, our experience in Bosnia on the illnesses side has been very, very good—really extraordinarily good. The illness rate in Bosnia has been lower than the average illness rates of troops in CONUS without deployment.
    I'll stop there. I'll be happy to go back and pick up any of the areas you wish to talk about.

    [The prepared statement of Dr. Joseph appears on p. 344.]
    The CHAIRMAN. Thank you, sir. We may get into some of these others at a later hearing in more detail.
    Dr. Rostker from the Department of Defense.

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    Dr. ROSTKER. Mr. Chairman, thank you for the opportunity to appear before the Committee this afternoon. As you know, the Deputy Secretary of Defense, Dr. John White, appointed me Special Assistant for Gulf War Illnesses on November 12, 1996.
    As a special assistant, my first priority is the health and welfare of our veterans and our troops. In this capacity, I serve as the DOD coordinator for all issues relating to Gulf War illnesses.
    I see the Gulf War illnesses mission in three parts: first, to ensure that all who served in the Gulf receive appropriate medical care; second, that DOD does its part to ensure that we conduct a complete and thorough investigation to determine why so many of our veterans are ill; and, third, to apply our findings to future deployments.
    The guidance from President Clinton is clear. He said, and I quote, ''I want to assure all of you that we will leave no stone unturned in our efforts to investigate Gulf War illnesses and to provide our Gulf War veterans with the medical care they need. There are mysteries still unanswered, and we must do more.'' I make it my business every day to leave no stone unturned.
    To carry out this important task entrusted to me by the Deputy Secretary, I have expanded by an order of magnitude the Department of Defense's investigative organization. The original team of 12 has been subsumed by a larger, more focused organization. And I have completely revamped the way we do business.
    We are ensuring that we have the investigators and the analysts necessary to fully review current known episodes and I have the authority to search out and pursue reports of new incidences.
    I have expanded into new areas to initiate a proactive risk communication strategy with two-way communications between the DOD and VA and the veterans as recommended by the President's Advisory Committee that you heard from earlier.
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    Today when a veteran calls our telephone hotline to offer information, the veteran receives a follow-up call and is interviewed by a trained investigator, who ensures that information is incorporated into our case files. We are making significant strides in eliminating our backlog in all types of communication and in calling back to our veterans. These callbacks not only provide an in-depth debrief but for the future establish a dialogue between a single point of contact in my office and the reporting Gulf War veteran.
    We are also placing e-mail capability on our GulfLINK Web site, which will enable us to be even more responsive to the concerns of our veterans and to more easily involve them in the investigative process. All of these actions contribute to increasing our understanding.
    We also collaborate very closely with the veterans' service organizations to increase their knowledge about potential exposures during the Gulf War. For example, on December 11, 1996, we hosted the VSOs at a demonstration of the protective gear and chemical equipment used during the Gulf War, particularly the M–8 alarms, 256 test kits, and the Fox chemical reconnaissance vehicles. They indicated to us that they appreciated the opportunity to become more familiar with the equipment that has often been described in the media and was the subject of congressional debate.
    Additionally, on January 30, last week, we hosted a group from the VSOs to tour our new office complex and callback operations, which allowed them the opportunity to meet with our people and to focus on our operations.
    We have also formalized the structure for our incidence investigation. We are now preparing a series of case narratives that summarize what we know about such incidents as Khamisiyah, the Marine breaching operation, operational logs, Fox alarms, pyridostigmine bromide, and every other issue under investigation. And I'd like to add that within the next week, we expect to publish our first case narrative on Khamisiyah.
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    These narratives will be a status report to the American people of what we knew, when we knew it, and what actions we're taking. As we prepare these narratives, they not only show us what we know, but they also, and perhaps most importantly, reveal what we don't know, allowing us to focus on our investigative actions.
    The first case narrative is Khamisiyah, and it will be available in the near future, as I indicated.
    We expect this process to facilitate the dialogue between us and our veterans and their families. This is the start of a process, not the end of a process. We expect that veterans will contact us with more information so we can flush out the record and provide the best information possible.
    The expansion of my office has also allowed us to broaden our focus on other possible causes of Gulf War Illness. For example, we are beginning to devote more resources to the investigation of possible environmental hazards such as pesticides and insecticides as we reconstruct the events that occurred during the Gulf War, we will look closely at our doctrine, policies, and procedures.
    We must be completely open minded in our analysis and make the requisite changes based upon the lessons that we learn.
    We are building on the major health programs initiated by DOD to care for those still on active duty or otherwise eligible for DOD care. The Comprehensive Clinical Evaluation Program that Dr. Joseph spoke about was established to provide in depth evaluations of health concerns of Gulf veterans who are on active duty or serve in the National Guard or Reserve.
    We have asked all personnel who want to be evaluated to contact the program to schedule an appointment for medical evaluation. And this is very important. Sometimes there's some confusion about who was at Khamisiyah or not at Khamisiyah. Anyone who has a concern about their health who served in the Gulf needs to contact DOD or the veterans—Department of Veterans Affairs.
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    To date, more than 38,000 Gulf War veterans have registered. And of those, 30,000 have been—requested medical examinations. The Department of Veterans Affairs has completed in excess of 63,000 examinations.
    As you know, last month I withdrew the DOD staff paper published on GulfLINKS which discounted low level exposure as the cause for Gulf Illness. In doing this, I noted that the PAC had concluded that current scientific evidence does not support a causal link between low level chemical exposure and undiagnosed Gulf Illnesses.
    However, the PAC also recommended additional research is warranted. We concur in this assessment and plan to fund the appropriate research. I appropriate this subject with a completely open mind. Our research agenda is clear evidence of this. And again, we will coordinate this research program with HHS and VA through the established Persian Gulf Veterans' Advisory Board.
    The CHAIRMAN. Do you have very long to go?
    Dr. ROSTKER. About another 2 or 3 minutes. Want me to stop?
    The CHAIRMAN. I wish you would, sir.
    Dr. ROSTKER. Okay.
    The CHAIRMAN. We've got seven, eight more witnesses to go and two more panels. We appreciate it very much. Thank you.
    If you could maybe just briefly summarize what you have left there, and perhaps members— —
    Dr. ROSTKER. Well, let me just say in conclusion that we are wholeheartedly committed to finding out everything we can about the factors that impact on Gulf Illness. This is absolutely necessary, not only because it's right for our veterans, but also because it's imperative for the future safety of our troops.
    Thank you, sir.
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    The CHAIRMAN. Thank you, sir. And your entire statement will be put into the record.
    Dr. ROSTKER. Thank you, sir.
    [The prepared statement of Dr. Rostker appears on p. 356.]

    The CHAIRMAN. Dr. Jackson.


    Dr. JACKSON. Good afternoon. Mr. Chairman, thank you for the invitation to be here.
    I'm Dr. Richard Jackson. I'm Director of the National Center for Environmental Health, the Centers for Disease Control. To my right is Dr. Stewart Nightengale, Associate Commissioner at the Food and Drug Administration.
    We're here to comment on the Presidential Advisory Committee recommendations, and I have extensive comments on CDC's involvement in my written testimony. I'll just summarize our comments here. Dr. Nightengale will respond on the FDA comments as well.
    We would like to commend the Presidential Advisory Committee for its comprehensive review of the complex issues involving examining the health consequences. We take note of the PAC's finding that many veterans were clearly experiencing medical difficulties connected with their service in the Gulf War.
    In fact, CDC's—HHS's own studies have reached a similar conclusion. The causes of these illnesses need to be thoroughly investigated. However, answering such questions is exceeding complex, and we may never be able to determine the precise causation of illness in all Persian Gulf Veterans.
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    That is why it's important for us to examine future actions that can be taken to control or prevent health problems among our military personnel. In this regard, it's essential that HHS continue its close collaboration with DOD and VA.
    This collaboration has resulted in several well designed investigation of health outcomes among Persian Gulf vets.
    We concur with the Presidential Committee on the importance of health communication in—health education in dealing with Gulf War veterans. Several centers at CDC, NIOSH, also at the Agency For Toxic Substances, have a lot of expertise in this area. As recommended by the PAC, we were very willing to provide that help and those services.
    The PAC also emphasized the important role of public advisory groups. HHS has had a lot of experience with this. In fact, the IOWA study that CDC was the lead on, we worked with both a veterans' advisory group as well as a science advisory group.
    The public advisory groups often provide a lot of critical information and advice—the use of language, whatever, in the design of these studies. And they also help to increase the public awareness of both the strengths and the limitations of epidemiologic studies and hopefully will help in public acceptance of the study results.
    I'd like to make a strong point about the importance of peer review, and that whatever results come out have to be reviewed by arm's length third party reviewers in order to stand that kind of scrutiny.
    The advisory committee recommended several priority research areas. For example: the long term effects of low level exposure to chemical agents, the long term effects of stress, the long term effects of carcinogens and mutagens, and the long term effects of the interactions between drugs such as pyridostigmine bromide and other agents.
    Obviously we concur with those recommendations.
    HHS is in full agreement with the committee on anticipating post-conflict health concerns associated with military employment. Now the ongoing studies of Persian Gulf veterans will contribute to our understanding of the effects of military service.
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    However, most of these studies are limited by their retrospective nature. By looking back over time, we're very aware of the difficulties in trying to address concerns that develop months and years after deployment.
    In most instances, investigators are called in only after an environmental health problem is suspected. And as a result, base line data on the health of the military personnel is often lacking.
    It's essential that we take a more forward looking approach to evaluating veterans' health concerns. And such an approach would consist of a) gathering baseline data on the health of military personnel; b) surveillance systems for adverse health outcomes; c) developing better troop locator methods, knowing where people are serving; and identifying risk factors for stress related conditions.
    And this would include—and this is very important—collection and storage of baseline and post-deployment serum samples, blood samples.
    We would like to commend the PAC for its emphasis on stress related disorders. As the report points out, stress is known to affect the brain, the immune system, heart, other endocrine immune responses. And further study of the impact of stress on physical as well as psychological functioning can only benefit our efforts in helping the veterans.
    The Presidential Advisory Committee recommends that the Government consider methods for routinely sampling military populations regarding reproductive health so that an appropriate baseline exists. In particular, the report suggests that DOD work with CDC's Center For Health Statistics on our national survey for family growth.
    This is a survey of women of childbearing age to look at reproductive health, family planning, maternal and child health, sexually transmitted diseases, HIV infection. And obviously, CDC would be pleased to provide the technical consultation to do so.
    Finally, the PAC commented on FDA's Interim Final Rule permitting waiver of informed consent for use of unapproved products in a military emergency. The committee expressed concern about the time FDA has taken to reopen the rule making process.
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    The FDA intends to reopen the rule making process and will solicit public comment in line with the committee's report. This public comment will be directed towards whether FDA should finalize the rule, modify it, or eliminate it completely. And FDA will also continue to work, as it has over the last several years, with DOD and others on this.
    I will not comment on the IOM report because of time. But in summary, DOD and VA have the primary responsibility for protecting the health of military personnel, and HHS will strongly and does strongly support the findings of the Presidential Commission.
    To the extent possible, we will work closely with these two agencies on this. We owe a debt of gratitude to the veterans and to all men and women in military service.
    And I will be glad to answer any questions that the committee may have.
    [The prepared statement of Dr. Jackson appears on p. 362.]

    The CHAIRMAN. Thank you, Doctor. And thank you, gentlemen. If you would respond to the questions, we'll move right along. Mr. Evans.
    Mr. EVANS. Thank you, Mr. Chairman.
    Dr. Garthwaite, you indicated that there are some 80 studies in progress at this point, research studies, by the VA. Can you submit to us kind of a summary of each one of those studies?
    Dr. GARTHWAITE. We will be more than happy to, sir.

    [The information follows:]

