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House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, DC.

    The subcommittee met, pursuant to notice, at 9:38 a.m., in room 334, Cannon House Office Building, Hon. Cliff Stearns (chairman of the subcommittee) presiding.
    Present: Representatives Stearns, Smith, Bilirakis, Cooksey, Hutchinson, Gutierrez, Kennedy, Peterson, and Evans (ex officio).


    Mr. STEARNS (presiding). The committee will come to order.
    Our subcommittee meets this morning to continue our review of issues raised by the U.S. troops' participation in the Persian Gulf War and to examine VA's sexual trauma counseling program.
    In the Veterans' Health Care Act of 1992, Congress enacted the first of several measures to address the health problems of Persian Gulf War veterans. In that law, Congress also established a specific authority for VA to provide counseling to women veterans to overcome sexual trauma in service. The specific statutory authorities under which VA provides trauma counseling and treatment for Persian Gulf War veterans will expire on December 31. This hearing can help guide us as we consider the need for further legislation.
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    Certainly the Veterans' Affairs Committee and this subcommittee have a long record of oversight on the health status of Persian Gulf veterans. As we've learned, scientists have not identified any single Gulf War illness or any single cause for the illness seen in these veterans. There remains large, unanswered questions about the nature and prevalence of their illnesses.
    This hearing, however, provides us an opportunity to provide the Persian Gulf veterans' experience in the broader context of the military combat experience generally. A recent study on a group of World War II veterans, for example, found that overseas combat was a significant predictor of a physical decline or death in the 15 years after the war. Another important study concluded that unexplained war-related illnesses with symptoms similar to those reported in Persian Gulf veterans have been documented after wars from the Civil War on.
    These and other studies led me to develop legislation which I believe can help us apply lessons painfully learned from our Persian Gulf experience, our hearings record on Gulf war illnesses, and the medical literature highlighting the importance of early treatment in overcoming health problems thought to be linked to wartime service.
    Conversely, the failure to address war-related health problems early and effectively can lead to chronic illness. At the same time, it has become very clear that medicine lacks a full understanding of how some of these war-related diseases develop and how to best treat them.
    In my view, the Department of Veterans Affairs, working closely with the Defense Department, can and should be a leader in fostering research on war-related illnesses, in developing improved treatment techniques, and in disseminating its findings.
    The legislation I've developed would call for VA to establish a national center for war-related illnesses to carry out needed research, treatment, and training.
    The bill would also create a broad new authority for VA to provide needed care for veterans of future combat missions and would extend and expand VA's special authority to treat Persian Gulf veterans.
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    I particularly appreciate the enthusiastic support expressed for the bill by our largest national veterans' organization, the American Legion, and by others. I welcome the opportunity to obtain testimony on this legislation as well as to hear testimony on VA's sexual trauma counseling program.
    Before calling on my first panel of witnesses, let me turn to my good friend and ranking member of the subcommittee, Mr. Gutierrez, for an opening statement.


    Mr. GUTIERREZ. Thank you, Chairman Stearns, and allow me commend you on your work as chairman of the subcommittee. Your commitment to ensuring that this subcommittee addresses the most important issues affecting the health care provided to our Nation's veterans should be duly noted by all those who follow these matters.
    Today, in reviewing the research and treatment of war-related illnesses and Department of Veterans Affairs sexual trauma counseling program, this committee is once again demonstrating its dedication to improving veterans' medical care.
    Mr. Chairman, our country has been compelled to restore peace to the world and protect the interest of our people many times during the past half century. We are living in a time of relative peace today, but we cannot be sure that threats to our freedom and national security will not arise again. Thus, we must be prepared as a nation for this unfortunate possibility. When I say prepared, I do not just mean with new weapons and technology. I also mean we must be prepared to deal with the possibility that thousands of brave men and women who serve in future conflicts may come home from war sicker than when they left. These veterans may also suffer from complex illnesses that we cannot readily diagnose. We must be prepared for this event, so that we do not repeat the failures of the past. We must be prepared, so that we do not treat future veterans as we have those who have served in Vietnam and the Persian Gulf. We must be able to provide answers and sound treatments for future veterans, and we must develop these procedures now for those who served in Operation Desert Storm and Southeast Asia.
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    I am pleased that this subcommittee will look at ways to address this issue today. Anticipating our future obligations and improving our current programs that help the veterans of America heal from war-related illnesses are wise steps for us to take.
    I'm also encouraged that this morning we will address another issue of the utmost importance to the future of veterans' health care. In July of last year, I introduced the Veterans' Sexual Trauma Treatment Act. I did so because I believe that Congress must improve the current law governing the provision of sexual trauma counseling at the VA. In conversations with women veterans and VA medical practitioners, I've also learned about significant gaps in the law that have prevented some veterans from receiving this needed care for sexual trauma. Sixty-seven Members of Congress, including thirteen members of the House of Veterans' Affairs Committee, co-sponsored my legislation to eliminate these discrepancies and improve health care for our veterans.
    I want to briefly summarize the important highlights of this bill. Current law does not govern, Mr. Chairman, for veterans who have served less than 24 months in the military. Yet we know, from Aberdeen and other high-profile incidents of sexual violence in the military, that often the victims of these crimes suffer these incidents in the early months of their service. Often, these crimes go unreported. Because of the drama caused by these actions and the stress of working with offenders, these women are often discharged prior to the 24-month period. Upon discharge, our laws do not enable those veterans to receive the care they need and deserve to overcome the varied physiological and psychological effects of sexual trauma. This is wrong. The VA is wrong and is taking steps to address the problem. The VA General Counsel has stated that the 2-year service requirement no longer applies to the VA sexual trauma program. I strongly commend this interpretation of the law.
    By caring for veterans who have no choice but to leave the military because they have served 2 years because of sexual harassment or abuse should not be a matter of interpretation. It should be a matter of law. My bill will achieve this goal.
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    In addition, Reservists and National Guard personnel who have been the victims of these terrible crimes while on duty should also be eligible to receive sexual trauma counseling. My bill would qualify them to do so.
    Ensuring that all veterans in need receive sexual trauma counseling and treatment also demands that we make the VA program required. Currently, the VA has the authority to provide this care for veterans, but the law does not mandate that the VA do so. Under its current leadership, the VA has done a commendable job in establishing a sexual trauma program throughout our Nation. However, cases have been documented where VA officials have denied trauma counseling to veterans who need and qualify for these services. In addition, many VA medical facilities in regions of our Nation are not adequately served by this program.
    Revising the law to mandate the continuation of VA's sexual trauma program to take care of veterans who were the victims of abuse and harassment during their military service a priority is a goal this committee, this Congress, and the VA should work to achieve. I strongly believe that our Government has a responsibility, that it should be required to ensure treatment for women of sexual abuse and harassment. These women made the highest commitment to our freedom. They pledged to serve and protect our people and, sadly, their own safety and honor were compromised. We must do more to protect women in the military from future incidents, just as important as to acknowledge our responsibility to aid veterans already suffering the consequences of sexual trauma. Failure to accept this challenge is an affront to all veterans who have defended America.
    Mr. Chairman, thank you again for your interest in this matter. I look forward to working with you to re-authorize and make the improvement necessary.
    I also want to applaud the work of the VA employees and women veterans such as Joan Furey and Andrea Van Horn. You are absolutely critical to providing all our veterans with the quality care they deserve and require. I also want to thank the veterans' community and service organizations who have contributed so much to our knowledge and understanding of these issues. I truly appreciate their assistance.
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    Thank you once again, Mr. Chairman.
    Mr. STEARNS. Thank you. Mr. Evans, the ranking member of the full committee.


    Mr. EVANS. Thank you, Mr. Chairman. I will try to keep my remarks very brief since we have a full agenda. I do want to compliment you for the work you're doing in this area. I think it's bipartisan concern that we've seen on this committee, and I'm very pleased to see that the draft legislation we'll be discussing today offers another approach to addressing the problems that veterans of the Persian Gulf continue to experience 7 years after their service to our country. But I would add, it's just one of the approaches that has been offered to the House Committee of Veterans' Affairs for review.
    While I'm eager to hear the experts from the scientific and Government agencies discuss this proposal, I am equally anxious for other bills, including my own comprehensive Persian Gulf bill and Mr. Kennedy's legislation, to have a fair hearing on those pieces of legislation. I hope that the chairman of the full committee will work with me to ensure that our committee consider more of these measures before it chooses which course is most appropriate for action.
    And I ask that my entire statement be added into the record at this time.
    Mr. STEARNS. So ordered.

    [The prepared statement of Congressman Evans appears on p. 49.]
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    Mr. STEARNS. Mr. Peterson? Mr. Kennedy?


    Mr. KENNEDY. Thank you very much, Mr. Chairman. First of all, Mr. Chairman, I want to thank you. I know that it's the tradition around here for everybody to compliment the ranking member on—excuse me—the chairman of the committee on whatever is happening, no matter how ridiculous. But in this particular case, I think you really do deserve some credit for the leadership that you have shown on this committee, Mr. Stearns. Your willingness to really take the lid off the top on many of the issues that have surrounded the Persian Gulf illness, in particular, is something that I think everybody on both sides of the aisle should commend you for. It's been a privilege to be on this subcommittee with you because of that independent spirit. So I just want to thank you very much for that.
    Mr. STEARNS. Thank you, I appreciate that.
    Mr. KENNEDY. Mr. Chairman, as you know, there have been very serious issues over our Nation's veterans and, in particular, in the last 7 years those Persian Gulf veterans who have suffered from a series of mysterious symptoms that have led to a variety of unexplained illnesses. Lane Evans and I held a hearing in Boston in 1992 to gather testimony from sick veterans, and at that hearing we learned of a myriad of illnesses from which Persian Gulf veterans suffer. At that time, we were unsure of the sources of those illnesses, and today we are still faced with many of these same unanswered questions. Mr. Chairman, I want to thank you for holding this hearing in order to discuss veterans' access to health care problems that are caused by combat service.
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    As you know, both Mr. Evans and I have introduced Persian Gulf bills. It is my hope that the committee leadership will work with us and other members of the committee to craft a bipartisan bill to find effective treatment for our veterans' undiagnosed illnesses. I am an original co-sponsor of Mr. Evans' bill, the Persian Gulf Veterans' Act in 1998, and I appreciate his hard work to secure the highest possible compensation levels for Persian Gulf War veterans.
    My bill, H.R. 3661, the Persian Gulf Veterans' Health and Medical Research Act of 1998, researches the Persian Gulf research within the VA and DOD. It also establishes a database to monitor the Persian Gulf veterans' health. It requires attending physicians to be trained in new treatment protocols and directs the GAO to evaluate the research and database once a year and report to this committee whether the research and medical treatment are moving in the right direction. I want to thank the members of the committee who support the bill, and I look forward to the support of Ranking Member Evans and other members of the committee. It's my hope that we can negotiate a bipartisan bill which finally solves the Persian Gulf veterans' illnesses, so that they can get well and live normal lives again.
    I'd like to say a few words about the need for greater Persian Gulf treatment. Over the years, the VA and DOD have provided great services to our Nation's veterans and military personnel. But when it comes to Persian Gulf syndrome, VA and DOD simply have not had a coordinated effort to provide coherent research plans since the Persian Gulf War ended. VA and DOD have spend millions of dollars over the course of the past 7 years predominately looking into the cause, but they have initiated very little research into finding effective treatment for low-level exposure to chemicals.
    I know the VA chose to do this research this way because for years the Pentagon continued to deny any link between the veterans' health problems and exposure to chemicals while serving in the Gulf. But in April of 1996, the CIA released a report showing solid evidence that thousands of chemical weapons were stored in Khamisiyah, and that while U.S. troops were demolishing the bunker they may have been exposed to these deadly agents.
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    We need a fresh start. In June of 1997, in the GAO report entitled, ''Gulf War Illness,'' it was pointed out that research had been primarily focused on the cause of Persian Gulf illnesses and that the VA has done very little in finding effective treatments for exposure to chemicals. That's why my bill directs the Persian Gulf research will still be done within the VA and DOD. However, the research agenda will be established and managed by the National Institutes of Health.
    NIH is the natural organization to manage the research. They have a far superior research infrastructure already in place. They have a scientific approach to the peer review process, and they can reach out to toxicologists from around the country who understand the health effects of chemical and biological agents entering the body.
    And again, Mr. Chairman, I hope that we can craft a bipartisan agreement on Persian Gulf veterans' health care bill. And I want to thank you for refocusing today's hearing on extending the VA authority to treat any illnesses that can be attributable to a veteran's service during combat.
    On a second topic—and I'm also a co-sponsor of Mr. Gutierrez' bill to make VA sexual trauma counseling program permanent and mandatory—I'm pleased that the AMVETS, the American Legion and VFW and Vietnam Veterans, all support his bill and I hope that it will be enacted during this legislative session.
    Again, Mr. Chairman, I want to thank you. I just, again very briefly, want to recognize the fact that under this legislation it is true that there would be other committees that would be looking at this legislation, but I do believe that it is important that we recognize that we ought to be looking out after the health needs of our veterans first. And if, in fact, the GAO has been so critical of both the VA and the Pentagon's ability to conduct this research not only in terms of what the relationship is between chemical and biological agents and these illnesses, but how to actually treat them, it seems to me we ought to go to the best agency in the Government to get the veterans the health care that they need and deserve.
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    Thank you very much, Mr. Chairman, for your consideration.
    Mr. STEARNS. Thank you, Joe, and I thank Mr. Evans for his work, too. Dr. Cooksey, opening statement?
    Dr. COOKSEY. No, Mr. Chairman.

    [The prepared statement of Congresswoman Chenoweth appears on p. 50.]

    Mr. STEARNS. Without further ado then, we'll have the first panel come forward. The first panel will testify to the need for study and treatment of war-related illnesses. We have Captain Hyams, Dr. Richard Miller, Mr. Puglisi, accompanied by Dr. Hodgson. We want to welcome all you folks this morning, and I think we'll start with Captain Hyams for your opening statement.