OFFSET FOLIOS 1 to 171 insert here
MAKES pp. 48 to 218

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    Mr. EVANS. Okay. And you indicated there was a March symposium concerning research, is it?
    Dr. GARTHWAITE. Yes, sir.
    Mr. EVANS. And where will that be and what dates?
    Dr. MURPHY. It's sponsored jointly with the Society on Toxicology. It's going to be in Cincinnati on March 7 and March 8.
    Dr. GARTHWAITE. My apologies. Dr. Fran Murphy is Director of our Persian Gulf War Veterans' Program, and Kris Moffitt is the head of our Compensation and Pension Service. So we have them here available as well.
    Mr. EVANS. Dr. Murphy, I recently met with you and the Secretary concerning research grant proposals. When is the deadline for those for the next fiscal year?
    Dr. MURPHY. Dr. Joseph can correct me if I'm wrong since it's a DOD-broad agency announcement. The first set of proposals is due on February 10, and the second set on March 19.
    Mr. EVANS. So we're already past that date at this point?
    Dr. MURPHY. For the first set. But the larger amount of money is actually going to be awarded for the amended proposal for a larger group of studies, and so there would be an opportunity for people to submit through the middle of March.
    Mr. EVANS. Vet centers have seen, I understand, some 69,000 Gulf War veterans since May of 1991. What has been learned about these veterans in terms of the problems that they're facing?
    Dr. GARTHWAITE. Could you repeat the first part of your question? I just didn't— —
    Mr. EVANS. I understand that some 69,000 Persian Gulf veterans have visited vet centers since May of 1991. What, if anything, have you learned about these veterans?
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    Dr. GARTHWAITE. I think the efforts with the vet center population has been on treatment more than diagnosis, so that our efforts have been at dealing with any readjustment issues they might have or any stress related PTSD-related issues that they might have.
    Mr. EVANS. But you haven't drawn together any of the vet center personnel to talk about Persian Gulf Syndrome and what they were seeing generally? That seems to me to be a—maybe nonscientific—but a good way of getting to the bottom of some of these issues. Dr. Murphy?
    Dr. MURPHY. We've coordinated our activities in the Persian Gulf Health programs very closely with Dr. Batres, who directs the readjustment counseling service, and we're well aware of their activities.
    Many of their activities are focused on the areas of readjustment counseling and family counseling related to some of the issues of stress and physical symptoms.
    Mr. EVANS. All right, thank you.
    Let me refer this question to the Department of Defense people here.
    Can you comment on a news report last month that the Army will investigate claims by California biochemist Garth Nicholson that illnesses suffered by many Gulf War veterans may have been caused by the difficulty to detect microorganisms and the possibility of these microorganisms being genetically engineered?
    Dr. JOSEPH. Let me comment on part of that, and Mr. Rostker may wish to add something.
    This is the same discussion we were having earlier about this researcher. Dr. Nicholson is well known to us in the Department of Defense. He proposed some time ago, a year or more ago, a study related to his somewhat novel theories about Persian Gulf illnesses.
    He's a very respected researcher, and his theories deserve to be taken seriously. But they are not exactly down the middle of the road.
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    Because of concerns about whether the laboratory methodology that he was using could, in fact, demonstrate what he claimed to demonstrate, the Army and the CDC arranged with Dr. Nicholson for a way to validate his laboratory procedures. This would be essential before one could know what one would get from his results.
    Unfortunately, Dr. Nicholson didn't come to closure with that validation. Things hung in the balance until a second round of claims by Dr. Nicholson about the need for his research to be funded.
    At that second round, the Army has agreed to have the National Institutes of Health serve, in essence, as a referee—as the CDC was going to do about his methodology. We've agreed, from the Department of Defense, that if indeed the NIH validates his methodology, we will go ahead and fund his activity.
    That's where it stands at the moment. And that should happen in the next month or so.
    Dr. ROSTKER. Actually, Congressman Norm Dix was very much involved in the discussions, and we agreed to ask the National Institutes to be an honest broker here. It turns out that the commander at Walter Reed is—had been the commander in the Army hospital in the vicinity of Congressman Dix's district, and he agreed to be a facilitator in this process bringing all parties together.
    So all together, we're talking—we believe we have a process that will lead us towards a resolution of the issue and concerns.
    Mr. EVANS. Thank you, Mr. Chairman.
    The CHAIRMAN. Mr. Quinn.
    Mr. QUINN. Thank you, Mr. Chairman.
    And I'd like to thank all the panelists this afternoon. Ms. Moffet is the new chairman of the benefits committee where we sort of combined a couple. I'm honored to serve. And while I don't have a question, you're not going to need the microphone.
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    Mr. Filner and I look forward to working with you as we look at Comp and PIN and how it relates to this with all the rest of the service. So we'll be in touch. Thanks for being with us today.
    Dr. Garthwaite, you talked in your opening remarks about some initiatives that have been taken on. And previously today, I talked a little bit about communications. I don't know if you were here for that part of it with another panel, but you talked about some teams as it relates in organized networks.
    Can you give me a minute or two more? You mentioned eight people in a team, is that correct?
    Dr. GARTHWAITE. Sure, sure. They don't currently exist, but we're targeting early March or the first of April, to have these teams in place. We anticipate they'll deal with issues way beyond Persian Gulf. We're going to start there.
    The goal is to—let me just back up slightly. In rethinking the VA and reinventing it, one of the things we've done is to decentralize to the network level, and we've established as a policy these management assessment councils. They're advisory councils to the network directors, and they include all different stakeholders.
    They may include some of your staff. They include veterans' service organizations, academic affiliates, and others. We believe there's a possibility and—or a need and likelihood that doing that at the clinical level may also be helpful at the care level.
    So we're going to look at the services we deliver. And each of those services will have an evaluation action team. These teams may take on several services themselves, the goal being to have a formalized process where, at a local level most of these things end up getting solved and occurring, there is a process for ongoing dialogue between our caregivers, our responsible management, people right in the front lines, and the veterans themselves.
    Mr. QUINN. Thank you. And I think that is critically important. We're going to talk about—Mr. Filner and I are going to talk about some hearings later in the spring and maybe next fall as it relates to comp in general. But the key—my staff doesn't need to be involved in anything more, thanks anyway.
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    But the veterans need to be represented on those teams not only from here and some of the service organizations, but around the networks, some rank and file veterans. We're going to hear from some later today, this afternoon. That's critically important. And we'll work with you on that.
    Thanks for you answer.
    Dr. GARTHWAITE. And we thank you.
    Mr. QUINN. Dr. Rostker, you have a very difficult job coming up. You've taken on—I don't need to tell you that. You've taken on a big assignment. You mentioned in your testimony that your office has expanded of late, particularly since your new charge, your new assignment.
    How has the office expanded? Has your funding increased?
    Dr. ROSTKER. Yes, our funding has increased. We have expanded really in two ways. First of all,— —
    Mr. QUINN. How much money? Excuse me.
    Dr. ROSTKER. I'm sorry?
    Mr. QUINN. How has the money expanded? Excuse me.
    Dr. ROSTKER. We right now have an operating budget of close to $15 million dollars. And frankly, as I see new opportunities to be responsive to the veterans and extend the inquiry, I have drawing rights so that we have not placed a limit on this except the good service that we can provide to our people.
    Mr. QUINN. Well, and frankly, that's where we come into play as well.
    Dr. ROSTKER. Yes.
    Mr. QUINN. I, for one, want to help you do that.
    Dr. ROSTKER. Right.
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    Mr. QUINN. We can't open end things, but we will be interested to see what—how about bodies; how about people at the— —
    Dr. ROSTKER. Right. In order to facilitate an expansion as rapidly as I have, I turn to contract organizations who could bring in people who had the requisite skills; both technical skills, but also had the experience of serving in the Gulf. So we have increased by over ten times.
    And we have done that not only in the investigative arm, but also in the veterans' outreach program, as well as bringing in other programs like correspondence and our GulfLINK program. These allow us to have one stop shopping and to get on top of the entire response that we need to make.
    Mr. QUINN. One last general question, Mr. Chairman, and then I'll finish.
    And I'm not sure to whom this should be addressed. Maybe Dr. Joseph. Just to make sure that we're both—everybody's talking to each other, I get back to this communication point that I mentioned earlier.
    As you've got participants in some of your clinical evaluations and they leave, or leave active duty, are they involved in the registry we talked about? Are they placed in the registry? Do they become part of that? Are they there already?
    I need some help from somebody on the panel that could— —
    Dr. JOSEPH. I'm not quite sure of your question. Let me try, and then maybe Dr. Murphy can pick it up.
    People come into the registry—the registry is a prior step in both systems to the clinical program. Active duty and reserves have access into our clinical evaluation program. Active duty have a continuing access, of course, as do their dependents, to care in that program.
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    Those who leave active duty would go over into the VA clinical program. I think that's the fairest way to say it, is that right?
    Dr. MURPHY. Yes. As Dr. Joseph is aware, his staff and I talk on an almost daily basis. And the Department of Defense transfers medical records from the CCEP to our registry data base.
    Mr. QUINN. Is that a—excuse me. Is that a formal process where it's transferred and there's discussion going on and you're satisfied with that?
    Dr. MURPHY. Yes.
    Mr. QUINN. And Doctor, you're satisfied?
    Dr. MURPHY. We have good cooperation.
    Dr. JOSEPH. If there's a soft spot in this process, it's not so much with those who leave active duty and go to the VA system, but those who remain in the Reserves. We've got some work to do to assure access to continuous care as opposed to only evaluation.
    Dr. ROSTKER. It's not just the care. It's also the issue of disability discharge. And we are very clear on the active duty person. We're very clear on the person who's separated and is a charge of the Department of Veterans Affairs. It's the reservist who has limited access and also who is in a position to have his career terminated because of health reasons.
    We have to really make sure we're not letting them drop through the cracks.
    Mr. QUINN. I've gone too long already. Thank you all for your responses.
    The CHAIRMAN. Mr. Filner.
    Mr. FILNER. Thank you, Mr. Chairman.
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    Let me just apologize in advance if I may sound skeptical, confrontational, even hostile, because I have been angry on this issue for some time on behalf of my own constituents and people. It does not appear to me that thousands of people who had serious, serious illnesses were either taken seriously by our Government, looked at with any credibility for far too long.
    And I'm not convinced that that has changed particularly. So let me—that's my assumption here. And when I—I just had a chance to begin to look at this committee report and heard some of the testimony this morning, and there are statements in there—this is an official Government thing that says the investigations previously were superficial, not credible; there were slow and erratic efforts to release information.
    I mean, I don't think it's too far to say ''cover up'' is a good word for this. And all I can ask—first of all, Dr. Joseph, how long have you been the Assistant Secretary?
    Dr. JOSEPH. Since March of 1994. Of course, what you're reading from, Mr. Filner, is not commentary on the clinical evaluation or clinical care efforts. Those— —
    Mr. FILNER. Well, I'm sure I can find— —
    Dr. JOSEPH. That same report they said were excellent, as a matter of fact.
    Mr. FILNER. Well, who is taking responsibility in DOD for these very serious problems that occurred for the last 4 or 5 years? I mean, has anybody taken responsibility? Are you responsible for any of this?
    Dr. JOSEPH. I'm responsible for the health and medical research activities.
    Mr. FILNER. Well, are you responsible for the refusal to confront this issue directly for 4 or 5 years?
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    Dr. JOSEPH. I'm not sure which issue we're referring to.
    Mr. FILNER. Well, the issue—we went through Agent Orange in this country where for years and years nobody took seriously that there was anything wrong. And it looked to me—as soon as I heard about these reports of illness, I said oh, they've got to look at it differently.     We have experience that—there's a reality behind here that we've got to figure out, and I didn't see any recognition of that from the DOD or from any official Government source. Everybody tried to say this was not—there was nothing going on here. We didn't do anything, there's no cause, there's no—these people are just stressed or it's in their head.
    I didn't see any—I didn't see the institutions taking this seriously.
    Dr. JOSEPH. I can speak only for the health and medical research side of it, but I think the evidence is really to the contrary. I mean, we began—and the VA began—very early, a series of programs designed one, to take care of our people; and two, to try to use those efforts to find out what was going on.
    Those programs have retrospectively been judged by every group that's looked at them as excellent. Speaking for the Department, not for the VA for the moment, the approach was quite the opposite from Agent Orange. We started a GulfLINK program declassifying documents and putting them on the Web.
    What we've done with our clinical evaluation data base is unprecedented in that we have now made it available to independent scientists who can use it for their own research.
    I just do not believe, with all respect, that the facts bear out your comment.
    Mr. FILNER. Well, who is responsible for—what is the report referring to when it talks about superficial, uncredible, slow, erratic, dishonesty? I mean, who are they referring to? Who was the report referring to?
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    Dr. ROSTKER. The report is characterizing the investigative effort that was in place during the PAC's— —
    Mr. FILNER. And who is responsible for that?
    Dr. ROSTKER. I'm now responsible.
    Mr. FILNER. I know. But who was responsible for that?
    Dr. JOSEPH. There was no clear line of authority for that. That was the problem.
    Mr. FILNER. Mistakes were made.
    Dr. JOSEPH. No, mistakes were not made.
    Mr. FILNER. Just a quote that I read recently.
    Dr. JOSEPH. Yeah, I guess you must have.
    Mr. FILNER. The reason I'm even dwelling on this—because I said earlier this morning I'm more interested in getting the care and the benefits done to people who are suffering.
    But Dr. Rostker, you sounded—I was very impressed with your statement. And yet, you're put over a bureaucracy that has not performed very well irregardless of what Dr. Joseph just said, in my opinion.
    Dr. ROSTKER. And I would not— —
    Mr. FILNER. And so why do we trust that bureaucracy to help you do what you have to do?
    Dr. ROSTKER. I can only say that I don't disagree with you. I found the PAC's characterization consistent with my own inquiry before I was asked to take this particular position. We're trying to put that behind us and look to the future with a program that is responsive.
    We're working with veterans. We're working with veterans' service organizations. I can't repair the past by—the only thing I can do is work hard and tell the truth and build to the future.
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    Mr. FILNER. Well, again, the reason I'm dwelling on this at all is that, as I said earlier this morning, the key national security imperative, in my opinion right now, is honesty. We have not had that.
    Why would we get an honest thing now when they've had 4 years of not being honest? We're relying on the same people.
    Dr. ROSTKER. Not completely.
    Mr. FILNER. Or the same institution, the same dynamics.
    Dr. ROSTKER. Not completely, because we have changed the way we are doing business. And I'm able to grab people and work with them in ways that my predecessors just did not do. And the question was raised to the PAC who had the opportunity to look over it, and their conclusion was ineptitude.
    And frankly, I would concur with that. I was asked to come in and advise the Deputy Secretary in September, and I had the opportunity to look over the entire institution of what we were doing, how we were doing it. And I wasn't a happy camper.
    And when we were getting ready in October to talk to the American people about Khamisiyah, the Deputy Secretary said to me how do I make sure there's no more Khamisiyah's; how do I make sure there's no more surprises?
    And I said John, you've got a big problem. The resources the Department has put against this problem were inadequate.
    They're totally swamped by the Khamisiyah investigation. They're not being responsive.
    For example, we had an 800 hotline where people could come in and report incidences. A very important part of risk communication. We had a thousand phone calls that had not been responded to. Well, I now have in place the resources to respond to it, and, since December 13, we've called, or have been in contact with, almost 700 veterans.
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    We've called back out of the thousand—we've gone back to that file and made contact with over 300. And by the end of next month, we will have wiped out that back log. That's working towards the future. I've initiated a process of writing what we knew.
    Believe me, we knew a lot more than we sat down and wrote. We weren't communicating it with anybody. Well, you will see in the next few days the first case narrative on Khamisiyah, and that's not a final report. It's just an initial report to generate the dialogue so that we can better understand.
    We're committed to bringing the veterans into the process. They were the people on the ground in the Gulf. They were the people that have the first hand information. We need to incorporate that.
    I can only tell you that I'm running an open process. I welcome public oversight. We have the PAC providing that. We report to congressional committees. I have the PAC at my staff meetings. They're open to talk to anything, to go to any meeting I have. We have absolutely an open process, and we welcome scrutiny to demonstrate that process.
    Mr. FILNER. Include me in on your meetings then.
    Dr. ROSTKER. Okay, tomorrow at 1 o'clock.
    Mr. FILNER. Again, I apologize for the tone. I am— —
    Dr. ROSTKER. Sir, you have a right to be— —
    Mr. FILNER. I mean, we have a long way to go to restore credibility of the DOD here.
    Dr. ROSTKER. Absolutely.
    Mr. FILNER. And I have not heard—I mean, I heard the words. I have not seen all the results yet.
    Dr. ROSTKER. And I can only tell you that—you know, stick with us; we're working the problem.
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    The CHAIRMAN. There will be more hearings, gentlemen.
    The gentleman from Louisiana, Mr. Cooksey.
    Dr. COOKSEY. I have four questions that—each one of which can be answered with one or two words, so I'll be brief, Mr. Chairman.
    First, is the CME on the Gulf War Syndrome available yet? You said it would be available in early 1997.
    Dr. GARTHWAITE. The self study?
    Dr. COOKSEY. Yes, you said it's going to be made available to the veterans' physicians.
    Dr. GARTHWAITE. We can make it available to—and anyone else who's interested.
    Dr. COOKSEY. Okay, there are two of us on this panel that are physicians, and— —
    Dr. MURPHY. It's in the final stages of development, and we'd be happy to provide you a copy.
    Dr. COOKSEY. I'd like to get one. It will help me keep up with my CME. It's not easy to do here.
    Dr. Joseph, what is the incidence of Gulf War Illness among the men that were involved in destroying those chemicals that were there on the site?
    Dr. JOSEPH. If we look at people who were already participants in the clinical program, which is all we can look at yet, both the prevalence and the nature of symptoms and illnesses do not appear different from the overall group in the CCEP.
    Now the questionnaire that Bernie was talking about being sent out, has been sent out to all members of units who we judged to have been within a 50 mile radius. We don't have all that data back, and even then it will be self-reported symptoms.
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    So, I can't really answer your incidence problem. But if we look at comparable incidence or prevalence and patterns of illness or symptoms within the group that had previously registered themselves in the CCEP, it is comparable. There are no significant differences that we can discern.
    Dr. COOKSEY. I think that's an important question that needs to be answered because of the Khamisiyah situation.
    Dr. JOSEPH. Sure.
    Dr. COOKSEY. Dr. Rostker, you have the potential to become the hero of this. I think the thing that really needs to be done instead of finding fault with people is find the reason for it. Because as a physician with scientific training, once we find the cause of it, then we can direct some treatment, and I hope you can do that.
    My question: have any studies been done or inquiries been made about—to the Saudis or some of the Arabic forces there, even to the Iraqis, to see if they've had symptoms?
    Dr. ROSTKER. There has been some. There was—the Army Surgeon General was in Kuwait. I intend later this spring to take a team to Britain, Czechoslovakia, Israel, and Kuwait and replow that ground. A lot of this ground has been plowed, but it's important that we take a fresh look and we go over this once more.
    And we'll be doing that, and we'll have an interagency team going with me.
    Dr. COOKSEY. Good.
    Thank you, Mr. Chairman.
    The CHAIRMAN. The Chair recognizes the gentleman from Georgia, Mr. Bishop.
    Mr. BISHOP. Thank you very much.
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    I look forward to working with Mr. Everett from Alabama, who is going to be the chair of the new subcommittee on oversight and investigations, and I will, of course, be the ranking member—with all of you as we explore this whole phenomenon of the Gulf War Illnesses.
    I'm given to understand that a number of Gulf War veterans are of the opinion that some VA doctors and researchers have been subjected to some retaliation for their efforts to really pursue the research and to really get to the bottom of whether or not there is in fact a common thread in these illnesses.
    Can—Dr. Garthwaite, can you tell me if any physician has been directed by the VA to cease providing treatment or has any physician been punished, reassigned, or put under a cease and desist order for activities with regard to the research regarding Gulf War Illnesses?
    And I specifically refer to anyone from the VA hospital in Tuskeegee.
    Dr. GARTHWAITE. Sir, to my knowledge, we certainly have not attempted to interfere with anyone who's taking care of Gulf War veterans. It is our hope that we can encourage everyone who's interested in doing research to put forward credible studies that can be scientifically reviewed to study Persian Gulf War veterans.
    And it's our goal to encourage people to study that. So to my knowledge, no. There have been some things in the press that we're currently looking at, which we don't think are related at all to any activities in the Persian Gulf, but we can provide you additional detail on that.
    Mr. BISHOP. There was a physician who was doing some discussion with veterans groups in the Tuskeegee area, at least veterans who are served by that particular VA facility. And there was some talk and some media coverage that he had been subjected to some retaliation or to some discipline for statements, comments, or information that was disseminated.
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    Can you shed any light on that?
    Dr. GARTHWAITE. Dr. Murphy may know more about that specific case.
    Dr. MURPHY. That was before Dr. Garthwaite joined the central office staff.
    I believe you're referring to Dr. Charles Jackson at the Tuskeegee VA. And he very early on, back in late 1992, expressed his feeling that some of the Persian Gulf veterans that he had seen might have had illnesses as a result of exposure to chemical and biological warfare agents.
    And he named some specific viruses that he felt might be responsible for their illnesses or chemical warfare agents that they may have been exposed to. VA took that very seriously. We sent a team of experts down to evaluate that, including our infectious disease consultant.
    And we established a special pilot program at the Birmingham VA where they have special neurologic expertise and neuropsychological expertise to further evaluate and treat those veterans. That program was expanded last year into a fourth Persian Gulf referral center at the Birmingham VA Medical Center.
    So VA actually took the concerns of that physician very seriously and responded, I think, in an appropriate way.
    Mr. BISHOP. What happened to Mr. Jackson?
    Dr. MURPHY. Dr. Jackson is still working at the Tuskeegee VA and still caring for Persian Gulf veterans. I had the opportunity to meet him in the last couple of months when he came up to Washington to testify.
    Mr. BISHOP. Was he disciplined or reprimanded for any of his activities?
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    Dr. MURPHY. No. To my knowledge is that his Chief of Staff at the Tuskeegee VA was very supportive. And certainly his comments to us have reflected that.
    Dr. GARTHWAITE. We'd be happy to take a further look at any specific information on that case. We'd be happy to. And we'll look into it on our own.
    Mr. BISHOP. Thank you very much, but let me just say that this just goes again to underscore the lack of trust, the cynicism, and the lack of confidence that many of the veterans have as a result of this whole fiasco really.
    It just has undermined to a great extent the confidence the veterans have in the Government that they have served. And of course, VA, of course, and DOD are the prime agencies that touch their lives. And certainly we want to create as much credibility in those agencies, and we want to make sure that the facts are forthcoming.
    And I just want to say that, and I don't have any further questions.
    Thank you.
    The CHAIRMAN. Thank you, sir. Mr. Stearns.
    Mr. STEARNS. Thank you, Mr. Chairman. I hope I don't go back over some things that have already been covered.
    But let me ask Dr. Joseph: what is gamma globulin? What is it and how is it used in vaccines in its purpose?
    Dr. JOSEPH. Gamma globulin is a naturally occurring product in the body which is part of the body's immune defense against various invading bacteria or viruses. It's not really used in vaccines, but preparations are used to boost or supplant the body's own defenses.
    In the days before we had a hepatitis vaccine, we gave troops and civilians gamma globulin when they were going to an area where they might be exposed to hepatitis virus.
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    Mr. STEARNS. Okay. Isn't it true that our troops were given that before they went over to Desert Storm?
    Dr. JOSEPH. Some troops were given gamma globulin. They were given it for the purpose that I have described. And they've been given that for a long time when deploying to lots of places.
    Mr. STEARNS. But isn't it true that the DOD used non-FDA approved products, that not all of the products came from American made approved FDA proved products; but in fact, some of these products came from Italy, and these were used on our— —
    Dr. JOSEPH. You mean gamma globulin that was not FDA approved? I don't know the answer to that. Dr. Nightengale might know. I doubt it very much. I will get back to you on it. I've not heard that before—that particular allegation before.
    Mr. STEARNS. Well, you know, I think we—my staff and I have found evidence that in fact the DOD used non-FDA approved products for the troops before they went to Desert Storm. And in fact, some of it came from a company in Italy. And— —
    Dr. JOSEPH. Well, I'd appreciate that information that you have, and I will certainly run it by both our people and with the FDA. I think that would be very unusual. Not unusual. I think we would not do that.
    Mr. STEARNS. Unusual for the United States to use non-FDA approved, or—because you have the authority, DOD, for exceptions. You can go outside the United States.
    Dr. JOSEPH. Yes.
    Mr. STEARNS. That's true.
    Dr. JOSEPH. Yes.
    Mr. STEARNS. Have you researched that fact? In fact, the DOD went outside the United States, used a product from Italy, and it was not FDA approved. Did you know that?
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    Dr. JOSEPH. That's the first time I've heard that. We'll certainly look at it. The allegation one usually hears about non-FDA approval has to do with the pyridostigmine bromide. And that's an instance where we, again, had an exception from the FDA to use an approved product for a non-approved use.
    Mr. STEARNS. Who is the American made company that provided the gamma globulin?
    Dr. JOSEPH. I can't tell you that sitting here. We can find out.
    Mr. STEARNS. Okay.
    Dr. JOSEPH. I assume this is back in 1990.
    Mr. STEARNS. When a veterans comes in and complains, the tests that he or she are given, do they check for hepatitis C? If you have absolute proof that every veteran that came in with Gulf War Syndrome, do you check for hepatitis C or— —
    Dr. JOSEPH. We do not, nor would the VA, check each and every veteran who ''came in'' for hepatitis C. The way the clinical evaluation programs work is a ladder-like series of exams that follow symptoms and— —
    Mr. STEARNS. Well, did you give them a blood test?
    Dr. JOSEPH. Yes.
    Mr. STEARNS. You gave them a blood test?
    Dr. JOSEPH. Well, for many things and for different things. But the simple answer to your question is no, neither in the VA system nor in the DOD program was every— —
    Mr. STEARNS. Did you keep samples of that blood? Once you gave that blood test, do you have records of that blood in file anywhere?
    Dr. JOSEPH. We would have serum samples on all our active duty people, not only those who came into the CCEP.
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    Mr. STEARNS. So if I came in and I complained of Gulf War Syndrome, you took my blood, I could be assured that that blood is on file—is kept, or is it thrown away?
    Dr. JOSEPH. You can be sure that we have a serum specimen on you.
    Mr. STEARNS. And do you know, when they do those blood tests, is there various biological contaminants and retroviruses and neurotropic viruses and paroviruses? I mean, is it possible that what we're talking about here is something that was given to the veteran perhaps through another country that's not FDA approved, and that veteran is experiencing some kind of problem—hepatitis A, B, C, D, who knows—and one we haven't checked for, we haven't kept a record of it, and we haven't gone back to the source to check the product that was given to us that was not FDA approved?
    Dr. JOSEPH. I think the chain of logic that you're describing is extremely implausible. But, I can't say that it's not so, especially since I don't know what the answer to your first question is. And I will find out.
    Mr. STEARNS. Okay. Well, I think—you know, that's the basic question. Because if that's true, then that's another tack that I don't think everybody has perhaps thought about that we could think about and followed along that line.
    Dr. JOSEPH. If I may, as sort of a tangential answer to that: if what you say is so, it is not impossible that there may be some small group of veterans who have a particular condition that might—although I think it's highly improbable—be related to that.
    But, what I think everyone who has looked at this issue seriously has found, and every study that's been done on the clinical side, and the reviews of those studies has found, is that there is no single one unique overriding cause of these symptoms and illnesses.
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    So that even if what you're positing is possible or true, and it may be, it would explain only a small group of people—if indeed it were true—rather than an overriding cause. But we will look at that. It's a completely new one to me. I thought I had heard them all.
    Dr. GARTHWAITE. I was just going to say, as the phase one of our examination process, everyone received liver function tests, and all those that were positive would have gone on to the phase two to get hepatitis screening or the phase two part of the examination.
    So we would assume that if they were infected with hepatitis C, which there probably wasn't a good test at the time, then we would have picked up—at the active time of the illness some liver function abnormalities to get us onto that diagnosis.
    Mr. STEARNS. If you did the test.
    Thank you, Mr. Chairman.
    The CHAIRMAN. The gentleman from Arkansas, Dr. Snyder, is recognized.
    Mr. SNYDER. Thank you, Mr. Chairman. Just for time's sakes, if I could just direct my questions to Dr. Jackson.
    Is it a fair statement to say to this table if we all have you back in a year or 2 years or 3 years that kind of all funded research, you all are going to know about it, what's coming through Government and be able to tell us what's going on—is that an accurate statement?
    Is this kind of the research gurus here in terms of the administrative part of it at least?
    Dr. JOSEPH. Some answers won't be in in 3 years.
    Mr. SNYDER. I meant in terms of what are the status of things.
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    Dr. JOSEPH. Yes.
    Mr. SNYDER. I'm not asking for—I don't—and then there has been a view expressed perhaps as we're hearing more and more folks say, you know, we're not getting all the answers, there's no one cause, and maybe we ought to forget the whole research thing and just put all the money into seeing folks at the—are you all in agreement that that's the wrong approach?
    I want to see if you all change your head from shaking. [Laughter.]
    Dr. JOSEPH. It's the wrong approach. CDC funded this study in Iowa, for example. We've captured a population of veterans. We've looked at the prevalence of illness in that population. These are not people that came through and said I have a problem.
    These are people that were going about their lives. They have higher rates of cognitive dysfunction, depression, anxiety, asthma, bronchitis, a number of other symptoms. So, following that population, they report those higher rates of illness.
    The next step is to go back and examine a group of them randomly selected. I think one of the problems has been the need to look at a profile of the population rather than only looking at people who come to you saying they have a problem.
    Mr. SNYDER. I assume that behind all this talk of research I'm in agreement on is to perhaps avoid problems in the future. I mean— —
    Dr. ROSTKER. That's exactly right. If we can't get to the bottom of this, how will we protect our troops in the future?
    Dr. JOSEPH. Well, the problem is, what's the bottom. That's the problem.
    Mr. SNYDER. I'm sorry, sir?
    Dr. JOSEPH. The problem is, what's the bottom. I think I can tell you with absolute surety that there are some questions in this morass that will never be answered. There are some questions that will be answered.
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    Mr. SNYDER. That may help shape future behavior.
    Dr. JOSEPH. That's right. The PAC representative, this morning in the other hearing, said that it is becoming increasingly unlikely that one, there will be a connection between a Gulf War Syndrome and the sort of commonly thrown about possible causes; and, two, that there will be any persuasive evidence that there is a Gulf War Syndrome.
    Mr. SNYDER. And it's the folks—go ahead. I'm sorry.
    Dr. ROSTKER. If I might. I may be the only non-physician on the panel, and so my bottom line is not just the health bottom line, but is a whole myriad of things that are necessary to protect our troops in the future from better chemical alarms, better reporting procedures, knowledge of where our troops were.
    So there are a lot of lessons to be learned here, as well as the medical lessons to understand why people are sick.
    Mr. SNYDER. You referred to the morass. My last question is—I mean, when is enough enough? I mean, do we even have a sense yet of—are we talking, you know, a money pit here that's going to go on 20 years from now?
    We'll be talking about additional research on Gulf War Syndrome with big amounts of money, or are we—do you all have some thought in your mind that we just need another, you know, 2 or 3 or 4 years of pretty good funding to kind of—I mean, I assume that you all talk amongst yourselves about how long we're going to be doing this or need to do this.
    Dr. JOSEPH. I think there is important ground to be plowed. On the medical research side there is important ground to be plowed on the Research regarding combination of agents, particularly with pyridostigmine. There is important ground to be plowed on the population-based epidemiology studies.
    And there is important ground to be plowed on the issues of the relationship between stress and psychological issues and physical symptoms and illnesses. In those three areas we have not begun really to get to the bottom.
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    Mr. SNYDER. I guess this is really my last question. Do any of you anticipate that perhaps out of some of that there will be a shift in treatment of some of the Gulf War veterans? I mean, is there some hope for that, or do we think we're just going to understand what happened?
    Dr. JOSEPH. Personal, professional opinion: no, that there will not be—there's not a magic bullet here. There's not a shift in treatment. We will not discover a thing that leads to a major difference in treatment.
    Mr. SNYDER. But you'll be able to call up veterans and say we've got the answer for you; come on in, take a pill?
    Dr. JOSEPH. I don't believe that's going to happen, sir.
    Mr. SNYDER. Thank you, Mr. Chairman.
    Dr. GARTHWAITE. I think what does occasionally happen is that as we take care of patients, we find things that are more or less clinically effective; and, there were drugs for depression that were very helpful in peripheral neuropathy in diabetics.
    So there may be further discoveries that very much help with symptomatic therapy.
    The CHAIRMAN. The gentlelady from Idaho, Ms. Chenoweth, is recognized.
    Mrs. CHENOWETH. Thank you, Mr. Chairman.
    Dr. Garthwaite, I wanted to ask you why the VA is proposing to cut research funding by 10 percent at a time when the President's Advisory Commission is calling for more research, and the President himself has stated that no stone should be left unturned?
    Can you tell me that?
    Dr. GARTHWAITE. I think that the Department's been faced with some very difficult decisions over the past few months as we've begun to put forward the budget for next year. We've been caught up in the debate over balancing the budget when we were—when there was a Government shut down.
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    And we really do understand the budget pressures. We are trying to put forward a very creative and aggressive budget for us into the future. So tough choices were made. We do believe that as we go through our prioritization process, we can keep at the forefront the needs of veterans.
    In addition, we're challenging our investigators to go outside the VA to bring in dollars. One of our new performance measures for our network directors and for our networks will be to increase the number of total dollars brought in to the VA for research so that we're going to add some additional pressures to compete with NIH and other funding agencies for research.
    Mrs. CHENOWETH. Doctor, I assume that you—when you talked about your priorities, that Gulf War Syndrome would be on the top of your list of priorities.
    Dr. GARTHWAITE. It's in the first tier.
    Mrs. CHENOWETH. Thank you.
    Dr. GARTHWAITE. Yes, ma'am.
    Mrs. CHENOWETH. It just seemed a little inconsistent, the 10 percent cut. But I look forward to working with the Department of Veterans Affairs on this.
    You know, it may seem a little bit picayune when one questions citations, but we have to admit that when a veteran would receive long sought after medical records with the stamp on the bottom that I read in my last questioning section about a $20,000 fine if any of these records should be released to any military personnel handling the records, they would be prone not to ship records out.
    And I did some research yesterday and my staff did too, and then counsel here on the committee has been working with me the last few minutes. Because the cite that is used, 38 USC 33.05, doesn't exist at all. And counsel actually referred me to the quality assurance section that does cite a potential of $20,000 fine.
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    But quality assurance, QA/QC, is not medical records of a patient. In the code, it states that for the first offense, there should not be a fine of more than $5,000. And it—the fine could go up to $20,000 on subsequent violations of a breach of the confidentiality of a quality assurance program.
    The confidentiality of medical records is elsewhere in the code, in 7332; and QA/QC is in 5705. Now, if we're confused about that here, can you imagine how a veteran feels when he gets this on his records?
    Mr. Chairman, with your permission, I would like to have Dr. Garthwaite take a look at this. Because my concern is how—although I'm so impressed with the testimony that you gentlemen and ladies have given, nevertheless, we need to get to where the rubber meets the road and what's happening to these veterans out there that are affected with symptoms that could be Gulf War Syndrome.
    And so it just seemed a little heavy handed, and I'm not going to publicly enter into the record the name of the hospital, but I know that you will take care of that for us— —
    Dr. GARTHWAITE. Sure.
    Mrs. CHENOWETH (continuing). And straighten it out.