    Captain HYAMS. Good morning, Mr. Chairman. My name is Kenneth Craig Hyams. I am a Captain in the Medical Corps of the U.S. Navy. Currently, I'm the head of the Infectious Diseases Threat Assessment Division of the Naval Medical Research Institute in Bethesda, MD. I am a physician, board-certified in internal medicine and infectious diseases, and I have a degree in public health from Johns Hopkins University. I am also an author on over 130 scientific publications. The following testimony represents my scientific and personal opinion and does not necessarily reflect the official views of the administration, the Department of Defense, or the U.S. Navy.
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    My involvement in the Persian Gulf War health care began in August 1990, when I deployed to the Persian Gulf to help set up a diagnostic laboratory. With the support of numerous military scientists and preventive health officers, and the U.S. Naval Medical Research Unit No. 3 in Cairo, Egypt, the Navy Forward Laboratory was established in Al-Jubayl, Saudi Arabia. The Navy Forward Laboratory served as the theater-wide infectious diseases reference laboratory during Operations Desert Shield and Desert Storm. Our job was to evaluate clinical specimens and environmental samples for infectious disease threats. We were able to identify the most important infectious disease problems during the war, which led to improved clinical care and preventive health efforts among coalition forces.
    The diagnostic and surveillance activities of the Navy Forward Laboratory have also helped prioritize and direct medical research programs since the war. The U.S. Army, Navy, and Air Force maintain an extensive medical research program which conducts epidemiological studies to determine the major health threats for our troops, develops improved preventive health measures, develops new diagnostic tests, and develops new drugs and vaccines.
    The military's medical research program has played a major role in the Government's effort to understand the health problems of Gulf war veterans. The first large-scale epidemiological studies of hospitalizations and birth defects among Gulf war veteran populations were conducted at the Naval Health Research Center, in San Diego, California, and a new form of parasitic infection, viscerotropic leishmaniasis, was identified in 12 Gulf war veterans at the Walter Reed Army Institute of Research in Washington, DC.
    In December 1993, I was detailed to the Tri-agency Persian Gulf Veterans' Coordinating Board and spent over 2 years at the Department of Veterans Affairs assisting in the evaluation of veterans' unexplained symptoms. One of the earliest questions we had to address was whether similar illnesses had occurred after previous wars. In a collaborative study between DOD and VA—the principal investigator for VA was Dr. Robert Roswell—we conducted an extensive search for scientific publications dealing with prior war-related illnesses. Initially, we expected to find psychological problems like post-traumatic stress disorder to be common after wars. What we discovered was a much more complicated picture of veterans' health problems.
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    In addition to well-know stress-related conditions, we found that similar unexplained symptoms have been associated with armed conflicts since at least the U.S. Civil War. War veterans have repeatedly suffered from fatigue, shortness of breath, headaches, sleep disturbances, and impaired memory and concentration. These symptoms have been categorized as distinct syndromes, which have been variously called DaCosta's syndrome, soldier's heart, neurasthenia, effort syndrome, and most recently Gulf War syndrome.
    Our research also revealed one other unifying factor. War syndromes have been repeatedly defined, explained, and studied in a similar manner since the U.S. Civil War. These postulated syndromes have been identified by diverse physical symptoms which do not fit easily into well-characterized diagnostic categories. In addition, war syndromes have remained unexplained, even after decades of medical follow-up of veterans who were finitely ill, because unique physical abnormalities were not identified.
    Lastly, there have been extensive governmental efforts in the United States, Great Britain, and Canada to understand war syndromes and provide clinical care and assistance to veterans. Despite these concerted efforts, the existence and causes of distinct war-related diseases have not been conclusively determined, which has resulted in over a century of unresolved public and scientific controversy.
    When all available clinical and research data is carefully weighed, it is clear that war veterans have suffered from a broad variety of medical and psychological illness which were due to complex and frequently unknown factors. There are two principal reasons for the continued uncertainly about the causes of these health problems. For one, epidemiological studies cannot be conducted in the midst of a chaotic and unpredictable battlefield where the overriding objective has to be the defeat of the enemy. Consequently, it has not been possible to collect the extensive risk factor data needed to conclusively answer all post-war health questions. Also, it is not possible in a research laboratory to recreate the exact combination of events, exposures, and experiences during a war to prove whether a potential health risk is the cause of illness.
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    The other principal reason why it has not been possible to explain war syndromes is that we are dealing with fundamental, unanswered health questions shared by every adult population. Symptoms such as chronic fatigue and pain are frequent causes of suffering and disability in all civilian populations, yet the underlying causes and most effective treatments for these symptoms remain largely unknown.
    The findings of our study of war syndromes clearly demonstrate that more research is needed to understand the causes of chronic physical symptoms. Basic scientific research is essential, as is increased surveillance of military personnel and veterans before, during, and after hazardous deployments. Just as clearly, our research demonstrates that some veterans may require specialized health care after life-threatening deployments. Because it may not be possible to verify an association between ill health and wartime exposures, even with well-designed research studies, requiring individual veterans to prove causation following future conflicts may be unrealistic. Although active duty military personnel automatically receive health care within the military health system and Gulf War veterans are covered by legislation, future Reservists, National Guard personnel, and troops who leave active duty soon after hazardous deployments will have to establish financial need or service connection before the VA can legally provide medical care. Given the unanswered scientific questions involving post-war health problems, the requirement for service connection can be very hard to meet, resulting in a frustrating process for ill veterans, their families, and health care providers.
    Mr. Chairman, I'll be happy to answer any questions you or the other committee members may ask.

    [The prepared statement of Captain Hyams appears on p. 51.]

    Mr. STEARNS. Thank you.
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    Dr. Miller, do you have an opening statement?

    Dr. MILLER. Yes, sir, I do.
    Mr. STEARNS. Okay. Feel free to start.
    Dr. MILLER. Mr. Chairman, members of the subcommittee, I'm Richard Miller, Director of the Medical Follow-Up Agency at the National Academy of Sciences. I speak as the head of the small organization that has been carrying out research on veterans' health issues for more than 50 years, since our founding by Dr. Michael DeBakey in 1946.
    It is appropriate to point out that I am the principal investigator of a study jointly funded by the VA and DOD into the health perceptions and health care seeking behaviors of Persian Gulf War veterans enrolled in the VA Persian Gulf Health Registry and the DOD Comprehensive Clinical Evaluation Program. Further, we intend to submit one or more proposals to the VA and DOD in the near future to conduct other studies of war-related illness. I am, therefore, a knowledgeable, but involved witness.
    I will also testify as a veteran of 29 years of active duty in the U.S. Army who now receives a portion of his medical care at a VA medical center and as a physician who has cared for both military and civilian patients. However, I do not feel qualified to comment on the portion of the bill dealing with health care of veterans except to make a personal observation that at least some war-related illnesses appear to be associated with psychological stress, and that a significant stressor for veterans is uncertainly about the availability of medical care. There could, therefore, be a paradoxical reduction in the need for medical care produced by the assurances to veterans that care is available. An additional personal speculation is that the provision of care to recent war veterans may well obviate the need for the complex and expensive registries and evaluation programs such as the Persian Gulf Health Registry.
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    All remaining comments will deal with the proposed National Center for the Study of War-Related Illnesses, which I believe is an excellent and long overdue effort to elucidate the causes of a major portion of veteran illnesses.
    Wars pose unique combinations of psychological and environmental exposures. A center organized around the phenomenon of war-related illness, rather than a single discipline or disease, can bring together the appropriate mix of expertise and foster appropriate collaborations. Cooperative efforts between psychologists, psychiatrists, toxicologists, environmental medicine physicians, and other specialties may bring new insights and perhaps help combat the stigma of psychological illness in the minds of some by treating war-related stress as just another unavoidable risk associated with going to war. I particularly like Dr. Hyams' term ''war syndromes'' since it connotes an occupational hazard for our Nation's warriors and not the perception by some veterans that Government doctors are saying their illness is not real.
    I hope that the new center will, as the draft bill states, fund studies of the causes of war-related illness. Epidemiologic studies of risk factors for developing war-related illness with the goal of preventing them, or at least ameliorating their effects, are essential.
    The recently published work of Dr. Hyams and his colleagues indicates that the problem of war-related illness is much more complex than originally believed and has been with us after most major military deployments. Sometimes, as after the Persian Gulf War, medically-unexplained illnesses constitute the majority of the resulting medical problems of veterans. The lack of an easy answer to the causes of these illnesses suggests the need to look at the problem in new ways.
    The work of a national center for the study of war-related illnesses may also have major implications for civilian health care. It is clear that medically-unexplained illnesses are by no means limited to veteran populations. Any physician who practices primary care or family medicine is well aware of the burden of unexplained illness for patients, for clinic staff, and for those who pay the ever-increasing costs of medical care.
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    Thank you, Mr. Chairman, and I will be happy to answer questions.

    [The prepared statement of Dr. Miller appears on p. 57.]

    Mr. STEARNS. Thank you. Mr. Puglisi.

    Mr. PUGLISI. Thank you, Mr. Chairman. Good morning, and good morning to the other members of the committee.
    Thank you for providing the American Legion the opportunity to participate in today's hearing regarding research on, and treatment of, war-related illnesses and your draft legislation to provide authority to furnish priority health care to treat illnesses which may be attributable to future wartime service.
    With my today is Dr. Hodgson, assistant professor of medicine at the University of Connecticut. The American Legion consults with Dr. Hodgson on Gulf war illnesses, and he assisted in the writing of portions of this testimony.
    Mr. Chairman, this is your third hearing in this Congress regarding Gulf War veterans' illnesses. Your leadership and energy have provided the public and Congress with the facts regarding the health effects of the Gulf War and a lucid analysis of the Federal Government's reaction to veterans' health complaints. The draft bill before the committee applies the knowledge gained through this subcommittee's exhaustive investigation of Gulf War veterans' illnesses and investigations of illnesses found after past wars. If passed, it would represent a historic step in addressing the health problems of today's veterans and tomorrow's as well. It would also be a bright display of how Congress can learn lessons from the Nation's experience in preceding wars. This could signal another step forward in the Nation's revolving commitment of caring for its war veterans, and it has the enthusiastic support of the Nation's largest veterans' service organization.
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    Since late 1991, thousands of veterans returning from combat service in the Persian Gulf have reported a broad range of symptoms, syndromes, and diseases. The possible causes of these illnesses have been summarized in a series of committee reports. Now, 7 years later, many veterans still feel ill and seek answers that will help them feel better. Increasingly, the questions is where they, and future redeployed veterans, should receive health care. Returning veterans have reported similar symptoms after previous wars; symptoms that were chronic, disabling, and medically unexplained.
    In spite of the appearance of medically-unexplained symptom syndromes after all our wars, since at least 1860, the Federal Government has not responded with programs that would anticipate these illnesses and provide access to health care for these veterans. That would change with the passage of this draft bill.
    As you mentioned earlier, Mr. Chairman, World War II, Vietnam, and service in the Gulf all predicted poor health in those who deployed to those theaters and poor health at a significantly greater rate that those who didn't deploy to those theaters.
    Today we are confronted with thousands of ill Gulf War veterans. The population of Gulf War veterans is significantly more ill than those non-deployed Gulf War veterans. They appear to use the health care system more frequently for a broad range of problems, from asthma to ill-defined conditions. Some of these represent identifiable diseases commonly treated in primary care settings. Some veterans are commonly seen but not treated well by primary care physicians who have little training in veterans' health.
    The American Legion has long held the view that the most pressing issue facing sick Gulf War veterans was the development of effective use of medical treatments for their illnesses. There have been obstacles in the way, the most apparent being the failure to recognize that medically-unexplained symptom syndromes may be a natural consequence of participation in a war. Another was that Gulf War veterans were only gradually given access to health care, when the medical literature is clear that the sooner interventions occur the more likely a sick patient will get better.
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    The bill overcomes these obstacles. First, it provides health care for Gulf War veterans through the year 2001 and future war veterans. Secondly, it will eventually enable VA to effectively treat these illnesses through medical knowledge developed at a national center on war-related illnesses.
    The bill not only is a key part of VA's current efforts to determine which medical approaches effectively treat these illnesses, but it will help create a VA system ready to ''hit the deck running'' after our next war. The bill provides VA with the opportunity to address the next Gulf War syndrome competently.
    At the height of the Second World War, veterans of the First World War sat in Legion and Posts across the United States and talked about the hardships they faced upon their return from France in 1919. These discussions turned into ideas and soon into action. Congress passed the Serviceman's Readjustment Act, the GI Bill of Rights, before the war had ended. Discharged veterans didn't return home unemployed while the Federal Government slowly decided what could be done for them. Instead, the GI Bill enabled these veterans to attend college and buy homes, and it generated the greatest era of prosperity in the Nation's history.
    This bill, although much more modest in scale than the GI Bill, parallels its vision. It applies the lessons learned from our recent and distant past. It implements policies before they are needed by veterans. This will enable sick war veterans to return from future wars and be given every chance to recover their health and lead productive lives.
    Mr. Chairman, this concludes my testimony. I'll be happy to answer any questions.

    [The prepared statement of Mr. Puglisi appears on p. 65.]