    [The information follows:]

OFFSET FOLIOS 172 to 184 insert here
MAKES pp. 234 to 246

    Dr. GARTHWAITE. We'll try to fight through the legal issues here. But it is our intention clearly to give every patient their complete medical record if they request it, and to provide a complete medical record to any other practitioners they wish to have treat them.
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    And that has always been the case. The problem we get into is that other people occasionally request the records or it's sort of by word of mouth, and then we inadvertently release it to someone they don't want them going to, and it causes all sorts of havoc.
    So our biggest problem is training all our staff not to let them go without a signed consent. Because I don't want my medical records, and I'm sure you don't want your medical records, being given to just anyone. And so it's a fine line between protecting the confidentiality of the patient, which is a critical and important part of trust, and allowing the records to get to where they need to go.
    We apologize for it, if, in any way, we've gotten in the way of a patient getting the record to where they want it to go.
    Mrs. CHENOWETH. Thank you, Doctor.
    And I just have—I notice the yellow light, and I just have one more very quick question. We have had a multitude of complaints come into my office about not being able to get medical records. But I just want to ask you would you judge, from your professional work, that a sudden, severe onset of abdominal pain; sudden, unanticipated, uncontrollable bowel evacuation; sudden, severe headache; and a loss of consciousness that was sudden but prolonged; and then followed by eruption over the next few weeks of subcutaneous but benign lesions, multiple, in the forehead— —
    I bring this up because the patient I'm talking about here was asked to go to a mental health hospital to have this kind of physical ailment taken care of. Doctor, my concern is that—I wonder if there isn't some sort of threshold that we might be able to meet soon that if a patient exhibits even one of these symptoms that could be related to Gulf War Syndrome, that immediately they're put in a classification of Gulf War Syndrome victims and treated with immediate attention.
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    I think that's what our veterans need, what would help satisfy me anyway on this committee; and I'd like to work with you on that and the Chairman. Of course, this is at his pleasure. But this threshold is something that I think is really needed, because there's so much frustration now mounting out there in the field where the rubber meets the road.
    Dr. GARTHWAITE. Sure. It's a great concern to us if any veteran goes to a VA medical center and has less than an ideal experience. Individual cases we're more than happy to review, and we can do that at the local level; and we can get involved in Washington, if that's important.
    But we're very interested in that. As we enhance our computer capabilities, I think the ability to have a veteran walk into any VA medical center and to have us know basically what's wrong with them and take that into account as we treat them, is becoming increasingly possible.
    And we're excited about some of the developments we're making in those areas. So I think that if you go to the same place presumably and the medical record is immediately available, then it should be possible to understand the background that goes with the patient.
    And we'll continue to work through those issues. And if you have specific ones, please let us know.
    Mrs. CHENOWETH. Thank you, Doctor.
    Thank you, Mr. Chairman.
    The CHAIRMAN. The gentleman from Texas, Mr. Reyes.
    Mr. REYES. Thank you, Mr. Chairman.
    I have a few questions. One of my first questions concerns the region of the world where this all occurred. And since there has been—or there have been incidents in the past—for instance, the Iran/Iraqi war where they used extensively both biological and chemical weapons and are well documented—is there not, in the Department of Defense, a division or a department or a section that—whose responsibility it is to research and anticipate some of these types of chemicals and weapons that might be used against our troops before we deploy?
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    Dr. JOSEPH. Yes, there is. I'm not aware that there's a known use of biological agents in the Iran/Iraq war. Chemicals agents, yes; but that's not really your question. The Department has, on the medical side of intelligence, a quite sophisticated capability to know what is where and what threats might be expected.
    Mr. REYES. In this particular case, before we deployed to the Gulf War, what—was this system in place and activated; and in fact, is there a record somewhere of what was anticipated that we would run up against?
    Dr. JOSEPH. Yes, yes, yes, and yes. There was great anxiety and concern at the deployment about the risk that the troops were facing from chemical weapons. In fact, that's probably a major issue in many of the symptoms of people sitting under that risk for 6 months.
    Dr. ROSTKER. Our troops were extremely well prepared. For example, in the 24th Infantry Division, they didn't wear regular utilities. Their standard issue was gear that had carbon inside of it, the standard chemical gear. And that's the way they went into battle.
    Same way with the Marines. In fact, we were probably so primed that we were seeing chemical agents in every cloud in every dust storm. And that's part of the difficulty in sorting all of this out.
    Mr. REYES. Well, and that leads me to my next question, which is the—I think the break down in trust given what has occurred post-Gulf War— —
    Dr. ROSTKER. Part of the break down—for example, we had a chemical alarm that was very sensitive. It was called an M–8 alarm. We've demonstrated the alarm for our veterans' service organizations. Except every time you change the battery, you had to test the alarm.
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    Several times a day, you had to take the little filter out of a compartment and clean the filter. And every time you put the filter back, you tested the alarm. It was like a fire alarm in our house that we had to tend to two or three times a day.
    You get to the point where you're not sure what to do with the alarm. We now are moving towards alarms that do not require us to sound the siren to change a battery, to change a filter. So there's a whole range of things that did not work as well as we had hoped they would have worked.
    Mr. REYES. As a result of whatever this mixture or combination of things that didn't work exactly as we had planned or anticipated, the bottom line to a degree is that we do have a mixture of conditions or of symptoms that as a result of whatever occurred, maybe the battery was being changed or maybe the troops or whoever was in charge became so conditioned to the fact that this mechanical device was not working properly, that in that context, our troops did suffer exposure.
    Part of what, and I'll just be perfectly frank with you. Part of the frustration that we hear from Gulf War veterans is the fact that they feel more than a little insulted at the fact that a lot of this is being blamed on stress. Commander Nier earlier mentioned that specifically.
    Then secondly, are we not at a point where you could support the affirmation that in fact a Gulf War syndrome does exist or that we ought to at least entertain instead of just blatantly saying, which is what I'm hearing and correct me if I'm wrong, that there does not exist nor do we anticipate in the near future having the ability to definitively say yes, Gulf War syndrome is in fact— —
    Dr. ROSTKER. Let me answer the exposure question. I think Dr. Joseph can answer the syndrome question.
    We would have to say today that we're just not sure that we know that our troops may have been exposed to chemical agents at Khamisiyah. We are investigating all of the other cases through the veterans hotlines and others that have been reported, to try to understand the situation around the operation so that we're not relying on a single report. We're trying to put it into context. It's those reports that we'll be making available to you.
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    So we are trying to weave this tapestry to get the best assessment of where and how our troops may have been exposed.
    To the issue of syndrome.
    Dr. JOSEPH. Let me say first that there hasn't been, from either agency, a blatant or ''off the cuff'' no it's not. The conclusion about a syndrome or the absence of a syndrome—which is much more widespread than just the two agencies sitting here—comes after a lot of hard careful work and extensive analysis. Whether it's right or wrong, it's not blatant or ''tossed off.''
    Second, while I believe that no one in this room has experienced one, a chemical attack or an exposure to chemical weapons in any significant quantity is a rather dramatic event. It would not be logical to expect that had troops been exposed to a weaponized attack that it would have gone unnoticed. What we do know, from not only what people have written about but also from the First World War, and from what we know occurred in Iran, Iraq, and what we know from experimental work with primates at Cipra, we would expect to have a lot of very visible casualties.
    So what the issue comes down to, then, is whether there might have been sub-clinical exposures to minute amounts of agent that did not give rise to any observable symptoms at the time, but might be responsible for illness some months or years later.
    As I think we said earlier, the existing research base says that that does not happen; but the research base is inadequate. That's why we need to continue to do more research on that particular question, to see if it might be so. I think it would be very unlikely that we would have missed, or that people who were there at the time would have missed, an exposure of the type you have described. There would have been many, and many severe, casualties.
    Mr. REYES. But you do agree that the possibility exists in the context of you know, what has been described as mechanical failures and things along those lines. I mean I am asking could it be possible that we could have missed it?
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    Dr. ROSTKER. Let's take the alarms, for example. We would have expected that the alarm might have gone off and there would be other factors we could have looked at, physical factors in terms of sick people.
    If your folks' smoke alarm goes off in your house, you don't immediately run and file a claim with the insurance company because your house burnt down. You look to see where the alarm might have been, what might have caused the alarm. It sets you off. It's exactly that. It's an alarm. It makes you look, stop, look and listen. It makes you check. That's what the alarms did in the Gulf. It made people check, but there was no corroboration. That's what we're trying to put together to either demonstrate that there was corroboration or demonstrate there wasn't corroboration.
    We take the alarms, particularly the most sensitive alarms, very seriously. We're trying to document what can be learned about the operations that these alarms were part of.
    Mr. REYES. Thank you, Mr. Chairman.
    The CHAIRMAN. The gentleman's time has expired. Now to the gentleman that's waited so patiently, from Florida, Mr. Bilirakis.
    Mr. BILIRAKIS. Thank you, Mr. Chairman. In the interest of time, hopefully I won't have to take anywhere near the 5 minutes, mainly because Mr. Reyes almost like he was reading my mind, asked many of the questions, at least the initial portion of many of the questions that I would ask.
    Many of us, the chairman and I and others, tussled with the Agent Orange problem, still with us actually for years. I am not sure what we learned from that. Now we have this particular problem. I don't know why I have the feeling quite frankly, maybe it goes to lack of credibility, lack of confidence, faith, et cetera, but I have the feeling in the next war that our boys and girls might be in, we're going to have the same sort of problems. It will be a new syndrome coming out of the woodwork.
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    I just wonder are we prepared? Dr. Jackson, you were not in your current position back during the Gulf War. Were you?
    Dr. JACKSON. That's correct.
    Mr. BILIRAKIS. That's correct. Dr. Rostker or Dr. Joseph have already said they weren't. In your opinion, did we do things right? Now maybe we didn't have adequate research. Dr. Joseph talked about plowing ground and that sort of thing. But if the ground had been plowed prior to that point in time, was everything in place to do things right? Were the environmental people adequately coordinated with? Was your office, your predecessors adequately coordinated with and what not?
    I mean the Gulf War did not take place just like that. There was an awful lot of planning, at least from a military standpoint at least, that went into it. I mean it was something that we could have adequately planned for. Maybe we did, I don't know.
    But you know, this committee is focusing on, and thanks to the chairman, on reviewing the health consequences of service during the Persian Gulf War. That is of course the function.
    But wouldn't it be nice if we didn't have that problem to deal with?
    Dr. ROSTKER. Sir, I would say we were very well prepared for the chemical and to a lesser extent, the biological threat, but particularly to the chemical threat.
    What we were not well prepared for is to fight the post-war battle over Gulf War illnesses.
    Mr. BILIRAKIS. What do you mean by that?
    Dr. ROSTKER. I mean we did not have an adequate means of capturing where our people were, even at the unit level. So to this day, we are not adequate in telling you where a given unit was on a given day or where individuals were on a day, which is really very necessary to do the kind of epidemiological work.
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    Mr. BILIRAKIS. In other words, we could not have forecast where particular— —
    Dr. ROSTKER. We should have been able to.
    Mr. BILIRAKIS. We should have been able to.
    Dr. ROSTKER. But in fact, the people who put the database together have told us that they had a better ability to do that during Vietnam and World War II and Korea than they had in the Gulf because they had made some changes that actually hurt our ability to put that kind of information together.
    So one of the charges that we have for the future is to identify those cases and areas where changes need to be made, and make sure we put into place those changes. But there are other examples in environmental monitoring, which is better today. We collect and maintain serum samples which we didn't do.
    I think Dr. Joseph can give you a number of things we do today that we didn't do during the Gulf.
    Dr. JOSEPH. I think, Mr. Bilirakis, that many of the improvements we have made in force protection, medical force protection, are with the wisdom of hindsight. But one thing that I think we ought to have known to be prepared about at the time. That one thing has to do with a smoother and more intensive connection between operational intelligence and medical.
    As I look back now in hindsight, I can see some things we need to do and things we have done in the process.
    Mr. BILIRAKIS. That's really what I am getting at.
    Dr. JOSEPH. As I look back in hindsight and learn about how the links were made, or were not made, between the operational intelligence that was coming in and the medical coverage, care, and response, that we could have known better then that we should have done the linking better. Most of the rest is hindsight.
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    Mr. BILIRAKIS. Well my time is just about up and this panel has taken a lot of time. It's our fault, not yours. I appreciate your testimony. It's been very good.
    But I guess, you know, I am looking forward to the day when we can have one of these, where is the next war going to be that we don't know, hopefully never, but obviously these things take place. It might be in the jungles of South America or something of that nature. We should have adequate intelligence and adequate communication and coordination of knowledge with the environmental people, with the health people and what not in order to be better prepared. Apparently we weren't, in spite of the fact that this war was sort of a planned thing, that we should have been able to do.
    I am not trying to belittle it because I know it's a heck of a lot more complex than my knowledge would impart.
    Well, thanks, Mr. Chairman.
    The CHAIRMAN. Thank you, Mike.
    I believe the gentlelady from Idaho has one brief follow-up question.
    Mrs. CHENOWETH. Thank you for your indulgence, Mr. Chairman. I want to ask Dr. Jackson one quick question. I assume that the inoculations for anthrax and botulism were okayed by the FDA. I mean that's an assumption we can feel pretty safe with.
    The second part of my question is, is there any ongoing studies with regards to the cumulative effects of the inoculations plus the application of whatever it was that they put on their skin when they were over there to make sure that nerve gas didn't affect them as quickly otherwise.
    So I assume that the cumulative effect studies are going on and if they are, I would be very interested in taking a look at them too.
    Dr. JACKSON. Multiple different questions there. Quickly, I would like to quickly put in the next time we deal with this it's very important to have the blood specimens before, during, and after people go.
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    When I was a young epidemiologist and they were going to send me off to deal with this or that, they took a whole liter of blood to make sure that when we caught something out there that they know what was going on with us. I think that's very important. In the rush, the next time we prepare for war, people will begin to think it's not so important this time around.
    The second question about vaccines, I know that the advisory panel to the armed forces has been dealing with how many are really needed, and what's going on with these mixtures. It's a difficult issue because we certainly don't want to put someone in harm's way and then find out oh, we really should have immunized them against this or that.
    On the question of research, it is very important to look at these cumulative issues. It's not easy research because of just the nature of when you start adding things up, it becomes very expensive and very complicated very quickly. There is some of that underway.
    On the issue of drugs and approval, I'm going to turn to my FDA colleague, Dr. Nightengale.
    Dr. NIGHTENGALE. Thank you. I guess what I can say is what we had done to help prepare DOD in this. We certainly had approved a botulinum toxoid for use through a special investigational protocol with information to be given to the troops. I understand that that was used.
    As far as the anthrax vaccine is concerned, my understanding is that they did use an approved vaccine on the troop, a licensed vaccine.
    Dr. JOSEPH. The other agent, of course, was pyridostigmine bromide, which is an FDA-approved drug; but not approved for the specific purpose of nerve gas preventive treatment, because there is no research on that. We sought and obtained FDA approval to use that drug. That was challenged in court. We won in court.
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    I would like to, if I may, take 30 seconds more?
    The CHAIRMAN. Very briefly, sir. Please.
    Dr. JOSEPH. When we get to this part of the discussion about the immunizations and the nerve gas prevention treatment, it's important to say—in fairness to the people who were here then and made those decisions, and I believe they made the right decisions—we knew he (Saddam Hussein) had those agents. He knew we knew he had those agents. There was significant and well-based concern that he might employ them. The people who made those decisions then, medically and the line commanders, made those decisions to try to protect the lives of our troops.
    I don't think any of us would want to be in this hearing today knowing what we knew then, if we did not protect our troops as best we could with what we had and he had used those nerve agents.
    That is the balance that often gets forgotten in this discussion.
    The CHAIRMAN. Dr. Nightengale.
    Dr. NIGHTENGALE. Yes. Just to shed some light on actually the last statement. There is in the letter from Dr. Mendez, who preceded Dr. Joseph in that position, there's a letter that we published as part of our Federal Register notice when we put the interim rule in place that actually talks about the concern about the use of the chemical and biological warfare. I can give you that for the record. It's in the public domain.
    Dr. Joseph mentioned briefly the pyridostigmine bromide. While it is an approved drug for other uses, this was handled exactly the same way the botulinum toxoid was, in that it was handled through an IND, an investigational new drug procedure. There was a specific protocol approved for the use in the Persian Gulf, which is under the framework interim rule.
    The CHAIRMAN. Thank you.
    Mrs. CHENOWETH. Doctors, I just want to say that my main concern is, although each one of these individually were approved, the cumulative effects studies I think should be vigorous and enthusiastic. I hope you can share the information with the committee as soon as possible. Thank you.
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    The CHAIRMAN. Gentlemen and ladies, thank you very much. I am sure you can anticipate some questions in writing, if you would respond as expeditiously as possible, it would be greatly appreciated. Thank you very much for giving us your time.
    If the next panel, number four, would come up. We have two panels and six witnesses to go. I would admonish the members to try to hold their questions as briefly as possible, please.
    We have Mr. Puglisi, the Assistant Director of the National Veterans Affairs and Rehabilitation of the American Legion, Joseph Violante, the Deputy Legislative Director for the DAV, and Jeffrey Ford, the Executive Director for the National Gulf War Resource Center. If you would come to the table, please.
    Let me remind you that your statements will be included in their entirety in the record. If you can summarize, it would be greatly appreciated. We have another panel to go.
    The CHAIRMAN. Mr. Puglisi, would you like to start off?