    Mr. STEARNS. Thank you. Dr. Hodgson.
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    Dr. HODGSON. Mr. Chairman, thanks for the invitation. I'm just here to help Mr. Puglisi answer questions you would have.
    Mr. STEARNS. Okay. Okay, let me just start. Captain Hyams, I heard your testimony. And let me just say I had a young man, Michael Adcock, in my congressional district die when he came back. He was a star athlete in high school. He went over in the best of health. He came back, and he had three or four different illnesses. He finally died of a brain tumor—an excruciating death. He was 22 years old. If I went to the mother of Michael Adcock and said that there has been historically Gulf War-type syndromes since Civil War, that probably wouldn't alleviate her pain, and I understand that.
    But let me just ask as a general question: Don't you think, though, that something that happened in the Gulf War, it's distinct and different than what happened in other wars? Or do you think what happened in the Gulf War is very similar to what's happened in all wars since the Civil War?
    Captain HYAMS. I think all the wars are very different. They're conducted in different locations; the sort of weapons that are involved, and the sort of experiences of soldiers are very, very different. And, yes, the wars themselves are quite different, but some of the post-war health questions are similar. I think you have to draw a distinction between the actual experience and the health-related questions we ask after the war.
    Mr. STEARNS. Mr. Puglisi, in terms of health care and research issues, do you feel that our legislation—I think the words you might have used are ''a modest step forward''—will provide or create more priority on these problems and get some more concentration of interest and discovery?
    Mr. PUGLISI. Yes, Mr. Chairman, I think it would. After the Gulf War, VA was very well-prepared for things it thought would happen after the Gulf War. It was looking for respiratory illness in veterans from the smoke from the oil well fires. It was looking for post-traumatic stress disorder from those who had experienced traumatic events, and it found bulk.
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    But as growing numbers of Gulf War veterans reported illnesses and diseases that didn't fit either one of those categories, they had a more difficult time in getting in the system. VA didn't have a uniform approach to those veterans. If, after every war, we have vets who have unexplained symptoms regardless of what the cause is—and the American Legion isn't suggesting that it's stress or stress alone. Stress seems to be an ingredient, according to a number of scientific panels that have met, but there are other possible causes that are being investigated as well.
    So we are not getting into the cause of the debate so much as just acknowledging that, if this has always happened, and it may always happen, VA needs to be ready and able to treat people who have these kinds of illnesses after future wars.
    Mr. STEARNS. Dr. Hodgson, are you familiar with the legislation that we have in place here?
    Dr. HODGSON. Yes.
    Mr. STEARNS. I think then what I would ask you is, tell me a little bit what you see as the role of the Center for the Study of War-Related Illnesses. How should it be structured, staffed, operated? Maybe give some insight into, if you were the administrator, if you were effectively implementing this, how would you go about to structure this?
    Dr. HODGSON. Some of the points that Dr. Miller made are crucial. Those include the pulling professionals together with a broad range of expertise, not just in epidemiology and toxicology, but also in evaluating the outcomes of certain intervention strategies. One of the weaknesses of the research portfolio as it's evolved is that it took a while to get an overall agenda focused on some specifically-measurable benefit to, not just the scientific community, but also to the affected individuals. The way Dr. Miller presented the center, I'm looking at the effectiveness of whatever is being done is essential.
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    The question of how to structure that, whether in specific disciplines that involve toxicology, epidemiology, clinical medicine, or organizing it around teams that are more specifically around specific research projects, is really something that will probably change as different conflicts arise. For example, in some of the work that is going on right now, the VA has, in fact, begun planning on a randomized controlled intervention trail for fatigue-like symptoms. If the VA had not, the war disease center would have to do that. But I'm not sure at this point if one could actually say A, B, or C is the preferable structure without knowing all the things the different agencies are internally shifting.
    Mr. STEARNS. When we started this investigation, we heard different concerns from different agencies. And we talked to the Department of Defense, and then the Department of Defense told us, and then different things came out. Is it appropriate to keep the investigation, control of it, with the Department of Defense? Should they play in the operation for a center for war-related illnesses? What steps should we take to ensure that appropriate coordinated concerns are implemented? Because I think a lot of us, when we looked at this problem, just didn't know even where to go, what agency to start with, and who to believe, and so to try and bring this into focus so that we have one agency, one individual's group that's on top of it. I think the question is open to the panel, as far as the appropriateness of the Department of Defense to be involved here.
    Mr. PUGLISI. Mr. Chairman, I'm assuming that you're asking about the Department of Defense in investigating chemical exposures and chemical weapons and—the Department of Defense has really become the whipping boy on this issue, and to its own credit really, and no one else's. By denying that chemical weapons were even in the Kuwait theater of operations for a number of years, set back the research agenda by that period of time and left a real bad taste in the mouth of all Gulf War vets.
    Since then, they've expanded their investigation from 12 folks to over 125, and the Presidential Advisory Committee has overseen their efforts, as has the General Accounting Office, congressional committees, and now an oversight panel that the White House is putting together. So, there's plenty of oversight of DOD, and so far over the last year and a half, they've shown a good-faith effort in trying to get the bottom of what's been going on in the Gulf—or what occurred in the Gulf. The important thing, however, is in researching war-related illnesses; the Department of Defense must play a role; otherwise, there isn't going to be a good handoff of these future war veterans from DOD to VA. So, I would encourage that the legislation, as it does, continue to ensure that DOD is involved in this process down the road.
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    Mr. STEARNS. Well, certainly the DOD—they have the records; they have the data and all the information on exposures and everything. So, hopefully, you know, that would make them as a prerequisite. Yes?
    Mr. PUGLISI. Actually, if I could just touch on that last comment, actually, one of the biggest problems with the Gulf War was that the Department of Defense didn't have the records, didn't have the exposure data, and didn't maintain good medical records and shot records for troops. I know that they've addressed that, or attempted to, in Bosnia, and GAO said that they did a better job in Bosnia but fell a little short. But the key isn't after the war; it's before and during.
    Dr. HODGSON. One of my hats is occupational medicine. There is an interesting model that's evolved in the U.S. since the 1950's in the controversial area of occupational disease. So called tri-partied studies were pioneered by the National Institute of Health in the 1950's to address some of the conflicts that arise in the use of the scientific method to get data used both by industry and labor. So, for example, the National Cancer Institute, for the first time in 1959, set up the co-government workers mortality study and put a steering committee in place that had equal representation from the Steel Workers, the National Cancer Institute, and the steel industries. And only by having this tri-partied steering committee did, in fact, that work become as useful as it is. That model has been used in occupational studies not just in the U.S. now, but also in Canada. And most academic scientists will push very hard for having a tri-partied committee to help guide and, shall we say, take some of the heat off of their findings when the work is actually published. Making sure that there is representation of the affected individuals on that committee also ensures that the work is done with an eye towards the affected subjects.
    Mr. STEARNS. That's an interesting observation. Before I conclude, I think every member here wishes we could ultimately find the answer to the Gulf War syndrome.
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    And lots of stories have come on the AP wire. I have one that came in April 21. A doctor in Belfast believes he's found the key to unraveling the mystery of the Gulf War syndrome, and with a pioneering treatment, that could mean the end of suffering. The claim by Environmental Practitioner Dr. Magee comes just a month after he teamed up with a leading pharmaceutical company to find out why so many former soldiers were acutely ill. He found that former soldiers based in Northern Ireland when suffering from Gulf War syndrome had been poisoned by a toxic mix of eight chlorinated and organophorus pesticides. He made the discovery after having fat samples from former soldier Steve Fords examined by a London laboratory and hit upon the idea of having fat tested because poisons in the blood break down within a few hours. And, evidently, that same technique was used to come up with the identification of Agent Orange.
    I put that in the record because, as you know, there's many people that claim that they have found the solution to the Gulf War illness. But I think, on the other hand, we cannot discount when people come forward with new ideas.
    And Captain Hyams, I'm going to obviously give you a copy of this, but do you care to comment at all on perhaps what I've just read to you? I know you haven't had prior presentation on this idea.
    Captain HYAMS. No, without reviewing the data, it'd be very hard for me to say something about it. But we have a peer review process where we evaluate and research findings. When that data is published and other scientists have a chance to evaluate it and try to duplicate the findings, then we'll know exactly what it means in relationship to the Gulf War veterans. These findings have to be re-created scientifically before you can really act on them.
    Mr. STEARNS. Well, I think if you could for me, then, is review it, and we'll give you a copy of the article, and I'd like to have your written reply into the authenticity of it or perhaps what you think if there's any——
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    Captain HYAMS. Yes, sir.
    Mr. STEARNS (continuing). Credibility to it, because I understand that fat sample analysis from the toxins found in soldiers sprayed with Agent Orange were finally identified, and this is the process. And so, you know, I think many of us in Congress say, ''Why wasn't this done a long time ago.'' And, so that's something that——
    Captain HYAMS. Let me add just one other thing. I think there's no substitute for first-hand experience. We had a lot medical personnel in the Gulf. A lot of scientists and researchers had a chance to observe the conditions over there firsthand. These first-hand experiences by people who really were there and understood what happened, are essential to any evaluation of post-war health problems. In that regard, I think DOD is essential.

    [The information follows:]

                INFORMATION PAPER
    Representative Cliff Stearns (R-FL) requested CAPT Hyams to evaluate an April 21, 1998, news article from PA News: ''Gulf war syndrome—Doc hopes for breakthrough.'' An environmental practitioner, Dr. Finbarr Magee, is reported to have diagnosed the cause of Gulf war syndrome (a toxic mix of eight chlorinated and ''organophorus'' pesticides) in one veteran by testing his fat tissue and to have found a treatment for this condition after teaming up with a leading pharmaceutical company.
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    CAPT Hyams response: I had difficulty evaluating this news item because I was unable to locate: 1) the report in the scientific literature; 2) previous scientific papers by a Dr. Finbarr Magee; and, 3) specific findings from our British colleagues who are working on Gulf war health questions. Eventually, I was able to contact Dr. F. Magee in Northern Ireland.
    Dr. F. Magee related that he tested just one Gulf war veteran and considers his findings very preliminary. He is planning to test more veterans. At this stage, I cannot determine the relevancy of reported findings. More Gulf war veterans will have to be evaluated to ascertain whether the test results in this one veteran is a widespread or an isolated finding. Also, a control group will have to be tested in a blinded fashion to evaluate the accuracy of the test in measuring chemical agents in fat and to evaluate local or job-related exposures, rather than exposure in the Persian Gulf seven years ago.
If I learn more about this report from Northern Ireland, I will relay the information to the Subcommittee on Health, Committee on Veterans' Affairs.

    Mr. STEARNS. Do we work with the British? We work with the British Government and the British military and we've been corresponding with them, haven't we?
    Captain HYAMS. Yes, sir.
    Mr. STEARNS. In terms of their research?
    Captain HYAMS. We have a liaison officer here that we work with almost on a daily or weekly basis.
    Mr. STEARNS. Okay. Well, I've finished my questions.
    Mr. Gutierrez.
    Mr. GUTIERREZ. Thank you, Mr. Chairman. Thank you to the members of the panel.
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    I think probably the only question I have is, how do you see this center—given that I arrived here in 1993 and the problem didn't seem to be one of much of diagnosis, but just that both from the Veterans' Administration and from the Department of Defense kind of—they used words like, there is a certain level of malingering going on here and people who have excuses and are looking for pensions. There were those kinds of responses brought up—much as we hear in the general community about people who try to access any kind of Government program, you know. So how do we deal with—I mean, how does the center deal with that if we have a center and they come up with great information and we have a—how do you advocate for veterans? Or does it advocate for veterans? That's the only question I have for anybody on the panel.
    Mr. PUGLISI. Well, Congressman, as a Gulf War veteran who served with Gulf War vets who are sick, I took great exception to those things you pointed out when folks would suggest—usually very subtly that—''Wow, gee, an awful lot of compensation is probably at stake for this person.'' And that was sort of the explanation as to why these unexplained symptoms were being reported. It's clear that that's not the case. And scientific studies have shown that this population is more ill than you would expect and more ill than their peers who didn't go to the Gulf.
    So, I believe that anyway, and the science has now validated my beliefs that this center would, for the first time, acknowledge that folks who go to war and come back and were not always going to understand or explain exactly why they're ill. And instead of making them prove that their illness is tied to the war, we just presume that it is. And instead of making them prove service connection in order to get care, we're going to give them care, and the center is going to try to figure out, hopefully before the next war, what medical treatments work.
    Because when you ask Gulf War veterans, as all of you have Gulf War veterans in your districts, and you talk to them, and they tell you, ''I just want to get better. I just want to get whole,'' I mean, these are young people who have their whole lives ahead of them. And getting $150 a month from VA for the rest of their lives isn't going to pay the bills and take care of things. So, they want to get better. They're not looking for compensation, and this center is part of a very comprehensive effort to find medical treatments to make them better.
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    Mr. GUTIERREZ. Anyone else care to comment? Yes, Doctor?
    Dr. HODGSON. It turns out that the idea of compensation neurosis is vastly overrated in the medical literature over the last 20 years. There's been a major re-thinking of that.
    First of all, we don't think it happens as often. Second, from a social perspective, no matter where you look at which disability system, whether it's workers' compensation or social security, it turns out that most people who rely on disability payments would far rather work. In this society, work is still used as a measure of success and respectability. And for most people, being dependent on the pension is not desirable.
    That has, in fact, given rise to a very different model of managing disability in the medical context. Rehabilitation medicine, or psychiatry, focuses aggressively on identifying obstacles to getting people to where they want to be. And so a war-related center could, in fact, do that in a far more aggressive way than physicians who are often out of tune to, you know, problems that would be hard to recognize for a primary care doctor.
    Mr. GUTIERREZ. I think we should obviously look forward to working on this legislation and seeing how we can do it because I think the questions have been answered. I mean we need to figure out that veterans don't have to come back and basically, you know, confront us to—from those who said they were going to help them when they came back. I think those are very vital, important issues. I think we've seen that over—if we've learned nothing else—over the last 5 years, that's what we've learned.
    Thank you, Mr. Chairman, very much.
    Mr. STEARNS. I thank my colleague. Mr. Evans.
    Mr. EVANS. Thank you, Mr. Chairman.
    Captain Hyams, your statement concludes that, for a variety of reasons, it may be impossible to determine associations between ill health and wartime exposures, and requiring individual veterans to prove causation following future conflicts may be unrealistic. Would you apply the same type of rationale to Persian War veterans? And on what basis should VA award compensation if the associations between exposure and health outcomes can not be found?
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    Captain HYAMS. It's very difficult to prove causation after a wartime event. Wars are focused on a lot of different issues, conducting large-scale epidemiologic studies where comprehensive data is collected is not one of them. Also in the strictest scientific sense, it's not possible to prove causation after a wartime event. You have to be able to get in front of the event and do what we call clinical trials or experimental studies to prove causation. Causation is a difficult term to apply to a single event that comes and goes. And you can't go back in time and recreate all the circumstances that occurred in that event, so causation is always very difficult to determine after a wartime events.
    As far as compensation, I really have no background or knowledge about that.
    Mr. EVANS. Let me ask for the veterans of the American Legion official position on the highest priorities of the Persian Gulf veterans in this Congress.
    Mr. PUGLISI. Well, Mr. Evans, Gulf War veterans want to see Congress absorb the lessons from the Gulf War and past wars and ensure that they're going to be taken care of for the rest of their lives, should we not find medical treatments that can make them better now or anytime soon. They want some hope that they'll be taken care of. Mr. Stearns' bill is going to do that, and you, yourself, have introduced a bill that combats the problem of Gulf War illnesses and attacks different problems associated with Gulf War illnesses, but also is very long ranging in its vision and would take care of veterans as far as presumption and compensation as well.
    So, the American Legion sees your bill and Mr. Stearns' bill as being very important and complementary—not mutually exclusive—because they each tackle different aspects of the problem.
    Mr. EVANS. Have you had a chance to look at the Kennedy legislation?
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    Mr. PUGLISI. Yes, sir, I have.
    Mr. EVANS. Does the Legion support it or——
    Mr. PUGLISI. Well, the Legion, as you know, supports your bill very strongly. It meets the mandate of the members as far as an approach to the research and an approach to presumption and compensation. And we're just looking forward to Mr. Kennedy and yourself working out something to where one bill is put forward, and perhaps that approach and Mr. Stearns' approach can be joined together, and the ultimate outcome from this Congress would be something that tackles all the problems that are outlined in all the bills or attacked in each bill.
    Mr. EVANS. All right. Thank you. Thank you, Mr. Chairman.
    Mr. STEARNS. Dr. Cooksey.
    Dr. COOKSEY. Thank you, Mr. Chairman. Mr. Puglusi—Puglisi—is that close?
    Mr. PUGLISI. Yes.
    Dr. COOKSEY. And Dr. Hodgson, I understand that there is in this legislation proposal to really shift a lot of the research from the VA and DOD over to NIH to do the analysis—analysis of veterans' records, their treatment, their medical management. Do you think this is a good use of resources, assuming the resources are finite?
    Mr. PUGLISI. Well, Congressman, actually you're referring to Mr. Kennedy's bill which has provisions that would shift the authority for the research, in our interpretation of it, to the NIH. And the American Legion, however, supports Mr. Evans' bill which would establish a contract between the Institute of Medicine and VA for the Institute of Medicine to review the published literature at certain periods—2-year periods—and publish a report determining what illnesses and diseases have been associated with the Gulf War vast population, much as what we see with the Agent Orange Act of 1991. So it's a similar approach. And the American Legion supports Mr. Evans' bill.
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    Dr. COOKSEY. So basically, you're saying that you support Mr. Evans' concept instead of Mr. Kennedy's concept?
    Mr. PUGLISI. Well——
    Dr. COOKSEY (continuing). Reflected in their concepts in their legislation?
    Mr. PUGLISI. Yes, Congressman, and what we're looking—it's because there is a lot of overlap between the two bills, and we're confident that at some point in the near future they'll be probably one cohesive approach to that part of the problem as far as research.
    Dr. COOKSEY. Dr. Hodgson, what do you think about the records, the medical records of the military—I've assumed you've looked at some of them—as far as quality of information, volume of information, accessibility?
    Dr. HODGSON. The whole——
    Dr. COOKSEY. DOD records, not Veterans' Administration records, but DOD records primarily and then maybe the Veterans' Administration records secondarily.
    Dr. HODGSON. I actually have not seen DOD records at all.
    Dr. COOKSEY. You're an internist by training?
    Dr. HODGSON. That's correct.
    Dr. COOKSEY. Okay. I'm a physician, also, that's the way I used to make an honest living before I got this new day job. (Laughter.)
    But one of my criticisms of our colleagues in medicine is that we do not have electronic medical records to date. I do in my medical office and have had for 10 years, but too many physicians are still doing pen and paper, which is the way this Congress was run until 3 or 4 years ago, too. But in this information age, all physicians should be using electronic medical records. And I happen to know that the Department of Defense is ahead of probably a lot of people in the private sector, a lot of physicians in the private sector, in moving into this electronic medical record age that we're well into. If we had that, then I think that this study that is proposed by this legislation would be easy to accomplish. You could do immediate transfers of great volumes of information and then—but what is your reaction to that? Do you share my criticism of our colleagues?
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    Dr. HODGSON. I'm privileged to have very thoughtful colleagues who actually in the hallway before this meeting actually pointed out the DOD and VA were moving towards a far more aggressive structured and thoughtful approach to medical record management for the next conflict that arises. The question that was on the table in the hall beforehand was whether the presence of a uniform accessible medical record would solve problems as they have been arising. Whether, for example, the early recognition of war-related psychological syndrome or other problems would be possible simply on the basis of a record-keeping system without heightened awareness or active seeking of such problems. And I think that's more philosophical than a, you know, technical question.
    Dr. COOKSEY. Dr. Hyams, I'm intrigued by your paper. I've read your paper last year. It is an interesting paper. What is your reaction to this move toward more electronic reactions?
    Captain HYAMS. Well——
    Dr. COOKSEY. Electronic medical records?
    Captain HYAMS. It'd definitely help, Congressman. It would allow us to answer lots of questions. It may not answer all the questions, but it would certainly help in this process. Within DOD, I'm working on a part of the electronic medical record process by obtaining baseline health information from all of our military personnel. It will help, but it will not answer all questions. We have basic unanswered questions both in the military and in the civilian population on just what causes chronic fatigue or chronic pain or some of these other chronic symptoms. Until we understand those causes, it's going to be difficult to answer all of these post-war health questions.
    Dr. COOKSEY. Sure, well, I feel very strongly that we need to move in that direction. You know, I was in the military when I was in my twenties and I still have my medical records because, when I went off active duty, I acquired them. And back then, you know, when you're in your twenties, you feel like you're immortal. You have good health. You have dark hair and a lot of it. (Laughter.)
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    And a flat belly. (Laughter.)
    And, you know, I feel like that's true. A lot of the veterans that were over there, they were young and healthy, and probably did not have extensive records. And yet I, as a physician and as a Member of Congress, I've had occasion to review some medical records of veterans that come into my office with problems. And incidentally, veterans and social security problems are about three-fourths of the work that's done in my district offices. But anyway, in reviewing these records, they really become quite lengthy. But they become lengthy after most of these people are off active duty, unless they had some devastating injury in combat. And it needs to be moved in that direction.
    No other comments, Mr. Chairman. Thank you.
    Mr. STEARNS. Mr. Hutchinson.
    Mr. HUTCHINSON. Mr. Chairman, I, as lawyer, get a little nervous following Dr. Cooksey on medical testimony. And I just want to express my thanks to the witnesses for their testimony today and for your leadership and your work on this legislation.
    And I want to yield back my time.
    Mr. STEARNS. I thank my colleague.
    I would thank the panel very much. We appreciate their time and efforts. And now we'll have the second panel, dealing with sexual trauma counseling and legislation on the war-related programs.
    We have Dr. Garthwaite accompanied by Dr. Murphy, Joan Furey, Andrea Van Horn, and Mr. Christopherson accompanied by Dr. Mazzuchi. And we welcome the second panel. And I think we'll start with the opening comment of Dr. Garthwaite.
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    Dr. GARTHWAITE. Thanks. Mr. Chairman and members of the committee, I'm pleased to be here to discuss draft legislation to extend and improve our authorities for responding to the health needs of Gulf War and future conflicts veterans. As requested, I will also comment briefly on existing programs to respond to the health needs of Gulf War veterans and will also provide an update concerning VA's sexual trauma counseling program.
    First, VA generally supports the draft bill. After periods of war or hostilities, veterans have experienced illness that current medical knowledge cannot fully link to a causative agent. Some of these health problems can become chronic. The draft bill would ensure that VA can provide health care for such illnesses to war zone veterans while research is conducted to determine the causes, mechanisms, and treatments of these illnesses. The current draft provides this authority 5 years following discharge from military service. An alternative construction could be to extend this authority for 5 years following the veteran's departure from the combat theater.
    VA supports granting a higher enrollment priority to veterans seeking care for disabilities possibly associated with exposure to Agent Orange or ionizing radiation, or with service in the Gulf War or a future war or conflict. These veterans, who are currently placed in enrollment priority six, would be elevated to priority four under the draft bill. It is entirely appropriate for war zone veterans to have a higher priority for care during the time it takes to assess the relationship between their illnesses and service.
    We also support extending the authority for VA to furnish health care to Gulf War veterans with disabilities possibly associated with such service. As you know, there's ongoing research into health problems of Gulf War veterans, and it is appropriate to continue their treatment authority while this research effort is in progress.
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    We also support the establishment of a national center for the study of war-related illnesses. Historically, ill-defined post-war health problems occur following every war. We should anticipate their occurrence after future conflicts, be prepared to provide health care and treatment, and develop methods to prevent post-war health problems in the future. A National Center for Study of Gulf War-Related Illnesses would enhance our ability to create a comprehensive VA program for post-war clinical care, medical education, health risk communication, and research.
    Mr. Chairman, VA testified before the full committee on February 5, 1998, and provided information on our Gulf War health care and research efforts. My formal statement provides an update on that previous testimony.
    The VA has sought broad scientific and other input to help inform us about the best course of action with regard to Gulf War health care and research. As we have gained knowledge and information, we have continued to consult the best scientists available. As lead agent for federally-sponsored Gulf War research, VA has developed a structured research portfolio to address the currently-recognized highest priority medical and scientific issues. Over 120 federally-sponsored research projects are pending, underway, or have been completed. My formal statement provides an update on key research activities and detailed information regarding each study as provided in the just released annual report to Congress for federally-sponsored research on Gulf War veterans' illnesses.
    Mr. Chairman, you also requested an update on VA's sexual trauma counseling program. Over the last 6 years, VA has undertaken a focused effort to expand and improve sexual trauma counseling services at our health care facilities. To date, more than 18,000 women veterans and 200 male veterans have accessed sexual trauma counseling services. The number of veterans accessing the sexual trauma counseling program has increased each year since its inception.
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    VA research indicates sexual trauma is more prevalent among women veterans seeking services at VA health care facilities than we had previously thought. And the negative impact of sexual trauma experiences on the physical and mental health of affected veterans is significant. Therefore, VA is committed to continuing this program and has submitted a legislative request to extend VA's authority to provide this care through December 31, 2003.
    Mr. Chairman, that concludes my comments. My colleague and I are happy to respond to any questions you or the Committee members may have.

    [The prepared statement of Dr. Garthwaite appears on p. 78.]

    Mr. STEARNS. Thank you. Dr. Mazzuchi.
    Dr. MAZZUCHI. We want——
    Mr. STEARNS. Oh, okay. We'll switch you to over there. Mr. Christopherson?

    Mr. CHRISTOPHERSON. Thank you very much. Mr. Chairman, members of the committee, I'm coming here today both as the Acting Assistant Secretary as well as the Principal Deputy. We'll talk about for just a couple few moments our Force Health Protection program, the health experience of our military personnel deployed overseas since the Gulf War, and our current Gulf War illnesses research efforts.
    Dr. Mazzuchi will speak to both the research efforts, and he'll also speak to the issue of the sexual counseling/responding to sexual trauma problems.
    Mr. Chairman, as I've testified before this committee and others, it is no doubt at all that mistakes were made during the Gulf War. We learned a lot from those mistakes and we apply a lot of those new lessons today. In Bosnia, we made substantial improvements. We still need to do even more. In Southwest Asia, making more improvements; again, more lies ahead of us. Many lessons learned; many lessons need to still be applied.
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    We have changed our policies significantly over the last 8 years, including putting in place a major Force Health Protection Program, which we recommended to the President and the President adopted. As part of the lessons under the Force Health Protection programs we are now doing pre-deployment, deployment and post-deployment health assessments. We're improving recordkeeping. We're doing more work in terms of looking at the risk of deployment. We're looking at better work in terms of risk communication. We're also looking for better medical countermeasures to deal with biological and chemical warfare agents. We are also looking at issues of more extended research programs, working very closely with the VA.
    And I think another key other element that came out is the need to have a much closer working relationship right from the beginning with both VA and DOD especially, but also with the Department of Health and Human Services. That is in place, and that is operating today.
    We have also put into place, as part of this program, our medical surveillance directive clearly laying out for all future major deployments that we will be looking at surveillance and making sure we understand better what goes on during any kind of major war and what the sort of consequences might be that we may have to deal with in the post-war period.
    We are also looking at better coordinating mechanisms. The experience of the Persian Gulf Coordinating Board has been very positive, but we are building upon that experience and looking to create a Military and Veterans' Health Coordinating Board which would again bring together both VA and DOD and HHS to formalize many of the initiatives we are working on in the clinical, research and medial surveillance.
    Our CCEP, our Comprehensive Clinical Evaluation Program, continues and will stay in place as long as necessary, having served over 42,000 veterans of the Gulf War. And, again, in the clinical program we will continue to work closely with VA on that program as well to make sure we are ready for any future war situations, where, again, we need a comprehensive clinical program to support that experience.
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    But again, clearly, all that is not enough. There are some areas, for example, in the chemical and biological warfare agent area, where we need to do more. We need to find better medical counter measures out there. It's an area that we and the Food and Drug Administration are working very closely now in trying to find better tools to bring that into play.
    In closing my part of the remarks before turning it over to Dr. Mazzuchi, we will maintain a strong post-deployment evaluation and care program. We will continue to move forward and mature and strengthen our Force Health Protection Program as well as our total Military Health System. We will continue a strong program for the prevention of sexual trauma and aid to victims of sexual trauma.
    And we appreciate the opportunity to testify before the committee. And we'll be prepared to answer your questions as well.
    With that, let me turn to Dr. Mazzuchi.

    [The prepared statement of Mr. Christopherson and Dr. Mazzuchi appears on p. 89.]