    Mr. PUGLISI. Yes, sir. Mr. Chairman, distinguished Members of the Committee, the American Legion appreciates the opportunity——
    The CHAIRMAN. Pardon me just a minute. If those people that are finished would clear the room, please, so we can move on here very rapidly. We're running way behind time. Thank you very much.
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    Mr. PUGLISI. Again, thank you very much, Mr. Chairman and Members of the Committee for staying so late today. I know you have had a long day with the hearing this morning as well. The American Legion appreciates the opportunity to offer testimony concerning the final report of the Presidential Advisory Committee on Gulf War Veterans Illnesses or the PAC, as I'll refer to it throughout my testimony.
    The Legion commends you, Mr. Chairman, for convening this hearing on a document that has and will continue to have a significant impact on how the Federal Government responds to Gulf War illnesses.
    The PAC's final report is a thoughtful analysis of the Federal Government's response to and the nature of Gulf War illnesses. The compilation of clinical and epidemiological data is the most complete and well organized on this topic to date.
    The PAC in its report has had a significant positive impact on some areas of the Federal Government's response to Gulf War illnesses, notably the Department of Defense's investigation into chemical and biological weapons exposures.
    The final report has a number of limitations or weaknesses, however. Most notably, its inability to adequately evaluate the medical treatment provided to Gulf War veterans from DOD or to the Department of Veterans Affairs.
    I would like to talk about the greatest strength of the report. The PAC will long be remembered for the impact it had on DOD's investigation of possible chemical and biological weapons exposures of US troops in the Persian Gulf. This impact can not be overstated. DOD maintained for over 5 years after the Gulf War, that there was no presence, no use, and no exposure of US troops to CBW agents in the Kuwaiti theater of operations. The three no's, as now famously described by the PAC.
    DOD no longer maintains that position. It now has over 10 times the manpower devoted to this investigation, as Dr. Rostker talked about in the previous panel. The PAC's aggressive and thorough investigation and the articulate and damning staff reports sparked the Pentagon to revamp its entire approach to Gulf War illnesses months before the final report was submitted to the President.
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    I would now like to address two limitations or weaknesses of the report. The PAC did not find a causal link between many of the well known risk factors associated with Gulf War illnesses except stress. The final report describes in detail the well-defined and well known psychological consequences of exposure to traumatic stress, post-traumatic stress disorder or PTSD, and the subsequent poor physical or physiological health found in PTSD patients.
    However, except for two studies, PTSD does not appear as a major contributor to symptoms associated with Gulf War illnesses. This has been found by a number of epidemiological studies underway and completed conducted by the Centers for Disease Control, the Boston VA Environmental Hazard Center, the Iowa Persian Gulf Study Group, and the University of Texas.
    All of these studies, except the Texas study, carefully screened veterans for PTSD. They did find PTSD in some veterans. However, all found veterans suffering from symptoms of fatigue, joint and muscle pain, headaches, et cetera, but these very veterans did not meet the criteria for PTSD.
    PTSD does not explain Gulf War illnesses because those whose symptoms fall into Gulf War illness's very broad category do not suffer from PTSD according to most of the peer reviewed research reported to date.
    The final report alludes to ongoing research that is investigating the link between non-traumatic stress and adverse physiological or physical health outcomes. This research is fascinating, and in its early stages. The final report recognizes this fact by carefully explaining that ''scientists are beginning to unravel the physiological connection between the brain and various parts of the human body.'' Furthermore, that ''some researchers suspect that the inadequate production of stress hormones and stress response occurs in some, not all humans with chronic fatigue syndrome and PTSD.''
    Suspicions are not data or scientific findings. The PAC's finding that stress is a likely cause of Gulf War illnesses is premature at best. One of the Nation's leading PTSD experts recently commented that ''likely should not be used by the PAC to describe stress, not yet.''
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    Overall, the PAC's final report accomplished the mission given to the PAC in its charter. Evaluate the Federal Government's response to Gulf War veterans illnesses. In some areas, the PAC had a significant positive impact on the Government's response, particularly DOD's investigation into CBW exposures. In others, such as medical treatment provided to Gulf War veterans, it fell short of the mark.
    Because its charter did not allow the committee to conduct original research, it could not follow up with Gulf War veterans 6 months or a year after they received treatment from DOD and VA. Therefore, the PAC may have visited some centers and talked to DOD doctors and VA doctors, but they couldn't find out for sure how effective the treatment Gulf War veterans received.
    The American Legion commends the PAC and its staff for their professionalism and dedication to helping Gulf War veterans receive the care and answers that they deserve.
    Thank you, Mr. Chairman. That concludes my testimony.
    [The prepared statement of Mr. Puglisi appears on p. 372.]
    The CHAIRMAN. Thank you, sir. Mr. Violante.


    Mr. VIOLANTE. Mr. Chairman, Members of the Committee, on behalf of the more than one million members of the Disabled American Veterans and its auxiliary, I wish to express our deep appreciation for this opportunity to provide our assessment regarding Gulf War illness.
    The issue of Gulf War illness is a serious problem, made more difficult because of its complexity, the lack of scientific/medical evidence, the failure to maintain complete military and medical records, the failure of the Department of Defense to come forward with critical evidence establishing the possible exposure to chemical agents by US troops, and the conflicting reports and conclusions reached by various scientific and medical commissions and individuals.
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    These are not new dynamics for veterans. However, the fact that there are still so many unanswered questions and so many conflicting medical opinions only serves to exacerbate the situation.
    Mr. Chairman, the plight of Persian Gulf veterans suffering from undiagnosed illnesses continues to be one of our foremost concerns. Of the 11,257 environmental hazard claims considered by the VA, slightly less than 1,400 have been granted service connection, and only 620 or five percent have been granted service connection for undiagnosed illnesses.
    DAV continues to suggest that the presumptive period be left open-ended until the scientific/medical community determines the cause or causes of these ailments. We believe that the passage of time has demonstrated the soundness of our position.
    We caution this committee, however, not to take legislative action that would trigger pay-go provisions of the Budget Enforcement Act. In fact, Congress should exempt veterans benefits and services from the pay-go provisions.
    Mr. Chairman, the most frustrating aspect of Gulf War illness is that 6 years after the end of the war, we are still unable to answer the question about what is causing these undiagnosed illnesses. Unfortunately, the report by the Presidential Advisory Committee on Gulf War Veterans' Illnesses does not provide any concrete answers to this question.
    While the PAC has stated that veterans clearly have service-connected illnesses, they conclude that current scientific evidence does not demonstrate a causal connection between so-called Persian Gulf illness and the environmental risk factors that veterans were exposed to in the Persian Gulf.
    The PAC report focuses on stress as a likely contributing factor to the broad range of psychological and physiological illnesses currently being reported by these veterans. It is noted that based on decades of clinical observation, physicians recognize that many physical and psychological diagnosis are the consequences of stress. The PAC concluded that, ''Stress can be contributed to a broad range of physiological and psychological illnesses. Stress is likely to be an important contributing factor to the broad range of illnesses currently being reported by Gulf War veterans.''
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    We note with great interest the statement that decades of clinical observations demonstrate a causal connection between stress and many physical and psychological diagnosis. For decades, the VA has denied any connection between service-connected post traumatic stress disorder and most physical or psychological disabilities. Veterans have routinely been unsuccessful in attempts to obtain service connection for other disabilities secondary to post traumatic stress disorder.
    Should Congress decide to give VA the authority to provide benefits or services to children of Persian Gulf veterans, as suggested by the PAC, because of the adverse health effects resulting from their parent's service experience, current VA programs and benefits will have to be cut to satisfy these new services. Therefore, we call upon the Committee to assist us in returning the excess Gardner Funds to VA for use by the VA to implement or enhance programs and/or benefits.
    In conclusion, let me state that the PAC report has offered important suggestions and recommendations with regards to dealing with the current problems in health care and outreach needs of Persian Gulf veterans. Unfortunately, we are not provided with any concrete answers as to what is causing their illnesses.
    Mr. Chairman, we call upon this committee, the entire Congress, VA, DOD, Health and Human Services, and all other departments and agencies involved in Gulf War illness to continue to seek answers to explain the mysteries surrounding the illnesses suffered by Persian Gulf veterans.
    This concludes my statement. I would be happy to answer any questions.
    [The prepared statement of Mr. Violante appears on p. 380.]
    The CHAIRMAN. Thank you, sir. Mr. Ford.