    Dr. MAZZUCHI. Mr. Chairman, good morning. And good morning to members of the committee. It's my privilege to appear before you this morning to talk about Persian Gulf-related research and sexual trauma counseling in the military.
    The coordination and management of our research efforts on behalf of Gulf War veterans has required the establishment of an overall research policy framework linking each department's research management hierarchy. This essential linkage is provided through the Research Working Group of the Persian Gulf Veterans Coordinating Board. The DOD has two individuals permanently assigned to work with this board on research matters.
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    Research in Gulf War veterans' illnesses is a complex undertaking that involves a number of different approaches. The Federal research effort addressing this problem involves scientists in the Federal, academic, and private institutions both in the United States and abroad. The entire Federal research portfolio consists of over 120 projects—with a total research investment to date of approximately $115 million. Of these, 39 projects have been completed, 78 are ongoing, and 4 have been newly awarded and are awaiting start up. Additional research projects are at various stages of planning.
    The DOD expenditure for Gulf War veterans' illnesses-specific research from fiscal year 1994 through fiscal year 1998 totals $62.6 million dollars. The full report of our research activities has received final departmental clearance and, as Dr. Garthwaite has mentioned, is on its way to the Hill for your review.
    The path of science is difficult, expensive and often time-consuming. Historically, though, the match of scientific merit and program needs has been the foundation upon which our national leadership in medical science has been built. Over half of our research projects involve non-government scientists who received Federal funding for their research through a vigorous, competitive peer review process.
    Our experience in the Gulf War has focused attention on the importance of strategies for prevention of diseases and illnesses, early intervention when exposures take place, and effective treatment. Medical surveillance has been recognized as the critical element for force protection and a medical surveillance reporting framework has been developed by the Joint Staff.
    With respect to sexual trauma, sexual trauma and sexual abuse are serious problems in our society with long-term health consequences. In the United States, a woman has about a 20 percent lifetime chance risk of being raped, yet only 5 to 15 percent of these are reported to police. Rape-trauma syndrome is a type of posttraumatic stress disorder. Researchers demonstrated that about 55 percent of people with PTSD have two or more common psychological problems, including depression, anxiety disorder, and eating disorders.
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    People with a history of childhood or adolescent sexual abuse or exposure to family violence are significantly higher risk for developing PTSD or being victimized again. Studies suggest that a history of attempted and completed rape in childhood may be far more widespread among female service members than among women living in the community at large.
    Research has shown that military personnel have a significant history of preexisting sexual trauma and subsequent risk of developing PTSD. A recent Navy study of basic trainees found that 45 percent of women trainees had been either victims of rape or attempted rape prior to their entry onto active duty. An Army study of female active-duty soldiers showed a lifetime history of sexual assault to be about 51 percent, with 81 percent of these occurring prior to entrance to active duty. In addition, almost 41 percent of females and nearly 39 percent of male trainees have been victims of childhood physical abuse. The results of these studies suggest that it may be cost-effective to develop treatment, education, and intervention programs for military recruits.
    The Navy has developed a trial 3-hour intervention program for Naval recruits. The focus of the program for females is how not to be victimized. The focus of the program for males deals with informed consent issues.
    The Services have programs for prevention and treatment of sexual assault and family violence. The Sexual Assault Victim Intervention Program, or SAVI Program, is an innovative program developed by the Navy at the installation level. A specifically-trained coordinator establishes installation prevention training, a system of victim advocates, and develops the best counseling programs for victims by utilizing the best resources available in the community, both military and civilian.
    Since 1992, the VA has provided sexual trauma counseling for women who have experienced sexual trauma while on active duty. The information is provided to departing service members through our Transition Assistance Program, and in addition, the Office of the Assistant Secretary of Defense for Health Affairs published a policy memorandum requiring each medical treatment facility to review its ability to provide counseling to this group of patients and to utilize VA sexual trauma counseling programs as appropriate to meet the needs of the service members.
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    In addition, VA has developed a Memorandum of Understanding to expand the systemwide cooperative use of the sexual trauma counseling services for active-duty personnel. This Memorandum of Understanding is currently under departmental review. It would formalize reimbursement issues as well as facilitate reporting of co-morbid, psychiatric diagnoses to the services. These co-morbid diagnoses could have significant impact on command responsibilities for security and personnel management issues. The agreement, once finalized, would provide a valuable adjunct source of services for treatment for those who may not be appropriately treated in the military setting.
    But we will continue to work with the Department of Veterans Affairs to ensure that the Government meets its commitment to victims of sexual trauma while in the military and after they retire.
    That concludes my statement.
    Mr. STEARNS. Thank you. Dr. Murphy and Dr. Garthwaite, I'd like to ask the same question that I asked the earlier panel of Dr. Hyams about the proposed legislation to merge the databases—acquire databases from both DOD, Veterans' Administration, and private health insurance to carry out this study. What is your reaction to the legislation offered by Mr. Kennedy and Mr. Evans?
    Dr. GARTHWAITE. Well, I think from a theoretical standpoint, as someone who also used to legitimately earn a living by—(Laughter.)—caring for patients, I would say that computerization of patient records offers great opportunities for improving the quality of care in doing the kind of epidemiologic research that will be very helpful in the future.
    There's a variety of problems with getting from the theoretical piece to the practical piece. Everything from confidentiality of patients' records and safeguarding what is really a patient's information, to how to get doctors to type, how to get them to agree on what definitions of various physical findings and symptoms are, how to get the same software or standards for moving data to all those individual doctor offices around the country. I think there are just enormous issues.
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    I think a great piece in this is what was alluded to in the previous panel is that the Department of Defense, Department of Veterans Affairs, the Indian Health Service, and the Louisiana State University have signed an agreement to develop a Government computerized patient record. And I think that will force some standardization to occur. We'll begin to collect the data and collect the patient information in a way that allows patient records to move transparently with a patient when they want it to. And I think that's a tremendous stride in getting a computerized patient record that will benefit veterans over time. I, also, don't underestimate the enormity of the task of doing that while keeping the current system completely functional because we depend on it.
    I think the suggestion is that we're not doing any health outcomes research which I don't think is true. I think that health care, in general, isn't doing as much health outcome measurement in a non-research setting as it needs to do. And the VA, I think, is committed to do that. And we can show you a significant amount of data where we've used HEDIS like measurements and other measurements of patient outcomes to try and assess the quality of care we are providing. We are also trying to over-sample Gulf War veterans in those efforts to try to understand better what their health status is, and we expect to have some data in the next several months.
    In addition, we are doing research studies, we're in phase three of the Gulf War veteran study, which is more systematically looking at health outcomes of veterans. I wouldn't say that any health care system has gotten to the point where we know for any given individual, or every individual, their outcome, and the quality of their care. But I think we're beginning to do that better, and I think in the VA we've made tremendous strides.
    Finally, we've asked the Institute of Medicine to give us some feedback on how we might better study the outcomes for Gulf War veterans, and I think next week, or the week after, is their first meeting beginning to attack that problem.
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    Dr. COOKSEY (presiding). Good. Thank you. I know that Congressman Stearns appreciates the support of his bill, but do you have any recommendations for fine-tuning his concept of a national center for war-related illnesses other than what you've just covered in terms of electronic medical records?
    Dr. GARTHWAITE. Well——
    Dr. COOKSEY. Or does this bill already have everything covered, all the bases covered? Do you think it's a good bill as it is?
    Dr. GARTHWAITE. May——
    Dr. COOKSEY. He's not here, so you can tell me what you really think. (Laughter.)
    Dr. GARTHWAITE. Right. We have some experience in putting together centers which have been dedicated to research, education, and clinical care of specialized populations of veterans. We've done that in geriatrics. We have just awarded some grants, or support, for mental illness-related centers—or MIRECC's, as we call them. So I think we have some history. But we also, I think, have attempted in the last 3 years to get broad input. And so my assumption is that we will put together a draft request for proposals outlining what we would like to see in these centers, and then get the input of a variety of people both inside and outside of Government, including various Service organizations and others, so that as we design a center we'll have that kind of input. I think critical to that input is the Department of Defense. I mean, very clearly, we're talking about the health continuum of patients who start with the Department of Defense and that we take through the rest of their lives.
    So, I think it's going to require multiple inputs to get a very diverse look at this so we can design it right from the outset.
    Dr. COOKSEY. And so you feel like this piece of legislation would accomplish what its goals are as it is presently drafted, then? Pretty good shape?
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    Dr. MURPHY. Specifically, on the National Center for Study of Post-War Illnesses, we were very supportive of the current draft. We were happy to see the mandate for interagency coordination because we feel that DOD needs to be an active partner in that center. They have expertise with military occupational medicine as well as VA. But they, also, maintain some of the databases that would be really key to be able to do quality research and epidemiologic studies in this area.
    Dr. MAZZUCHI. I'd like to add to that, that one of the improvements, I think, that's coming very rapidly is new DOD policy which requires pre-deployment, during, and post-deployment medical surveillance. And, as we begin to capture those data electronically, we'll be able to share with VA much more readily information for its center that will deal with the exact health status of the service member prior to and during the deployment, or right after deployment. You're going to get a nice continuance of records that's—it's not just something that you see as the person who has left the military service and has been 2 or 3 years out, and then you really can't capture those data. So, I think our new deployment surveillance effort is going to go a long way to feeding into that center.
    Dr. COOKSEY. Good. I know during the Vietnam period they're were so anxious to get physicians in that I had a colleague that actually was a resident, senior resident, ahead of me when I was in medical school who only had one eye. He had an artificial eye and a God-given eye. But he not only went into the military, he went to Vietnam. And yet today, I think that the military is able to be a lot more selective in all their personnel, in not taking people who have any kind of a health problem, because I know there are people that would like to get into the volunteer services right now that have health problems. These need to be screened out and that needs to be done.
    Let me move into another area. I have three daughters, no sons. We never learned how to have boys. (Laughter.)
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    But I am very biased toward women. And I was surprised, and my colleague, Dr. Gutierrez, was surprised, at the numbers you gave us about the number of people that go into the military that have had preexisting or childhood sexual trauma. Do you really think those numbers are accurate—accurately reflect the makeup of the military? And what is your source for acquiring that information?
    Dr. MAZZUCHI. These are basically studies of the Navy Training Center and a study that was conducted by the Army. They are not generalizable to the entire population. But I'm not surprised that the numbers are high, that they are as high as they are. I'm somewhat surprised in whether they would hold for the entire population; I don't know. But, clearly, we have a group of people coming into the military who, because of past experiences, either sexual trauma or family violence, are at greater risk for continuing these problems. People who have been victimized once are much more easily victimized a second time.
    Dr. COOKSEY. So these studies were done on Navy personnel, then?
    Dr. MAZZUCHI. Yes, at their recruit centers.
    Dr. COOKSEY. Well, this past year we had two generals at our home for dinner, and I had my district director there who was also in the Air Force, and I commented to him that the Air Force usually has to bale out the Army. Well, a little while later—this was in the time period they were trying to get a Chairman of the Joint Chiefs of Staff. Well, the two generals—one of them got me back, and he said, ''Well, you know, we don't worry about the Chair of the Joint Chiefs of Staff being anybody from the Air Force because they can't find anyone in the Air Force that hasn't committed adultery.'' (Laughter.)
    So I would hope that we that these numbers that you're reflecting are a little bit—are inaccurate, because it's really a—it would be a concern if I felt that everybody that went into the military had that kind of history, because my contact with people in the military is that they're a lot of good people, well adjusted people that are committed to doing the right thing, and very professional people. And yet when these problems occur in childhood—I know people cannot prevent it a lot of times and it's unfortunate. But it's surprising numbers.
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    Mr. Gutierrez.
    Mr. GUTIERREZ. Thank you. Well, it's good to see that we are moving in the direction of—I just thought in order to have your tonsils taken out, they've got to give you all these tests, and it's a pretty simple procedure that most of us go through. And you can go to war and not have any medical records. I certainly hope that this leads us in that direction of having at least the medical records that someone who's tonsils got taken out. It is a pretty routine experience in youth. I don't remember a lot of people who kept them. That's certainly good.
    Let me just ask Dr. Garthwaite—I want to, first of all, thank him and commend the work of the VA in establishing the comprehensive sexual trauma counseling program. And Dr. Garthwaite, on November 25, 1997, the Under Secretary of Health circulated a letter to VA medical facilities clarifying the eligibility criteria for VA health care to veterans seeking counseling and treatment for sexual trauma. This letter was based on a VA General Counsel opinion from earlier that year which deemed that the minimum length service requirement contained in section 5303(a) of title 38 doesn't apply to the provision of sexual trauma counseling; thus, to receive this vital care a veteran no longer has to service 24 months of active duty.
    Doctor, as you may be aware, this General Counsel ruling is similar to provision contained in legislation I introduced last July. It exempted veteran seeking sexual trauma counseling for minimum service requirement. I believe it's important. Many of the incidents of sexual violence in the military occur prior to 24 months of service and where the requirement would come in.
    Doctor, since the clarifying letter was distributed throughout the VA, has the VA medical practitioners and administrators been admitting for trauma care veterans who did not serve the minimum service requirement? And could you——
    Dr. GARTHWAITE. My understanding——
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    Mr. GUTIERREZ (continuing). Start with some of your experiences and numbers?
    Dr. GARTHWAITE. It is my understanding that's true. I'll ask Joan if she has some more specific information.
    Mr. GUTIERREZ. Sure.
    Ms. FUREY. Yes, Congressman. We don't actually have numbers on the number of people we are seeing since that clarification and interpretation has gone out to the field. However, we have been in contact with our clinician providers, and they have pretty much told us that it is no longer a problem that they are encountering with people seeking the counseling under the provisions of the law.
    Mr. GUTIERREZ. So, we're working on guaranteeing that everybody knows about this new ruling and that's it's being implemented?
    Dr. GARTHWAITE. One of the advantages we have is that we have women's veteran health coordinators in our medical centers. We have Ms. Van Horn, from Baltimore—or the, I guess, VA Maryland Health Care System.
    Mr. GUTIERREZ. The experience in Baltimore, what happened after November of 1997 that used to be the trauma center—the sexual trauma center and if you——
    Ms. VAN HORN. I think I can quote our numbers from the VA Maryland Health Care System for all of 1997. We saw 80 patients, male and female. As of October 1997 to date, last week, we've already seen 78 veterans. So, we've doubled already in 6 months our experience with veterans.
    If I may address a question that Dr. Cooksey added, we, in Baltimore, did a study looking at the enrolled women in 1994. We had close to 900 women enrolled. We did a survey and, subsequently, wrote a paper which was published in ''Military Medicine'' in 1996. In fact, it was published 2 weeks before Aberdeen, which made it pretty clear that we have had a sexual abuse problem in the military for quite awhile.
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    One of the questions that we did ask was when did this act happen? And we asked specifically about age groups. Our experience was that 50 percent of our women veterans had been sexually abused as children. Our experience was also that 50 percent of those who went into the military were re-victimized. And this is the experience that the DOD is, I think, addressing at this point with many programs including the SAVI (Sexual Assault Victim Intervention Program) program which is, I think, one of the best programs that the Navy has at the present time.
    Dr. MAZZUCHI. One clarification and it's a question as to you, but also a comment to the committee is my understanding that it depends on how you view the definition of attempted rape. I think many people are victims of date rape, of being placed in situations where they feel threatened, and this is not a consensual act. I think most people, when they look at attempted rape, and conjure images of, you know, someone jumping out from the bushes with a knife or gun or something like that. There are many forms of rape, and I believe that those are included in all of these numbers. I think that's an important fact to have out.
    Mr. GUTIERREZ. But if you compare it to the general population, is it higher?
    Ms. FUREY. Yes, I'd just like to make a couple of comments.
    Mr. GUTIERREZ. Sure.
    Ms. FUREY. Certainly I think, in general, we see this—I think it was mentioned earlier that about 13 percent of women in the general population self report being victims of assault. And our data shows somewhere between 15 to 20 percent of women on active duty report having had these experiences of assault while they were on active duty, not in childhood. So, I think the perception and the numbers that we have in the VA is that this is a problem, and remains a problem in the active duty military.
    One comment I would like to address about this study that was mentioned of the Navy recruits and the military recruits. I always get concerned when numbers are given about the percentage of women who were victims of assault rape and violence during childhood or premilitary service, and not talk about the findings of men who, I think, have also been the victims of violence and physical abuse in childhood prior to their admission into the military; or how that dynamic may impact future interactions. I think it's important that we don't just select out the women as having had some of these negative experiences. And I would be interested to know what the data is for the negative experiences or abuse experiences of men, of the male recruits. Was that involved in this study?
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    Dr. MAZZUCHI. No, it was. I mentioned it. It was 38 percent were victims of childhood physical abuse.
    Mr. GUTIERREZ. Men?
    Dr. MAZZUCHI. Yes.
    Mr. GUTIERREZ. Good. We'll just keep going as people feel about the different questions. Mr. Cooksey, if you don't mind?
    Going back to Dr. Garthwaite, the General Counsel's rulings basically interpret the laws that Congress pass for Executive agencies, but they don't carry the weight of law, do they? That means——
    Dr. GARTHWAITE. We try to carry them out once they rule.
    Mr. GUTIERREZ. Once they rule?
    Dr. GARTHWAITE. Right.
    Mr. GUTIERREZ. They don't carry the weight of law?
    Dr. GARTHWAITE. We try to carry them out.
    Mr. GUTIERREZ. I understand.
    Dr. GARTHWAITE. We try to follow all their advice the best we can.
    Mr. GUTIERREZ. That's what it is. It's good advice, but it's not the law that you have to follow. So in the future, the VA could choose to permit veterans who have served less than 24 months not to receive sexual trauma care. In fact, unless you codify into law. Let me move back to a situation where veterans get discharged before the 24 months and not eligible. Could that happen?
    Dr. GARTHWAITE. I think, given their interpretation, it would be unlikely.
    Mr. GUTIERREZ. It would be unlikely, but—so you can't see a situation where, I don't know, Aberdeen kind of goes off the, you know, I would say the public spectrum scale and, you know, it's not an issue that's being raised and it's a new administration. You know, one not obviously not headed by Dr. Cooksey, because he'd continue doing this stuff, but headed by a new administration where they just think, you know, this isn't an important issue—isn't one. So they don't have to do it. I mean there are budgetary concerns here, aren't there? I mean it is not a requirement. It is not required even that I receive this kind of treatment is there? Anybody can answer that question.
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    Ms. FUREY. My understanding, and I think certainly it's something that we can get a clearer opinion on; is that the General Counsel's opinion is an interpretation that we act as being a legal interpretation, and it will be the regulations that we will follow.
    Mr. GUTIERREZ. Yes, and you can have a new General Counsel issue, a new opinion, but you can't have—the VA can't simply unilaterally change its mind about what the Congress of the United States dictates. They don't have that latitude or discretion. Would that be fair?
    Ms. VAN HORN. Correct.
    Dr. GARTHWAITE. That's fair.
    Mr. GUTIERREZ. Okay. So——
    Dr. COOKSEY. Could I comment on this point? It states here the Secretary shall give priority to the establishment and operations of the program to provide counseling and care services under subsection and on and on. So ''shall'' is a mandate, I would think. So I think there is a definite requirement there that the Secretary of Defense do this and it be carried out. Am I——
    Dr. GARTHWAITE. That's the way we are interpreting it, yes.
    Mr. GUTIERREZ. And we just want to—let me ask then, that's the way you're interpreting it. Before that interpretation that you made in 1997, was it a requirement for the Veterans' Administration to have to treat and have to personnel to treat victims of sexual trauma? Anyone who demanded the service?
    Ms. FUREY. I'd be glad to address that, sir. I think initially we did have some difficulty in implementing the provision of Public Law 102–585 and its amendments, and that it was open to interpretation at individual facilities. I think the reason that we went forward and requested the General Counsel opinion on the eligibility, and, also, the may/shall interpretation was that it was brought up by our Advisory committee. Dr. Kizer did send an interpretation to the field that basically said: this was something that the VA would provide, that the Secretary had determined we would provide it and, therefore, it was not an option. So, I think at this point in time today, as we sit here today, we feel we are in very good shape with the program. We have very little problem in terms of people being denied who meet our eligibility requirements. Certainly that was not always the case. But I think the steps that we've taken in developing this new program, interpreting the eligibility criteria, and reinforcing the commitment of the agency to providing the service in the field, has really demonstrated in improvement. Certainly the force of the Secretary and Dr. Kizer's commitment to the program has been significant in helping us accomplish that.
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    Mr. GUTIERREZ. I'm very happy to hear that since we have testimony of members of the military forces who did not complete the 24 months of service who were denied treatment—sexual trauma treatment, and indeed, and others.
    Last question for Dr. Garthwaite: In my research of the issue, I found that many women, veterans specifically, were poorly informed about sexual trauma programs. And I know that you've stepped up your efforts of late. I'm just raising one last concern with you about the extent to which women know about the program. That is, that when they come in they obviously give them the testimony of Ms. Van Horn in Baltimore, the services are increasing, and so that's good. And I'm just wondering what is being done so that they know it's there? So that they know to access it, not just because there's a higher incidence of the problem that people are coming up and asking for the service?
    Dr. GARTHWAITE. Sure, I think there are a lot of outreach efforts. I think they're detailed in the GAO report that I read last night, I think maybe Ms. Van Horn could comment.
    Ms. VAN HORN. Additionally, Secretary Brown last year, in the early part of the summer, sent a letter out to over 400,000 women veterans across the United States. The women veterans' program—health care programs have designed a question-and-answer tri-fold that is available at every VA facility. It has been distributed widely at health fairs, at women's meetings, at every venue that we Women Veteran Coordinators can use to address any female population about the availability of services that we have at most of the VA centers. And, of course, the mandate approximately a year ago to set up sexual trauma treatment programs at each medical division has been accomplished. And this is generally under the jurisdiction of the women veteran coordinator using licensed social workers, psychologists, and psychiatrists to deliver the acute care, or the crisis intervention, and then the therapy that's necessary for them subsequent to their call.
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    An 800-number was set up and monitored last year after a couple of television shows actually. It think it was ''20/20;'' ''60 Minutes'' did a piece, And, in fact, Ms. Furey was just on about a month ago on The Bryant Gumble Show.
    Again, we're taking every avenue that we can—newspaper stories, anything that we can use—to say we know that the VA used to be a male bastion; we now have female services and that does include medical services, mammography, pap smears, and sexual trauma counseling.
    Mr. GUTIERREZ. And then let me say to Ms. Furey—by the way, it's always good to see you. Sorry I didn't say hello. (Laughter.)
    Let me try to ask a general question, see if we can't get—what, given your experience, can be improved in terms of expanding what gaps? What women out there in the military—what gaps exist out there that who—this is shall and may, and who may not be getting the service but they are part of our armed forces?
    Ms. FUREY. Yes, I would just like to tag on one other thing to what Ms. Van Horn said before I answer your question, Congressman——
    Mr. GUTIERREZ. Sure.
    Ms. FUREY (continuing). Which is, the other thing that we have done has been working very diligently with the veterans' service offices and the national leaders to provide their membership and their counselors with information. We do go to their conventions. We go to their regional trainings, and really get the word out so that they'll get this information out to their membership, as well.
    I also think it's important to mention that it is not just women who access these services. I think we tend to forget that sometimes in talking about it. Certainly our clinicians have shared with us that they're seeing more men coming in every year to access these services. And you'll recall in 1994, I think, the Congress did pass a law to make that a gender-neutral bill.
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    Since we received the interpretation about the 24 months, we have not had a problem. Those individuals are now being seen under that General Counsel interpretation. I think, as has been discussed, and as you are aware, one of the issues that has been brought to our attention from clinicians and from the women veterans' community is that, women veterans or women who have been in the Reserves and are on active duty for training, who have these experiences happen to them, currently cannot access our services. They have presented that as a concern regarding eligibility. We are aware that you have a provision in your bill to address that, and the agency is studying it and is preparing, its position in response to what impact that change in eligibility would have on the agency or its ability to provide the services (the resource impact, et cetera). But certainly, I think that is the population that we are not able to provide services to right now.
    Mr. GUTIERREZ. And how about National Reserves, National Guard?
    Ms. FUREY. Well, that—yes. We actually can provide services to individuals who are activated, for service in Bosnia, or the Persian Gulf, et cetera.
    Mr. GUTIERREZ. So what happens if I——
    Ms. FUREY. It's the group of individuals who have this experience while they're on active duty for training. This status is excluded in the title 38 definition of veteran.
    Mr. GUTIERREZ. So, I go for my month of active duty; something happens. I have to stay on active duty in order to be able to get the service.
    Ms. FUREY. Yes.
    Mr. GUTIERREZ. Because when I go back to my civilian job, I'm no longer on active duty and cannot access this?
    Ms. FUREY. And by law, you're not considered a veteran. That is my understanding.
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    Mr. GUTIERREZ. Right, and you're not considered a veteran. So when you activate groups of people, we have to try to figure out a way to get them back into the thing.
    I'd like to ask Dr. Van Horn just that it seems to me that—I wanted to say that, you know, the Baltimore program is a great program, and it's one that I hope Dr. Garthwaite and everybody else at the VA is going to continue to duplicate throughout the system. Just a question, what is the level of service? Is the level of service as good in Wyoming, in California, in Chicago, and in Mississippi as it is in Baltimore? Is there the same level of service and quality service and access to that service throughout the VA health care system?
    Ms. VAN HORN. First, thank you for my promotion, but I'm a nurse practitioner. (Laughter.)
    Mr. GUTIERREZ. And you're welcome. (Laughter.)
    Ms. VAN HORN. We are across the Nation, as a very active group both with the women veteran coordinators in VBA, the Veterans' Benefits, and the Veterans' Health, trying very hard. And all of the program directors within the women's health services are striving to give the same services, or at least contract the same services if they're not available at smaller VA medical centers.
    Yes, I'm pretty proud of the Baltimore program, as you well know. But I think there are many, many programs across the Nation that are accomplishing the same things. The women are getting excellent services. And I think that once the women come in, or once they are identified, I have to say that the care is excellent. Yes, the reason for our program, and for this paper I should say, was that I had had so many responses to, ''Have you ever been sexually abused?'' And the women would say, ''I've never been asked that before''—and open up this floodgate of historical happenings. We would get them into therapy, and these are women that perhaps were over-utilizing medical care—and substance abusing—and all of a sudden we ask the question, they get into therapy, and we have now identified the woman and we know why she has this chronic pelvic pain, why she has the chronic headaches, why she has the chronic gastrointestinal problems. We treat the psychological sequela of this trauma, and she's a well person who's back to work.
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    We are finding that, once we'd get a woman, or male, back into therapy, they're back into a normal life within a year to a year and a half, two years max. Without this identification—and it's very difficult for anyone who has been raped to come forth because it's such a degrading happenstance—that once we ask the question, open it up, get them into therapy, they're pretty well.
    So we're finding that it's a very successful program, and what we're trying to do right now is, not only say, sure, those of us who know the problem, we knew to ask, but to ask every physician out there to ask the question, every primary care provider to ask the question, and then utilize the services that have been set up through each of the medical centers, that's our goal right now.
    Mr. GUTIERREZ. I see that Mr. Bilirakis has joined us and Mr. Cooksey has been more than kind in expanding the time, so I'm going to ask—that's very good Ms. Van Horn, but if anyone could answer the question, is the level of treatment available to women and men to sexual trauma equal? Is it just as good? Is the quality of service there? Is the availability there equal from region to region or are there lapses in this—in the body of the VA health care system?
    Dr. GARTHWAITE. Mr. Gutierrez, I would be the first to tell you that when you run a system as large as the VA, that absolute uniformity and consistency of care is difficult to achieve in every region in every medical center every day of the year. It is that guarantee of uniformity of care is, in large part, a major focus of the effort that Dr. Kizer and I and many other people in the VA have been putting forward in the last 3 years. We've begun to measure, as I answered Dr. Cooksey, that we're beginning to measure the patient's satisfaction with care and their outcomes from care. We have more measures than we've ever had which get at the issue of what is the outcome from care and what is the quality of those experiences.
    I think today more than ever in the history of the VA we can sit here and tell you that we've improved morbidity and mortality from surgery over the past 3 years, that we've improved patient satisfaction, our courtesy scores went up significantly, statistically significantly in every network last year around the country. We can tell you the major cohorts of medical illnesses have improved survival rates—the top nine medical diagnoses studied since 1992 to 1997.
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    If you say you can find someone who had a bad experience one day at one VA medical center, that may have happened. We are hoping to learn from that and prevent it from happening. But I think from a broad perspective, we have measures in place which have moved us in a very positive direction and we can tell you today that patients tell us when randomly sampled that they're happier with their care and that our data has shown that it's better.
    Mr. GUTIERREZ. And that's not really the focus of my question. And I'm just going to thank you all for being here this morning. We'll continue you this. I think you are making excellent strides at the Veterans' Administration in this—in our goal for providing services to men and women. My question is—I know that if I have a cold, I can go to any VA facility and I bet they got somebody who can treat me for my cold. If I break my finger, I bet there's somebody who can treat me for breaking by finger. You know——
    Dr. GARTHWAITE. True.
    Mr. GUTIERREZ. You get what I'm saying? I just want to make sure that if I need sexual trauma counseling——
    Dr. GARTHWAITE. Right, well, I think we have over 2,000 people trained and providing these services.
    Mr. GUTIERREZ. It's just that—I mean, I don't know that we're going to have the top cardiologists everywhere——
    Dr. GARTHWAITE. Right.
    Mr. GUTIERREZ (continuing). You know——
    Ms. FUREY. Right.
    Mr. GUTIERREZ (continuing). Or the top throat, theoretically, an individual should be able to access this service if they need it.
    Mr. GUTIERREZ. Well, that's my only point, because as you have said, they go back. As Nurse Van Horn suggested, within 2 years at max, they're productive and back and that their prognosis is a very good one in terms of getting back and being productive once again. And, you know, I just think they're so many things you said here today. I mean there's an increase in the number of people saying, ''I want the service.'' You're telling people about it. It's being, when they get the service, it seems like it might, you know, that it's good; that, unlike other traumatic experiences that need health intervention, this is one in which we can intervene and bring somebody back to a healthy situation vis-a-vis the Gulf War syndrome which we're still trying to figure out. It would be really nice if we said that everybody who had Gulf War syndrome ailment, right, in 2 years you could put them back to shape; we'd stop the hearings and give somebody a Nobel Peace Prize. I'm serious. That's what would happen. It would be so great. That's my only point.
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    And thank you very much, Dr. Cooksey.
    Dr. COOKSEY (presiding). I want to pose a question for the record. I do not have the answer. I assume you don't have the answer. But I'm still intrigued by your comments. If there are so many people that go on active duty in the military that have had adverse childhood experiences, should these people be precluded from being in the military? If you have had back surgery, they will not accept you in the military. If you've got bad vision, they won't accept you in the military. I don't know the answer to that. Does anyone want to touch it? It's something we should think about.
    Dr. MAZZUCHI. It's something we should think about. It's clear that psychological screening techniques need refinement. We do have standards that are very high for coming into the military service, but we don't demand that people have—that they come in without any problems of any kind. So, obviously, it depends on where on the continuum these problems are.
    I think it's very important for the military to develop early identification and early intervention programs for these people. But I think along the whole area of psychological problems that people may or may not have been experiencing as young people, we couldn't have a policy excluding someone who had every problem because we would have nobody in the military then. And we really have to make sure that these people would be treatable, would be able to serve on active duty, and finish a term of enlistment. I mean that comes to the critical piece for us. So exactly where on the continuum and how traumatic an experience was, and how serious the psychological problem, and how much psychological damage that is done, all that needs to be assessed. We attempt to do that in our overall psychological screening, but psychological screening is not a very perfect art as you know.
    Mr. CHRISTOPHERSON. Let me bring up a little more on that.
    Dr. COOKSEY. Yes. There are a lot of answers to my questions, aren't there?
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    Mr. CHRISTOPHERSON. There are, but let me go to the more basic part of it. I think, in general, you would not want to use sexual trauma as a reason for somebody not to come in to the military. I think that would be to identify a victim who would be victimized twice and that would be too unfair. I don't think our experience today here is that this is something that should eliminate a will to serve well the military. And so I would not want to see us go down that road.
    Dr. COOKSEY. Good. Would one of the ladies like to comment? Ms. Furey or Dr. Murphy?
    Dr. MURPHY. I'd like to comment. We know that childhood trauma is a significant risk factor for development of future problems including PTSD, especially with re-exposure to a traumatic stressor, but this isn't 100 percent predictive. Not every individual who has had childhood trauma develops those difficulties, and it would be discriminatory to exclude all individuals with any history of childhood trauma, whether sexual or physical, from military service. I think that would be a bad policy. A better policy would be to make sure that, if identified in recruit training camps, that the preventive therapy that we know works is offered to military members.
    Ms. FUREY. I'll just make a brief comment, sir. I think that when you hear the kind of data that's presented, it would automatically make one think that maybe we should keep these people out. I think, then, we forget that there are many people who have come from disadvantaged backgrounds who have actually benefited tremendously from military service both in their social, educational, economic, and occupational abilities. I think it's an area that certainly needs to be questioned and studied and looked at in terms of what happens in the environment that can either assist them or perhaps create some other problems.
    I, personally, would be very cautious to make any kind of blanket statement regarding screening these individuals out, particularly knowing the level of psychological screening available right now.
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    Dr. COOKSEY. Well, it's a very serious concern. Your presentation has been good. I'm glad we're having open discussions, and I think it should be available for everyone in the military from the, you know, the entry-level person all the way up through the ranking officers, maybe even the Commander-in-Chief.
    I will turn this over to Mr. Bilirakis. I have got to give a speech somewhere in a little while. And I'll let him ask his questions from the position of the chair.
    Thank you very much. You've been excellent witnesses.
    Okay, if there are no other questions, thank you again for coming, and we'll have the next panel.
    Mr. BILIRAKIS (presiding). The last panel will consist of Mr. Stephen Backhus, Director of Veterans' Affairs and Military Health Care Issues with HHS, General Accounting Office, accompanied by Shelia Drake, Assistant Director of Veterans' Affairs and Military Health Care Issues, the General Accounting Office, and Veronica A'Zera, National Legislative Director of AMVETS.
    Welcome, Ms. Drake, Ms. A'Zera, and Mr. Backhus. Stephen, will kick it off with you.