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    Mr. FORD. Thank you, Mr. Chairman, and Members of the Committee for allowing me to testify today on behalf of the National Gulf War Resource Center.
    We found that the PAC concluded, and I quote, ''Most DOD and VA outreach efforts concentrate on publicizing the clinical evaluation programs, then referring participants to them—these efforts do not fully educate veterans or sufficiently build their trust that the Government's efforts to help them are comprehensive.''
    They have ''not established clear pathways for veterans to provide feedback about clinical programs and/or concerns regarding exposures; nor have they canvassed Gulf War veterans' community regarding better methods of communication. It appears the only way in which a veteran can provide feedback would be through contact with the clinical personnel at local VA medical centers or military hospitals. This however does not appear to be a likely route for transmitting concerns to decision makers.''
    We veterans can assure you that his has been a serious problem from the start. In November of 1995, the PAC began visiting VA and DOD medical facilities. The facilities that they visited by their very nature are some of the better facilities treating Persian Gulf illnesses, and does not reflect a true representation of the level of care nationwide. Yet the PAC found serious problems even at these facilities.
    At several referral centers, it was noticed that ''the knowledge of level staff not specifically assigned to the registry or CCEP at both VA and DOD medical facilities was problematic. For example, the existence of the CCEP was largely unknown among staff at the VA facilities we visited.''
    They further quoted, ''clinical staff not directly involved in the VA's registry and DOD's CCEP are not well informed about the programs.'' Also, ''at the time of the Committee's site visits, some staff at VA medical facilities complained they were receiving less information about the program from VA central office than they felt needed.''
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    The Committee fails to mention that many VA Persian Gulf registry program coordinators also conduct Agent Orange, as well as compensation and pension appointments and exams, overburdening the often single individual. Therefore, Gulf War registry participants receive least consideration.
    The PAC says, ''The committee heard public comment at each meeting, citing insensitive attitudes on the part of the staff at both DOD and VA medical facilities.''
    ''Frequently, these reports by veterans and their families centered on a dismissive or cynical approach to the veterans' problems. The message received was that problems were not real or all in your head. Veterans who sought care after the Gulf War, but before the establishment of the Registry and CCEP appeared to suffer most from this treatment.''
    We veterans wish to know where are those veterans now, and how can the VA hope to repair this breach of trust and encourage these veterans to return to the system.
    Then I found this most interesting comment. ''Most facilities did not designate a separate clinic for phase I evaluations, seeking to mainstream participants as much as possible and reduce the possibility of symptom sharing.'' We wonder if the PAC assumes that over 100,000 ill Gulf War veterans from across the United States and around the world have shared their symptoms amongst themselves to conspire against the VA.
    From the first small group of Indiana veterans who came forward in 1992, a group that was dismissed as malingers, the symptoms reported have not changed. This seems to negate claims of so-called symptom sharing. This Government's trend of discounting reports from our own soldiers in favor of reports from Iraqi deserters, foreign governments, UN officials, and bureaucrats is disturbing.
    The PAC further found that ''VA has no policies in place to systematically address the concerns of Gulf War veterans regarding reproductive health.'' ''Both the Registry and CCEP programs are treatment programs, not research protocols. But the data have been used to generate research hypothesis.'' ''This committee and others have judged the protocol to be an excellent tool for diagnosing illness'', but we veterans must question then what is considered to be a useful tool for dealing with undiagnosable illnesses?
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    Yet the PAC asserts that ''DOD and VA have implemented innovative programs to help veterans cope with combat related stress.'' Then the ''Committee found that overall high-quality healthcare is [being] provided.''
    We find that since the majority of studies funded and nearly half of the studies completed to date were stress related, it is not surprising the Committee found stress to be an important contributing factor. It is also the subject area in which DOD and VA have provided the most information.
    We are also concerned about the FDA waiver, the process currently being used permitting DOD to evade legal safety requirements.
    ''The Committee also concluded that the unit locator has not proved to be a valuable tool for investigating exposure incidents.'' Therefore, we believed it should not be used to determine service connection based on a veteran's exposure at supposed unit locations.
    According to the PAC, ''DOD has conducted a superficial investigation of possible chemical warfare agent exposures that is unlikely to provide any credible answers to veterans and public questions.'' ''To ensure credibility and thoroughness, further investigation of possible chemical and biological warfare agents exposures during the Gulf War should be conducted by a group independent of the DOD.'' Yet the Pentagon will continue to be the lead investigative agency. We question the Committee's ability to provide credible answers, and in part because their report relies too heavily on information from agencies whose efforts have been criticized by the PAC as being superficial and inadequate.
    It also operates using consensus management. It may be a useful tool for looking at issues surrounding quality of VA care, but inappropriate for evaluating scientific research.
    Therefore, we request that any further investigation be conducted independent of any government agency and that all records and evidence the PAC now holds be turned over to Congress for proper and open investigation.
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    They also say that ''available data is sparse.'' ''Generalizable conclusions about the nature and extent of illnesses will come only from population-based epidemiological studies that will not be completed until well after the Committee disbands.''
    Their mission, and when I say they, the DOD, DHHS, and VA, to provide all veterans a complete health range of services necessary for medical problems that might be related to their deployment. We do not believe this has been done yet.
    Six years after the war, we still have no broad-based epidemiological data on the nature of the illnesses suffered by the veterans and their families. Mr. Chairman, it is now 6 years since the Persian Gulf War. We now know that veterans were exposed to a number of hazardous compounds which alone or in combination may be causing illnesses similar to those being reported. The Government still does not accept that these exposures may have resulted in our illnesses. We are still debating whether or not the Pentagon is involved in a coverup. It's time to move on.
    Time to presume that these exposures occurred. Time to initiative appropriate broad-based epidemiological studies for our veterans and their families. Time to enlist the support of independent scientists and researchers concerned about curing disease, not those who are more concerned about protecting their agency's bureaucratic interests.
    In conclusion, not only do I represent thousands of Gulf War veterans here today, I must note that I served with the 307th Engineer Battalion, and participated in the entire destruction of the Khamisiyah Weapons Depot facility in Iraq, and personally delivered and set the demolitions at the pit area containing tons of mustard agent.
    Finally, it is time that we stop investigating the investigation and move on to provide quality care to our veterans, and a review of the safety measures we implement to protect those still on active duty.
    Mr. Chairman, I thank you.
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    [The prepared statement of Mr. Ford appears on p. 387.]
    The CHAIRMAN. Thank you. Thank you, gentlemen. Mr. Evans
    Mr. EVANS. No questions.
    The CHAIRMAN. No questions. Dr. Cooksey.
    Dr. COOKSEY. So you were involved in the destruction of the weapons. Is that correct?
    Mr. FORD. I was in Khamisiyah from March 3 until March 15 of 1991. I hauled most of the demolition supplies for the entire operation.
    Dr. COOKSEY. You were aware of what you were destroying obviously.
    Mr. FORD. We were aware that we were denying Iraqi—the Iraqi forces munitions. We had no knowledge of any chemicals being present at Khamisiyah.
    Dr. COOKSEY. When did your symptoms begin?
    Mr. FORD. I am currently not expressing or showing any signs and symptoms of what we now know to be Gulf War illnesses.
    Dr. COOKSEY. Were either of you there?
    Mr. VIOLANTE. I was not.
    Mr. PUGLISI. I was in the Gulf War, yes, sir. I wasn't up around Khamisiyah. I was with the second Marine division in Saudi Arabia and Kuwait.
    Dr. COOKSEY. Are you still in the military?
    Mr. FORD. No, sir. I am not. I serve as the Executive Director of the National Gulf War Resource Center, which is a coalition of over two dozen grass roots Gulf War veterans' organizations from around the country as well as Britain.
    Dr. COOKSEY. What is your profession?
    Mr. FORD. This is my profession, sir.
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    Dr. COOKSEY. Okay. I am impressed with your testimony. Very significant.
    Thank you, Mr. Chairman.
    The CHAIRMAN. Dr. Snyder? Mrs. Chenoweth? Mr. Bachus? Mr. Bilirakis?
    Mr. BILIRAKIS. Mr. Chairman, I have no questions. But I just wanted to point out I am always very proud to point out that many of the Department of Veterans Affairs people stayed for the full hearing. So they are here to listen to these gentlemen, as well as to the three Gulf vets who are coming forward afterwards. I thought I would point that out, because I think it's just very good of them to do that. Thank you, sir.
    The CHAIRMAN. Thank you, Mike.
    Gentlemen, thank you very much.
    If we can have the final panel, please. We have three Persian Gulf War veterans, Mr. David Smith, Mr. Carl Wickline, and Mr. Derek Davis.
    Mr. Smith, since your name is first on the list, we'll start with you, please. If you would keep your remarks to 5 minutes, your entire statement will be printed in the record. Thank you, sir.



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    Mr. SMITH. Good afternoon, Honorable Chairman and Committee Members. Thank you for the opportunity to testify. I am David Troy Smith, a former United States Marine NCO who honorably discharged July 12, 1991, after 9 years of service. This ended with the Ninth Communications Battalion, First Surveillance, Reconnaissance, Intelligence Group in Operations Desert Shield and Storm from August 10, 1990, to April of 1991.
    Prior to deployment in Persian Gulf, I participated in the Marine Corps athletic program from 1986 through 1990. During this period I earned from the Department of Defense four certificates of achievement for athletic endeavors, and six all marine certificates for wresting, power lifting, and track and field, including competition at four United States national championships and five military national championships.
    I maintained unit integrity with microwave communications as a senior NCO with a secret security clearance. My career began as a marine series honor graduate. With these accomplishments behind me, I felt my personal mission in the United States Marine Corps was complete. I secured a job as a manger of a World Gym in New Jersey, where I won the state power lifting championship for the 242 pound class.
    After moving to Idaho, I secured a job as woodshop supervisor for an international arcade game distributor, all the time trying not to recognize the medical problems, not wanting them to interfere with my objectives, that of having a wife and children, whose mother did not need to work.
    Now I sit before this Committee, a 32-year old father of two, VFW service officer and Idaho State commander for the Desert Storm Justice Foundation. I am officially bankrupt, totally disabled by the Social Security Administration. I am able to receive vocational rehabilitation from Social Security or the Department of Veterans Affairs, and until recently, had no sign of compensation from the Department of Veterans Affairs.
    My hope is to bring to light the suffering that many of our United States veterans confront daily and that something as powerful as this committee can affect the necessary changes to ensure aggressive treatment and compensation for all ill veterans.
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    The testimony I am giving is a brief history of the past 5 years of my medical battle with the VA. Some significant people are Senator Kempthorne's office, Congresswoman Chenoweth, the American Legion and its Gulf War Task Force, especially Mr. Carroll Williams, for bringing the problems to the attention of the VA Central Office in Washington, DC, who now are aware of the problems and have worked quickly to resolve the situation.
    Prior to my deployment to the Persian Gulf, I was weighted on a freight scale to verify that my weight was 263 pounds. However, within 2 weeks of the ground war, I developed high fever, diarrhea, severe weight loss, which ended in a 24-hour period loss of consciousness. When I awoke in my sleeping bag, I was face down soaking wet, and I had defecated on myself.
    This incident came within 72 hours of being forced to receive injections from the Battalion Aid Station where they tried to force me to sign a form that stated, ''By signing this form, you relieve the United States Government of any possible side effects of this medication.''
    When I departed the Persian Gulf in 1991, the bowel problem was sporadic and my weight was returning to normal. I returned to the United States and began processing for discharge. However, this was delayed when I was placed on medical hold for stomach problems. During the internal medicine consult at Camp Pendleton, CA, it was determined that it would take 3 months longer for the workup.
    To me, this did not seem something that marines should do. This was conveyed to the internal medicine doctor who assured me that if I discharged, it would be noted on my final physical and in my medical records. I was assured that the VA would take care of my problems so long as it was documented. I agreed to go to the VA upon discharge and was released because this problem was not life threatening, and my weight had returned to a point of 255 pounds.
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    I returned to my unit, and finished my discharge paperwork, and was told that my medical records would be sought by the VA once I went for treatment. Having been discharged in July of 1991, I was eager to get on with life. Although my medical problems became bothersome, I felt as a Marine, the headaches and diarrhea were trivial problems to bother a doctor for.
    When I was advised by an American Legion post commander and Vietnam veteran that the medical problems needed to be documented by the VA, a New Jersey State service officer arranged for my first examination with the medical system at East Orange, NJ, in September of 1991, less than 3 months after my discharge from the Gulf.
    When I arrived for my visit to the doctor, it turned out to be a compensation and pension exam. During my exam, the doctor found no reason for the headaches, but recommended I see an opthamologist as part of the exam, who determined this was the cause of my headaches, and a prescription for glasses were issued.
    In September of 1992, I sought treatment at a Walla Walla VA Medical Center because at this time, the bowel problem had turned into explosive diarrhea that manifested without warning and the headaches were severe. The problems continued, and I was assigned a primary physician. From 1992 through July of 1994, I underwent numerous consultations with mental health, opthamology, neurology, and gastro-intestinal, all with varying diagnoses. Yet none were followed by my primary care physician.
    During this time, I also underwent two compensation and pension examinations with noted varying problems. Results were received in 1994 of the Persian Gulf Registry physical, which stated, ''Chronic diarrhea etiology unknown and chronic joint pain despite lack of findings.'' This was the last I heard from the medical side, yet mental health encouraged me to attend post traumatic group therapy. I did not see the necessity for therapy because flashbacks, bad dreams and problem adjusting to civilized world were expected.
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    I collapsed, in September of 1994, I collapsed on my kitchen floor too weak and from pain and had defecated on myself again. My wife became concerned. Through the intervention of Senator Kempthorne's office, I was given a medical appointment within 24 hours at Walla Walla VA Hospital for referral to the Persian Gulf Workup Center. Once my referral was in process, I became concerned as to what was expected and how would I support my wife and two children. Upon contacting the Persian Gulf coordinator at Walla Walla Hospital, her response was, I can try applying for welfare, go to my family or my friends or my church.
    I then contacted my referring nurse. She also did not know anything. I was given a number to contact the program director's office in West LA. The information he conveyed was quite disturbing.
    Upon arrival to West LA, I immediately became aware of what a teaching hospital was about. The problems I was forced to deal with during my actual 39 day stay were numerous. A good portion of the stay I maintained a journal to track exactly what was happening.
    My roommate was a 30-year retired Army sergeant major who was dying of cancer. He instilled a very stern warning. Watch the VA for PTSD therapy and any kind of narcotic painkillers.
    In December 2, 1994, I discharged with seven noted medical problems and nine medications, ranging from morphine to prozac. The last thing I did was go to records and sign the release of information for a complete copy of all medical records once they became available. Again, Senator Kempthorne was involved to get the records transferred and my copy of the records, which now carried a stamp that stated, ''These documents or records or information contained therein are deemed confidential and privileged information with fines up to $20,000 for violations.''
    Would you like me to wrap it up?
    The CHAIRMAN. If you would, sir. We appreciate your willingness to wait all this time. We will you allow you to go on, if you could kind of wrap it up.
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    Mr. SMITH. I only have one more page, sir.
    Upon arrival at Walla Walla, December 8, 1994, we had anticipated some problems, only arriving with a single discharge and a primary care physician who did not think I was sick. I was met by a nurse who told me the only thing that could be done was to schedule an appointment for 30 days from now, January 8, 1995.
    I then inquired about the medications which were to expire January 1, 1995, and was assured if I called the prescriptions one week prior, they would be refilled. What she did not say was this was at doctor's discretion.
    When I returned on January 8, to see my primary care physician, my records had not arrived from West LA, and he did not agree with the findings of the West Los Angeles hospital. This was the reason for not renewing the medications. The problem with stopping my medication for morphine without warning, was I had been on this narcotic for 2 months straight.
    I called Dr. Ronald Hamm for assistance in processing my medical records because treatment would not be continued until my complete medical file was present. He assured me the records were en route. The only thing he could offer me was a detoxification center in West Los Angeles, CA.
    February 5, 1995, is the last time I saw my primary care physician, who felt there was nothing else he could do for me. Mental health continued to offer treatment. I self-admitted October 2, 1995. During this time, I received group therapy once a day and no other treatment, even though more workups were ordered.
    The last time I received anything from Walla Walla Hospital, was a letter telling me that I was not eligible for treatment until service connection for medical problems was established. I tried to seek treatment at other hospitals, but with the same result. No treatment until service connection is established.
    A private dermatologist wrote a letter stating that diagnosis of a biopsy on my forehead that swelled out and it prompted a referral to infectious disease on January 16 of this year by a doctor I have not been examined by for over 2 years.
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    In closing, the chance to present my story before this committee is an honor and a privilege. Yet I have considerable concern that it takes a hearing by this House Committee to shed light on the problems that thousands of veterans are encountering daily after service to this country, much like myself, who clearly needed help to acquire medical attention. This, from a system that was established as Abraham Lincoln stated, ''To care for him who shall have borne the battle, and for his widow and his orphan.
    Thank you for the opportunity to appear before this Committee.
    [The prepared statement of Mr. Smith appears on p. 397.]
    The CHAIRMAN. Thank you, Mr. Smith. We'll get back to you in a minute.
    Mr. Wickline, if you would pull a mike over just as close as possible, we're ready to hear your statement.