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    Mr. BACKHUS. Mr. Chairman and Mr. Gutierrez. We are pleased to be here today to discuss VA's sexual trauma counseling programs. My remarks will focus on work we have undertaken for this subcommittee, that Shelia led, to describe the extent to which sexual trauma counseling services are available in the VA, their outreach and training efforts, the extent to which women veterans use these services, and what VA is doing to assess the effectiveness of its counseling programs. The work was conducted at six VA facilities and included discussions with, not only VA health care personnel, but with women veterans.
    Regarding the extent to which sexual trauma counseling is available, VA now offers services in all of its hospitals and in 62 of its 206 Vets' Centers. Four VA hospitals—Boston, Brecksville, Loma Linda, and New Orleans—also offer specialized programs for women who have been more severely affected by the stress or sexual trauma they experienced while in the military. These specialized programs are conducted by women veteran stress disorder teams that generally employ much more intense treatment protocols and include such treatment services as individual psychotherapy and crisis management. At those Vet Centers that do not offer sexual trauma counseling services, the staff do provide psychosocial assessments and do make referrals to other VA centers as appropriate.
    The VA has conducted a number of outreach efforts to increase staff awareness, and inform women veterans about available sexual trauma counseling services. For example, it has implemented a multi-faceted training program to educate and sensitize health care administrative personnel about sexual trauma. It has also informed many women veterans about the availability of counseling and treatment services. For example, it has sent letters to over 400,000 women veterans informing them of their services. It routinely provides information on available services and arranges for these services through a toll-free telephone number. And its services, as you've heard before, were highlighted as part of a national television network news documentary on sexual trauma in the military.
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    Turning now to utilization, the number of women veterans who seek sexual trauma counseling has dramatically increased over the past several years. Between just fiscal year 1993 and fiscal years 1997, the number of veterans receiving sexual trauma counseling has almost quadrupled from 2,300 to over 9,000. Over this same period, more than 18,000 women have been treated for sexual trauma by VA. And between just 1996 and 1997, the number of women receiving sexual trauma counseling services increased 20 percent.
    Not surprisingly, staff associated with the counseling programs we visited expressed some concern about their ability to continue to adequately respond to the increasing demand for counseling services. However, the women veterans we talk to are generally satisfied with the care and the services they have received through the VA and like having the different options available to them. A few though have expressed the desire to receive counseling on a more frequent basis.
    The primary complaints we heard about the VA sexual trauma services are directed at the process for awarding compensation. While documentation of sexual trauma is not required to received counseling, it is required for compensation claims. Since personal assaults often go unreported, there is commonly no documentation to support a claim for compensation. We understand, though, that VBA has developed guidance it helps will alleviate some of these problems by accepting information other than service medical and personnel records—in other words, personal diaries or statements of other people.
    Regarding the effectiveness of sexual trauma counseling programs, later this fiscal year, VA plans to initiate an evaluation of its four women veterans' stress disorder teams using a protocol similar to that which they've used to evaluate the effectiveness of intensive PTSD programs. And Vet Centers are currently evaluating the effectiveness of their programs. While these evaluations are positive steps, only about one-fourth of the counseling services provided to women veterans occur through either Vet Centers or the stress disorder treatment teams. Most counseling is provided by VA hospitals and outpatient facilities, and at this time, VA has no plans to systematically evaluate the effectiveness of its counseling programs provided at these locations.
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    Mr. Chairman, this concludes by statement. Shelia and I will be happy to respond to any questions you and other members of the subcommittee may have.

    [The prepared statement of Mr. Backhus appears on p. 78.]


    Ms. A'ZERA. Thank you, Mr. Chairman. I'm Veronica A'Zera. I'm the National Legislative Director with AMVETS, and I'm accompanied today by Carol Rutherford from the American Legion, Joy Ilem from DAV, and Kelly Willard-West from VVA.
    On behalf of AMVETS, Disabled American Veterans, Vietnam Veterans of America, and the American Legion we want to thank you for the opportunity to express our views on the sexual trauma counseling program at the Department of Veterans Affairs.
    We want to congratulate Congress and VA for having insight to establish such an essential program. We are here to evaluate the current program and make some suggestions on what improvements can be made when Congress re-authorizes the sexual trauma counseling program.
    The first thing is, and as Congressman Gutierrez brought up in his opening statements earlier, that we would like to see it opened up to Reservists and National Guard members. Current law requires 2 years of active duty service in order to be deemed a veteran for the purpose of seeking general VA health care. Yet, a VA Under Secretary for Health's information letter dated November 25, 1997, regarding eligibility criteria for VA health care to veterans seeking counseling or treatment for sexual trauma indicates that the minimum length of service requirement does not apply to the provision of these sexual trauma benefits. Members of the National Guard and Reservists who are called to active duty are eligible for this program. However, they are not eligible if trauma/harassment happened during their training. The law excludes active duty from training from the definition of their active duty. We believe that this presents some potential ambiguities, and we also fear a different and perhaps more restrictive interpretation in the future, particularly if resources become more and more constrained.
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    Because of this unique circumstance surrounding sexual trauma or harassment in the military, some men and women victims' service careers may be abbreviated. Some of the individuals involved in the situation at Aberdeen, for example, may have left the service as a result of these incidences during or shortly after their training. Also, members of their Reserve component called to active duty during the Persian Gulf War may not have fulfilled the 2 years of active duty service to qualify for these needed treatments.
    While current VA interpretation of the law seems largely appropriate, we want the statue to be modified to reflect the Under Secretary's policy and further allow Reservists and members of the National Guard traumatized while on training exercises to be eligible for the VA sexual trauma counseling program.
    Because this is current VA practice, based on the letter, we do not anticipate a significant cost increase that would be associated with providing this statutory authority, and this would help to ensure that men and women in these categories do not fall through the cracks.
    A second recommendation is to make the program permanent. In a perfect world, this program would not be necessary. Unfortunately, we don't live in a perfect world. According to the Center for Women Veterans' at Department of Veterans Affairs, 20 percent of all women veterans report they have been raped or sexually assaulted. In order to protect those who served, we need to have this program and continue beyond 1998.
    Along with making it a permanent authority, reporting requirements and outreach records should be kept and reports made to Congress each year by VA and the Department of Defense on the incidents that have occurred as well as how many people have participated in the program. Currently, these records are not kept and are sketchy at best.
    We would like to DOD and VA maintain and compare data. Currently, DOD cannot detail how many men and women were assaulted last year. There's no tracking system. This needs to be corrected.
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    We would also like to see sexual trauma listed in the next edition of the ''National Survey of Veterans'' produced by VA. They track several medical conditions, and we would like to also see them track sexual trauma.
    No matter how great the program is, if no one knows that it exists, it won't benefit anyone. We credit the VA for its efforts in getting the message out. We, as veterans' service organizations, also have the ability to help in this area and ask for a more coordinated communication plan.
    One misconception about this program is that some individuals will use sexual trauma counseling as a way to get into the VA system and then ''milk it'' for other services such as medical, dental, compensation. There is no incentive to do such a thing. All this Act entitles a veteran to is counseling and care as required because of the trauma. It does not entitle them to get anything extra, nor does it guarantee compensation. The very remote potential of people misusing the system is no reason to preclude the program improvements that we advocate.
    In conclusion, we all believe that this program with some minor modifications warrants being made a permanent program within the VA. H.R. 2253 introduced by Congressman Gutierrez addresses all of our concerns, and we are all supporters.
    We appreciate the opportunity to testify on this issue, and I'll address any questions you may have.

    [The prepared statement of Ms. A'Zera appears on p. 105.]