    Mr. WICKLINE. Thank you, Mr. Chairman. My name is Carl Wickline. I am a Gulf War veteran with numerous physical symptoms which I believe to be a direct result of exposures encountered while in service in Saudi Arabia and Kuwait.
    I served in the United States Marine Corps from November 1988, to August 1993, during which time I was deployed to Saudi Arabia with the Third Light Armored Infantry Battalion, in September 1990, for Operations Desert Shield and Operation Desert Storm. I remained with this unit until I was honorably discharged from the Marine Corps in August, 1993.
    While in the theater of operations within Southwest Asia, our unit provided tactical mobile ground combat support within the northeast area of Saudi Arabia, moving north from King Fahd International Airport to Jubayl, the Chicken Ranch, Manifa Bay, First Marine Division Support activity, Khafji and tactical support positions along the southern border of Kuwait.
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    During operations Desert Shield and Desert Storm, there were prolonged exposures to burning oil well fires, smoke, ash, minefields, which contained gas mines, artillery fire, enemy small arms fire, destroyed armored vehicles, spent ordinance air and artillery, dead bodies, human and animal, and enemy bunkers which we destroyed with explosives.
    Military operations within Kuwait ranged as far north as the Kuwait International Airport, often in blackout conditions due to the thick black smoke which blocked all light at times.
    Multiple symptoms began to become noticeable shortly after returning to the United States. Symptoms have included the following. Recurring severe headaches, chronic fatigue, recurring neuromuscular back pain, short-term memory loss, lapses in concentration, severe rash, depression which medication has not successfully treated, night sweats, insomnia, severe gastro-intestinal problems, blurred vision, photosensitivity, bleeding gums, immune system inefficiency, and multiple chemical sensitivities.
    Shortly after my return from the Gulf in 1991, my wife and I began to notice symptoms which we felt may have been the result of my service in the Gulf. As I sought medical treatment through the military prior to my discharge, I encountered several problems. First, although I was ill, doctors found no explanation for the symptoms.
    Second, I was refused treatment by at least one internal medicine specialist, due to the fact that he could not diagnose the problem and that medications did not alleviate the symptoms and often made the symptoms worse.
    Third, I was told by several medical professionals within the military that they understood I was sick, but I would have to learn to live with the symptoms.
    It was suggested to me that I was crazy or at least mentally unbalanced. Also, when I began treatment with a doctor, a civilian doctor in early 1993, I was threatened by military medical officers and personnel with court marshall, due to the fact that I had gone over their heads.
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    I would like to make three side notes before I talk about my experiences with the VA medical side. First of all, note that the Gulf War illness as well as hepatitis contracted in the Gulf were annotated on my discharge physical prior to separation from service. Second, it's also interesting to note that I applied for reenlistment in the Marine Corps in November, 1993, and was denied due to medical condition. Third, I have been denied healthcare insurance on two occasions since my discharge due to Gulf War syndrome, specifically.
    My first contact with the VA came shortly after being discharged from service. In September 1993, I filed a claim which sited both active duty medical records and discharge physical as support for this syndrome which has been so hard to diagnose and treat. Initially the complaints for these symptoms were overlooked, while I was referred to mental health for evaluation and treatment for depression.
    Several attempts were made to go through the out-patient clinic at the Lexington, Kentucky VA hospital. On each occasion I came in complaining of the same symptoms, with similar results each time. Attempts were made to alleviate the symptoms with medications. Most of these attempts were unsuccessful.
    Basic blood tests have been done, but any actual research or in-depth testing has been overlooked. Neurological workup has been done. However, the results were inconclusive, and no further testing has been done.
    It seems that I end up in the same place each time I attempt to contact the VA concerning my illness. Mental health must be the deadend for all cases which the VA has no knowledge or interest in treating. I have been prescribed several medications, none of which have had any effect other than to increase fatigue and gastro-intestinal problems.
    My most recent visit to the VA was the 16th of December, 1996, in Oklahoma City. At this meeting, I provided the doctor with a complete list of symptoms, as well as test results from several professional medical labs, along with diagnosis from a doctor in Santa Ana, CA.
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    I was told by this doctor that he was not interested in seeing any of the documentation which I had provided for him. I was told he did not have time to look at my paperwork and that I was obviously suffering from depression and possibly hypertension, after which I was prescribed an anti-depressant and a stomach medication. A return appointment and basic blood work were requested and have been scheduled.
    Once again I find myself in the same spot in which I always seem to find myself. The issues have once again been side-stepped and I still suffer from the same symptoms which I have seen no honest attempts towards diagnosis or treatment. Thank you.
    [The prepared statement of Mr. Wickline appears on p. 412.]
    The CHAIRMAN. Thank you, sir. Mr. Davis.


    Mr. DAVIS. Mr. Chairman and Members of the Committee, my name is Derek Davis. As a veteran of the Persian Gulf War, I appreciate the opportunity to testify today. My service in the Gulf was as a commander of the Army National Guard's 276th Military Police Company. My company was deployed to the Gulf in February of 1991, after approximately a month medical screening and final training at Fort Meade, Maryland.
    Our pre-deployment medical screening was very thorough, much more so than at the separation after returning from the Gulf. Several men did not deploy because of health problems that were uncovered. Those who left from Saudi were in excellent health and top physical shape. Ours was a cracker-jack company which had served several overseas missions with distinction, to include Panama and Hurricane Hugo.
    My company's mission in Saudi Arabia was to provide security for a large ammunition supply point in a desert area approximately 10 miles from Khobar. The company area where my company bunked and took our meals was just downhill from a munitions storage area. Within the first few weeks, first weeks after getting in-country in February, I became aware that several of my men were becoming ill, with difficulty in breathing, runny eyes, and diarrhea. Several men were hospitalized.
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    Because of suspicions that living and working full-time in close proximity to the munitions storage area had something to do with their illness, these illnesses, I requested a change in the location of our camp area and recommended the establishment of rotating duty shifts to cover the security requirements. These recommendations were accepted.
    I also asked headquarters to conduct a survey of the site to see what was wrong. An environmental assessment was conducted on May 15, 1991. I received a copy of a memorandum which I asked to be placed in the record, which states that this site, ASP Quarry, and I quote, ''has now been identified as containing significant respiratory hazards, both in the form of toxic gases and various airborne particulates.''
    The memo from a headquarters physician made reference to protective masks which had been found successful in filtering out particulates, and stated, ''It is vital that a protective mask of the above type be made available to every soldier who will be on duty in the ASP Quarry.'' Many of my men were alarmed by the issuance of these masks, but we wore them while on security rotations. My request to my brigade commander for a copy of this environmental report received no response.
    I do not have personal knowledge of what we may have been exposed to as ASP Quarry, but in attending a very high level meeting at a later date, I heard a conversation among high ranking officers that indicated that unconventional, highly classified ordnance was among the ordnance stored there.
    My company's experience in Saudi also included numerous warnings of SCUD launches. After many false alarms, my men had become more relaxed about the loud warnings, SCUD launch, but we were less than a mile from the SCUD that killed 23 men. I was relatively lucky. I only sustained a concussion in seeking cover from the clearly visible incoming rocket. The injury led to a total loss of hearing in my right ear.
    I am proud of my service in Saudi, and of the Bronze Star and Army Commendation Medal I received for that service. I am convinced, however, that something other than my hearing loss happened to me and to numerous of my men in the Persian Gulf. I began to have many problems almost as soon as I returned to the States. I couldn't pinpoint a cause, but I had difficulty sleeping, difficulty in breathing, and was constantly fatigued, had joint pain, memory loss, and stomach problems. I had had none of these problems before serving in Saudi.
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    I had been a relatively high achiever before my service. I completed college studies, earning a BA degree from the University of Maryland, College Park. I was unprepared, however, to deal with the health problems I experienced after returning from Saudi Arabia. I regret that I turned to alcohol to mask my pain. Only after serious family problems did I stop drinking, and I have been active in AA since 1993.
    My health problems did not improve. Finally, with the establishment of the VA Registry program several years later, I turned to VA. I was evaluated extensively by the VA Medical Center in Washington, DC, and later by Walter Reed Army Medical Center. These evaluations, which included extensive testing during a period of VA hospitalization, led to my being diagnosed as suffering from sleep apnea, fibromyalgia, degenerative joint disease, and PTSD.
    I especially want to acknowledge that I have gotten a lot of help from VA Medical Center's PTSD program, and I have a very high regard for the clinical staff. They have helped me cope with what I am going through. I continue to be under treatment from VA and receive medication. My other medical problems still give me a lot of trouble though. I have almost come to accept that if VA and Walter Reed have been unable to resolve these problems, that they are not likely to get better, and I will have to learn to live with them.
    As one who served in war for this country, and I believe became sick as a result, I do expect that those who work to assist veterans will be empathetic, and give me some special consideration. Many VA clinicians and staff have done just that, and I do want to acknowledge that. For example, when I have had problems there, the VA patient-advocate at the Washington VA Medical Center has jumped right on it and resolved them, but there have been frustrations.
    If it is not possible to cure my problems, my health problems, I believe the Government should acknowledge that they are due to military service and provide appropriate compensation benefits and vocational rehabilitation, because it is increasingly difficult with my joint pain to work at a job that requires me to stand all day. Unfortunately, I have had a lot of problems getting favorable actions of any type on my claim for service-connection, which I first filed years ago. Even my hearing loss, which is documented in my military medical records in 1991, has yet to be adjudicated as service-connected.
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    While the many physicians that have treated or evaluated me have generally been concerned, a few seemed like they were just going through the motions. In one particularly upsetting case, a psychologist at Walter Reed wrote a statement in my medical records to the effect that I might be faking these symptoms.
    It is also unsettling to have to wait about 4 months to undergo VA testing for a severe sleep disorder. This negative experience I have had as a patient, such as long waits to discuss my case with a physician, an error in my medication, and being billed in error for care that was supposed to be free. It may seem trivial, but after years of battling these health problems, even small issues become large.
    In closing, let me say that I am testifying not just for myself, but for the many others who are also hurting. Although I am not the man I was when I left for Saudi Arabia, many of my troops are still looking to me to take care of them. I hope this Committee will help me help them. Thank you.
    [The prepared statement of Mr. Davis, with attachment, appears on p. 403.]