    Mr. BILIRAKIS. Thank you, Ms. A'Zera.
    Let's see. Ms. Drake, I know you're not really a member of the panel, but since you are here is there anything you'd like to add very briefly?
    Ms. DRAKE. No, I'm just here to help Steve answer some questions if I need to. Thanks.
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    Mr. BILIRAKIS. Okay, great. Maybe you'll have that opportunity. (Laughter.)
    All right. Ms. A'Zera, obviously you're supportive the sexual trauma program. I think we all are supportive of a sexual trauma program. It might be what we now have, it may be an expanded program, but—I guess my question is, do you have any data or information regarding its effectiveness?
    Ms. A'ZERA. Well, I think it has been reported through GAO and with the VA on how many people have used it. And also, we have gotten letters from women veterans, specifically after the letter went out from Jesse Brown inviting people to come out to the VA for these kind of services. We, also, did receive letters from women veterans who said, ''We went out to the hospital and there wasn't anything there for us.'' So, we've gotten those kind of feedback.
    But as far as the statistics of how many people have used it, the VA and the GAO have those statistics. And it is, according to their reports, that it's increased.
    Mr. BILIRAKIS. All right.
    Ms. A'ZERA. It is being used—utilized.
    Mr. BILIRAKIS. But AMVETS really is going on record as saying that they think it's effective?
    Ms. A'ZERA. Yes. Yes, sir.
    Mr. BILIRAKIS. Okay. I know Ms. Van Horn—I came in during the time that she responded to a question, and she indicated incidences when an awful lot of people were able to become productive and that sort of thing. And that's obviously good to hear.
    Mr. Backhus, have you been able to compare the quality of any of the VA sexual trauma counseling programs with the kind of intervention quality, etc., that would be available through non-VA providers? I mean, how do they compare? Do you have any opinion in that regard?
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    Mr. BACKHUS. Well, we didn't have that as part of our study.
    Mr. BILIRAKIS. Yes, I can understand that probably it was probably not requested, specifically.
    Mr. BACKHUS. So, I really, I have no firsthand knowledge of that. However, I do know of people who have commented that there is at least comparability.
    Mr. BILIRAKIS. There is comparability?
    Mr. BACKHUS. Yes, with what's available outside the VA. Also, I know that the VA occasionally contracts out, of course, for this service.
    Mr. BILIRAKIS. Yes, so you've gotten sort of that information even though it hasn't been part of your study?
    Mr. BACKHUS. Correct.
    Mr. BILIRAKIS. Okay. Let me ask you—and I know that the focus here, as it should be, is on the counseling programs and are they effective, and should they be improved, etc. I guess there's always room for improvement, no matter how well any program is going on.
    Going back to prior days, Korea, people—men and women in the military during the Korean days, Vietnam, to those decades—let's say the 1950's, the 1960's. It may seem like ancient history to you all, but for people like myself who was in back at that time, it isn't. All of the years really fly. And I know that sexual abuse and sexual harassment is just not limited to women, but for the most part—there are a lot more women in the service now than there were back in those days. But on a per-capita basis, if you will, did we have as many problems in this regard back then as we do today?
    Mr. BACKHUS. Well——
    Mr. BILIRAKIS. In the process, Mr. Backhus, of your research, and what-not, any opinion in that regard?
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    Mr. BACKHUS. The only information I have—and it doesn't really very clearly get to your question—is that it wasn't until the early 1990's, earlier in this decade, that people began to talk about this. So, I would conclude from that——
    Mr. BILIRAKIS. So are you saying, then, the problems were probably there but people just didn't talk about it?
    Mr. BACKHUS. That's what I would say, yes.
    Mr. BILIRAKIS. Yes, and any further comments, Ms. Drake or Ms. A'Zera?
    Ms. DRAKE. We don't know to what extent it happened back then. It seems to be more prevalent now. When we were out talking to some of the veterans, at one of the regional offices, they did have a veteran who had been sexually traumatized back in 1948. And, then, we did meet with a couple of other women veterans who had been sexually traumatized maybe about 20 years ago. So, it did happen back then but I still don't know to what extent it happened——
    Mr. BILIRAKIS. Yes.
    Ms. DRAKE. But it seems to be more prevalent now, as Steve said, because maybe it's more in the forefront and people are more willing to talk about it.
    Mr. BILIRAKIS. Yes, that's reasonable. Ms. A'Zera, anything to add?
    Ms. A'ZERA. I would just add that there weren't any statistics kept so it's kind of hard to do that, to look back and see that. But——
    Mr. BILIRAKIS. There weren't any statistics kept?
    Ms. A'ZERA. DOD, right now, can't tell you how many people have been assaulted at any given time now, within a year. They can do surveys; they've done a survey on military members who have experienced it, but they don't keep the records as far as like each base, how many have been assaulted, or anything like that. They don't keep anything like that.
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    But when I did—I did an article for AMVETS a while ago, and on the veterans, and I went back through the history and talked to several women veterans from different eras, and they had all had stories about some sexual assault or abuse that had happened to them during their time or knew of some people that had. So I think it's been prevalent all along. I think we just now are—it's brought up to awareness.
    Mr. BILIRAKIS. Well, thank you. Mr. Gutierrez.
    Mr. GUTIERREZ. Thank you very much, Mr. Bilirakis. And welcome, Mr. Backhus, Ms. Drake, and Ms. A'Zera. Good to have you all here.
    Well, No. 1, you said it quadrupled, the use from 1993 to the present?
    Mr. BACKHUS. Yes.
    Mr. GUTIERREZ. So what about the number of women serving in the military? Do you have any correlation——
    Mr. BACKHUS. I do.
    Mr. GUTIERREZ (continuing). Correlation between the number of women increase and those asking for the service?
    Mr. BACKHUS. I do, but I don't have it memorized here.
    Mr. GUTIERREZ. Okay.
    Mr. BACKHUS. In 1980—here it is—in 1982 there were about 740,000 women veterans. By 1996 there were 1.2 million. So, it's not quite a doubling.
    Mr. GUTIERREZ. But it seems to be——
    Mr. BACKHUS. But for a much longer period of time.
    Mr. GUTIERREZ. Is there any projection of what's going to happen in the military——
    Mr. BACKHUS. Yes.
    Mr. GUTIERREZ (continuing). In terms of women?
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    Mr. BACKHUS. Yes.
    Mr. GUTIERREZ. What's going to happen——
    Mr. BACKHUS. Yes—I have that, too.
    Mr. GUTIERREZ (continuing). In the future? What do you know about it?
    Mr. BACKHUS. By the year 2010, it is estimated that there will be about 1.3 million veterans. And you know, I had it out to 2040, or Shelia did, and I said that's too far out. (Laughter.)
    So now I forget what the number is.
    Mr. GUTIERREZ. All right. (Laughter.)
    So that's very good. Well, I think it answers the question pretty well for the committee, so we do know that there are more women seeking the service, quadrupling of seeking of service. It's more now and people need it. And it's one that they like, for the most part, they like. And that we hear from the VA that it's a very productive intervention. Do you find that their interventions—that your study show that their intervention leads people to successful kind of reentry into life?
    Mr. BACKHUS. Well, you know, we didn't look at that specifically. However, in the conversations with the women veterans that's how they tended to portray the outcome of the service. We make mention in the testimony that there really isn't anything more than what I would call antidotal accounts of the program's effectiveness. There are efforts underway though to try to do something in a more systematic way to find out—for example at least at the Vet Centers and the special trauma teams that are taking care of the more severely ill patients. I tend to agree, though, that if there wasn't some sort of a ground swell of support among the women veterans that we wouldn't have seen the demand increase as it has. And that suggests to me that people are getting a lot out of it.
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    Mr. GUTIERREZ. So we have increase, and we will continue to increase the number of women veterans through the foreseeable future. And the people that are using the program, it's productive. People are getting good benefit out it. Let me ask you some yes or no, otherwise, I will certainly take up a lot of more than 5 minutes between the two of you.
    So, now, do you believe that more women's veterans stress disorder treatment teams should be established by the VA? Should they establish more of them?
    Mr. BACKHUS. I haven't seen any unmet demand for that at this time.
    Mr. GUTIERREZ. You have not seen any unmet demand. So that you don't see any reason to have an additional ones?
    Mr. BACKHUS. Not at this time.
    Mr. GUTIERREZ. In the hospitals and the Vet Centers that you visited as part of your report, did you find uniformity of care provided to veterans? And how consistent is the care offered for sexual trauma?
    Mr. BACKHUS. Dr. Garthwaite answered that, I think, similar to how I'm going to answer it. Like any other health care issue in VA, if you've gone to one VA facility, you've seen one VA facility. They vary; there's variation around the country as to how well these programs are run and how well supported they are resource wise. Some are more able to treat than others.
    Mr. GUTIERREZ. Just so there isn't uniformity?
    Mr. BACKHUS. There's not.
    Mr. GUTIERREZ. Not?
    Mr. BACKHUS. No.
    Mr. GUTIERREZ. There's not uniformity in terms of the care? You can receive better care at some facilities then at other facilities?
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    Mr. BACKHUS. Clearly.
    Mr. GUTIERREZ. That's why I just wanted to establish that. I think both——
    Mr. BILIRAKIS. If the gentleman would yield, should there be or is that a——
    Mr. GUTIERREZ. I believe there should be. I believe that a——
    Mr. BILIRAKIS. Well, I——
    Mr. GUTIERREZ (continuing). Women should be. And my point is if I have a sore throat—I bet if I ask the same question of Mr. Backhus and the same question of Dr. Garthwaite, I bet you I could list a series of ailments, a series of medical conditions, that there would be more uniformity than not in terms of the availability of drugs, pharmaceutical, and doctors to take care than this particular issue. And since the hearing is about this particular issue, I'm concerned about this particular issue because I want to raise it to be just as important, if not more important, than a cold. And the reason I bring a cold and a broken—that's my few times I visited—(Laughter.)—and it was like any hospital could take care of me in the city of Chicago, and any health care plan would have covered me. It's kind of universal—colds and broken bones.
    Mr. BILIRAKIS. I would suggest to you though, sir, that a cough—and you've just coughed—a cough or a cold or what not could be something more serious than just, you know, a cough or the flu or something of that nature. So, I'm not sure that we really want the uniformity that you talk about there.
    Mr. GUTIERREZ. No, no. It's not——
    Mr. BILIRAKIS. And this was on your time. I guess my question, though, was to Mr. Backhus and you responded to it. (Laughter.)
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    Do you think there should be uniformity?
    Mr. BACKHUS. Well, I think there's a value in establishing that as a goal or something to strive toward. I don't think it's possible, though. I'm not a clinician, but in speaking with those clinicians that work in this program, it's a very complicated issue. You treat people individually, depending on the circumstances, and there has to be variability in how you treat those people. The consistency that I see possible is in, the resources that are made available to people, not so much in the protocols that are established in——
    Mr. BILIRAKIS. Yes. So what you're saying is there should be consistencies a far as resources being available.
    Mr. BACKHUS. Right.
    Mr. BILIRAKIS. Which I know is what you're certainly very anxious to——
    Mr. GUTIERREZ. It's exactly, Mr. Bilirakis, my point. My point is pretty simple. A cold is a cold, is a cold. And if a cold is something other than a cold, then it's not a cold. But a cold is a cold, and I've been treated for a cold many times and it wasn't anything other than a cold because I'm still here. (Laughter.)
    And I didn't go back to get treated for anything else. And a broken finger is a broken finger, is a broken finger. And so my only point is that there are things that are what they are. Now let me just—watch, I'll ask Mr. Backhus. Has the VA improved over the last 5 years, their services to men and women in terms of sexual trauma treatment?
    Mr. BACKHUS. I would say definitely, yes.
    Mr. GUTIERREZ. They have improved? Is there room for improvement?
    Mr. BACKHUS. Of course.
    Mr. GUTIERREZ. Of course there's room for improvement. I'll rest my case. I would like to, if I could, ask Ms. A'Zera a couple of questions.
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    Mr. BILIRAKIS. A couple of questions with a couple of quick answers, please.
    Mr. GUTIERREZ. Fine. That's why I'm only the ranking member. (Laughter.)
    Ms. A'Zera, welcome again, and allow me to thank you and the member of AMVETS and your colleagues and the veterans' service organizations for your assistance and support in this issue.
    The GAO earlier testified that the VA's outreach efforts to women veterans—do you believe the VA has done everything it can or enough to inform women about sexual trauma services that they can receive?
    Ms. A'ZERA. I think that, after hearing all the comments from Joan Furey and everyone, that they are certainly doing what they can. And I think that there's always room for improvement. And, as I've said in my statement, there's also room for the veterans' service organizations and other agencies to help them get that word out. And I think that we all need to work together on doing a better job at that. Yes.
    Mr. GUTIERREZ. Current law authorizes the VA to establish a sexual trauma program but does not mandate that this be done or continued. Is that your understanding?
    Ms. A'ZERA. Yes.
    Mr. GUTIERREZ. Today the VA has established a viable sexual trauma counseling program throughout the VA network that people are accessing, quadrupling. They're the numbers from 1993 forward. Nevertheless, because this program is discretionary, uniform access to these services is not guaranteed for the future. Do you believe that we should revise the law to require that the maintenance of this vital program and to make the provision of this care a priority for veterans in need? And why do you believe it's important?
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    Ms. A'ZERA. Of course, and because there's clearly—they've shown the need is there by the fact that the numbers have quadrupled, and from what we heard from our women veterans and our members, that the need is there for it. And with the expansions and the improvements that we've suggested, as far as opening it up to the Reserves and National Guard, I think that you'll see the desire to use it will expand even further.
    Mr. GUTIERREZ. Last question: Do you believe the authority to establish the sexual trauma program should be extended permanently? And is that the position of your organizations and any other veterans' organizations that you might know of?
    Ms. A'ZERA. That's back to my perfect world situation. Yes, we would like to see it permanently.
    Mr. GUTIERREZ. And AMVET supports permanent. And are there any other veterans' organizations that you know of that support it being permanently extended?
    Ms. A'ZERA. The ones that I'm here representing today, yes, that's our case.
    Mr. GUTIERREZ. Thank you very much, and thank you very much Mr. Bilirakis.
    Mr. BILIRAKIS. The gentleman, Mr. Stearns, Chairman Stearns.
    Mr. STEARNS. Thank you for doing such an able job.
    Mr. BILIRAKIS. Well, I'm not sure if Mr. Gutierrez would agree with that. (Laughter.)
    In any case——
    Mr. GUTIERREZ. For the record, I do. (Laughter.)
    Mr. BILIRAKIS. Okay. In any case, we thank this panel. You know, this is a tough, complex subject. I know that there isn't anyone in this room, or elsewhere, who would not agree with that, and a willingness to work on it, address it, to solve it, you know, that sort of thing. Whether Mr. Gutierrez's legislation A through Z is the answer; whether—are there answers? I don't know. But certainly that's what these hearings are all about. And we could not never really come to any kind of conclusions without the type of testimony we've heard from you. Thank you very much for being here.
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    Mr. BILIRAKIS. The hearing is adjourned.
    [Whereupon, at 12:08 p.m., the subcommittee adjourned subject to the call of the chair.]