    The CHAIRMAN. Thank you, Mr. Davis. Thank all of you. Your testimonies will be very helpful. Mr. Evans.
    Mr. EVANS. Thank you, Mr. Chairman. I think it's been very important to have the human carnage of this war come before us today. I say that because I know it's not real easy for you guys to bring forth these problems. You are not malingerers. You are hard workers. You had excellent service records going over to the Gulf. I appreciate that very much. So I appreciate you being with us here today.
    Mr. Davis, you are discharged now from the National Guard at this point?
    Mr. DAVIS. That's correct.
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    Mr. EVANS. This is a locally based command?
    Mr. DAVIS. Yes. It's locally based.
    Mr. EVANS. Have you been able to keep in touch with other members that were with you in Saudi Arabia?
    Mr. DAVIS. Yes. I talk to them very frequently. In fact, some, a few of them are in the PTSD program with me at VA Medical Hospital here in Washington, DC. I get a lot of calls from my troops who served with me in the Gulf. They let me know how they are doing, their families are doing. Just running into them from time to time on the streets.
    Mr. EVANS. How are they doing?
    Mr. DAVIS. A lot of them are sick. A lot of them are ill. A lot of them are confused. One of my troops told me he had a parasite in his blood they found up at VA. Another one had a rash, butterfly rash on the back of his back. One my female troops I happened to run into had this rash all over her body. One of my troops shortly, and I guess within a week after returning from the Gulf died. They said it was heart, respiratory failure. That's Bernard Griffin, who we established an American Legion post 276 in his name. Another one of my troops, we called him Radar. I can't recall his name right now, forgive me for that. He's had testicle cancer. He never smoked or drank. He was one of those guys, if you watched MASH, he was like a radar. Just one of those nice humble guys. So there has been some illness.
    Mr. EVANS. Has there been any follow-up by the Department of Defense in investigating that specific unit, given the fact that you might have been exposed, I take it, to some kind of chemicals out of that ammo bunker? Was there any follow-up at all by the Department of Defense after you shifted to rotating?
    Mr. DAVIS. No. There is document. I hope you all have a copy of that. But the document that they did the environmental study out there, in which they brought out special masks for us to wear, for my troops to wear, everyone of them showed their document to, has always just handed it back to me. I do know a lot of people that got sick and special masks were provided. Nobody from DOD has called or contacted me or anybody in my unit that I know of.
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    (See p. 409.)

    Mr. EVANS. All right. Let me ask everybody on the panel. Do you have any specific recommendations on how the VA can improve healthcare programs for Persian Gulf veterans?
    Mr. SMITH. I would say first that the communication between hospitals, even within the hospitals needs to be addressed. If I can talk, I'm from Idaho. I flew out here to testify. If I can talk to somebody on the east coast with the Internet on my computer, there's no reason that the VA hospital shouldn't be able to talk from the travel clerk to the admissions clerk. I have run into that many times. That would be my biggest suggestion, communications.
    Mr. EVANS. Anybody else?
    Mr. WICKLINE. I think that I'm going to refer to this Persian Gulf War Illness fact sheet that I picked up when I came in this afternoon. So far, I haven't been offered all of these things through the VA. Possibly if everything on here was offered to us, then perhaps some things might be getting done, to put it quite bluntly.
    Mr. DAVIS. I am sorry. Could you repeat your question again?
    Mr. EVANS. What recommendations would you give to us to improve VA health care for Persian Gulf veterans?
    Mr. DAVIS. I think sensitivity is one. Maybe some, I guess what we call in our civilian world, staff development. Maybe some concern, people concerned in the sensitivity to the troops or to their patients that come up there that have had these medical problems I think would help a lot.
    I find, and even for myself, one of the main things and I have expressed that with some people here, I would rather not call their names because I don't know whether they would want their names called, but just somebody to listen to the nature of their problems and then getting on with it helps a lot. So I say communication and sensitivity.
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    Mr. EVANS. Thank you, Mr. Chairman.
    The CHAIRMAN. Dr. Cooksey.
    Dr. COOKSEY. Thank you, Mr. Chairman. First, I want to thank you veterans of this Gulf War for coming here, first for serving, and then for coming here today and expressing your symptoms. That means a lot to me, and it lends a lot of credibility to your complaints.
    I can assure you that as a new member of this committee, we will work very hard to find out what the problem is. First, we have got to find the cause of it. Then we can do something about the treatment.
    In the meantime, I can assure you that for myself, and I feel that the other members of the committee, we will work hard to make sure that the Veterans Hospital responds as best they can to your health care needs, because that is what we are all about.
    We do need to continue to have a strong military. We will probably face more problems like this in future wars. It will be the youth, as always, that fight the war. It's never a grey-headed old politician. They are the ones that get us into the war. The youth fights it. But we need to look out for you.
    Thank you, Mr. Chairman.
    The CHAIRMAN. Thank you, sir. Dr. Snyder? Mrs. Chenoweth?
    Mrs. CHENOWETH. Mr. Chairman, I want to thank you, this being the 11th hearing on this particular subject. I really appreciate your dedication to solving the problems. I appreciate the fact that you ushered through the House and to passage into final law, Public Law 104, 262, which authorized the Department of Veterans Affairs to give priority health care to our veterans. That is part of the question that I was asking about where is the threshold where they will determine that a veteran should receive priority care.
    So again, Mr. Chairman, thank you very much. I would like to work with the Committee on that threshold.
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    The CHAIRMAN. Thank you. We look forward to it.
    Mrs. CHENOWETH. David Smith, thank you for coming, and your wife Debbie, at great expense I know. But it's something else you are doing for the country. I really really appreciate you.
    You talked about your physical condition before you went into Desert Storm. Did you by chance remember having blood drawn before you went into the service, I mean before you were in active duty at Desert Storm?
    Mr. SMITH. None, no, as far as I know. I didn't have any. I rarely saw a doctor during my 9 years of service.
    Mrs. CHENOWETH. I asked that because the VA officials seemed to think that was important. I didn't know whether it was something that was normally done.
    Mr. SMITH. I was the first jump team out of my unit out of the ninth battalion. I said I was in Saudi on the 10th of August, not much time for anything.
    Mrs. CHENOWETH. And you were right on the front lines, weren't you?
    Mr. SMITH. I worked my way to the front line. Yes, ma'am.
    Mrs. CHENOWETH. Yes. Has your illness changed your quality of life?
    Mr. SMITH. The quality of my life was affected all the way from being able to eat to my bedroom with my wife. I have been told by the VA not to have unprotected sex with my wife. We have been married 4 years.
    Mrs. CHENOWETH. David, what is the prognosis of your illness?
    Mr. SMITH. I have a list of medical conditions. I have been told my condition was considered terminal by a VA doctor. I have that letter, if anyone would like to see it. Currently I receive 60 percent disability rating, dating back to the date of discharge. I received that on Friday, February 7, on the day before I left to come to this committee, after 5 years and 7 months of an open claim with no answer. They found clear and unmistakable errors in the rating decisions of 1992 and 1994. That's what the Phoenix office found. After a recommendation from Christine Moffit of the Central Office here in Washington, DC. This took you yourself and Senator Kempthorne and the American Legion Task Force to get this done.
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    Mrs. CHENOWETH. David, were part of those records that the new reassessment was based on, were those part of the records that were received with the stamp that if you give this to anybody, you might get a $20,000 fine?
    Mr. SMITH. Yes, ma'am. All those were submitted.
    Mrs. CHENOWETH. Were your medical records obtained easily by the VA? You have testified somewhat to that.
    Mr. SMITH. As far as I know, my records were not obtained by the VA. I have a letter from the Director of the Reserve Records Center to the commanding officer of the Ninth Communication Battalion that I pulled from my service record that states that my medical records never made it to the Reserve facility. That was the problem with my service-connected disabilities. Nobody could prove anything.
    Mrs. CHENOWETH. Are you aware of other veterans in Idaho or around the Lewiston area where you live who have run into these same bureaucratic entanglements?
    Mr. SMITH. Actually I have helped quite a few veterans try to receive treatment through the Department of Veterans Affairs from the Idaho area, over 20, that are not able to receive, are having to fight the Walla Walla Hospital for treatment.
    Mrs. CHENOWETH. David, did you sign a waiver of informed consent prior to receiving the inoculations for anthrax and botulism?
    Mr. SMITH. No. I did not. I received the shots and I was threatened with court marshall by the commanding officer of the medical BAS if I did not. I was raising a commotion, and I couldn't understand why that stamp was on the top of the form to sign. So I raised a commotion, and I was—I took the shots. I wouldn't have to sign the form.
    Mrs. CHENOWETH. How long, David, after taking the inoculations did your health begin to deteriorate?
    Mr. SMITH. Within 72 hours I had flown back from the front in a helicopter to pick up some gear. I picked up a vehicle and a van and I was headed back to the front, which is an 8-hour drive from my closest camp. I got sick on the way up there. The A driver had to take over.
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    Mrs. CHENOWETH. And that's when you lost consciousness and woke up— —
    Mr. SMITH. It went on into that. It went into a seven day period.
    Mrs. CHENOWETH. Thank you. Thank you, gentlemen.
    The CHAIRMAN. Mr. Reyes.
    Mr. REYES. Thank you, Mr. Chairman. I would like to echo the comments that we appreciate your service to your country.
    Mr. Smith, I just have one question. You stated that a VA doctor had told you you were terminal?
    Mr. SMITH. Yes, sir. From the West Los Angeles CCEP program. He was a consult for neurology, Dr. Baumzweiger, William Baumzweiger.
    Mr. REYES. And your compensation is 60 percent?
    Mr. SMITH. As of now, yes, sir. As of Friday I received a call from America Legion here in Washington, DC, who had received a call from Jack Garrison of Central Office notifying me that my compensation had been granted and I would have a check in 20 days.
    Mr. REYES. For 60 percent disability?
    Mr. SMITH. Yes, sir. Back to the day of discharge, July 12, 1991.
    Mr. REYES. Thank you. That's all.
    The CHAIRMAN. Thank you, sir. Mr. Bilirakis.
    Mr. BILIRAKIS. Mr. Chairman, just very quickly.
    Mr. Davis mentioned the pre-deployment medical screening and how thorough it was. You indicated that all the men going to the Gulf were in excellent health. Did you gentlemen experience that pre-deployment screening also, medical screening? Mr. Smith?
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    Mr. SMITH. No, sir. No pre-deployment screening.
    Mr. BILIRAKIS. You did not? Mr. Wickline?
    Mr. WICKLINE. Again, things were rather rushed so there wasn't a lot of screening done.
    Mr. BILIRAKIS. There wasn't a lot of screening done is what you said?
    Mr. WICKLINE. No. No.
    Mr. BILIRAKIS. So we really don't have a history before and after, if you will. If we do in Mr. Davis' case, and possibly your unit, but not in every case. Is that right?
    Mr. DAVIS. The reason why I guess I spoke to that was because we were a national guard unit. I guess if you were familiar with deployment, a lot of times National Guard Reserve units, they have to go to a mobilization process which takes a period of time.
    During that time, the months time, we had physicals, training, checkup this, checkup that, alarms calibrated and recalibrated, and calibrated again. They did go off several times over there. These things were supposed to be checked by the experts prior to going to deployment.
    As far as the question about the anthrax shot, it didn't appear in anybody's records in my unit, out of 160 something personnel. Every shot you get in the military appears in the shot record. It's annotated, it's supposed to be anyway. It doesn't appear in 160 some odd troops, that's immediate troops, prior to me becoming a base commander.
    Mr. BILIRAKIS. Mr. Smith, you said that in the 9 years that you were in, you didn't have any—you had physicals, obviously, didn't you?
    Mr. SMITH. Yes, sir. I was a first class. I maintained a first class PFT for the entire 9 years. I was also an elite athlete for the Marine Corps. As I stated, I earned four certificates of achievement from the Department of Defense.
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    Mr. BILIRAKIS. So as far as any medical history is concerned, there is something in the record. When would maybe the latest one have been closest to the deployment would you say?
    Mr. SMITH. My re-enlistment physical, 1987.
    Mr. BILIRAKIS. 1987, 4 years I guess before the deployment.
    Mr. Wickline, do you have any history in that regard? You have to have if you were— —
    Mr. WICKLINE. Of course there was some medical history. As far as a deployment physical, I don't really recall a specific deployment physical being done. We were pretty much lined up for shots and sent on our way.
    Mr. BILIRAKIS. But I believe there's some testimony earlier by one of the groups, I guess the VA or the DOD, to the effect that there are serum samples that are kept. So there would have been serum samples for each one of you.
    The CHAIRMAN. I don't think they did it then, Mike, but they are doing it now.
    Mr. BILIRAKIS. Oh. They are doing it now, but they did not do it then.
    Mr. SMITH. Right. They are just doing it now. They didn't do it back then.
    Mr. BILIRAKIS. Thank you, gentlemen. Thanks again for serving all of us.
    The CHAIRMAN. Any other questions? Let me ask a very quick question of you, Mr. Wickline. You mentioned a doctor that was not interested in your records. Was that a VA doctor at a VA hospital?
    Mr. WICKLINE. Yes. It was.
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    The CHAIRMAN. In Oklahoma?
    Mr. WICKLINE. In Oklahoma, yes.
    The CHAIRMAN. Thank you.
    Mr. WICKLINE. Can I mention, sir? This isn't an isolated incident. This has happened nearly every time I have walked into a VA hospital. If I walk into a VA hospital, go to the out-patient clinic or make an appointment with a doctor, specifically ask to be treated for Gulf War illness, I am denied plain and simple. I specifically asked the doctor, are there not facilities set up for the treatment and diagnosis of Gulf War illnesses, he said yes, but they are not available to you. I have gotten this answer numerous times. This is not an isolated incident.
    Mr. BILIRAKIS. Mr. Chairman, I wrote it down. Forgive me, I hope I didn't interrupt before you finished. I wrote a statement down by one of the gentleman who testified earlier. The veterans should contact the VA Administration and tell them that they want to be treated for Gulf War Syndrome.
    Mr. WICKLINE. I contacted the patient representatives at the VA hospital who were supposed to be our liaison with the VA health care organizations. I was told by them that they could not do anything more than schedule appointments. So I scheduled an appointment. Every time I call them, I schedule an appointment.
    The CHAIRMAN. Gentlemen, thank you very much. We appreciate your service to this country. We appreciate your patience for waiting today. This committee will do everything we can to expedite this procedure. Thank you very much. Thanks to the Members for having the patience to sit here through this long meeting. Thank you very much. If there's no objection, the meeting is adjourned.
    [Whereupon, at 5:44 p.m., the subcommittee adjourned, subject to the call of the Chair.]
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