NOTE: Unedited document




September 5, 1997

Holiday Inn

625 First Street

Alexandria, Virginia


Committee Members:

Joyce C. Lashof, M.D., Committee Chair

John Baldeschwieler, Ph.D.

Arthur Caplan, Ph.D.

Joseph Cassells, M.D.

Thomas P. Cross

David A. Hamburg, M.D.

Marguerite Knox, M.N., N.N.C., C.C.R.N.

Robyn Nishimi

Rolando Rios

Andrea Kidd Taylor, Dr.P.H.

P R O C E E D I N G S (8:33 a.m.)

DR. LASHOF: We will begin. Our agenda is to walk

ourselves through our final special report. We don't call

this one a final special report, a special letter report.

MS. NISHIMI: No, not a letter.

DR. LASHOF: Okay, it is a special report. We

have to get all this bureaucratic terminology straight,

reviewing, or responding specifically to the charge given to

us by the President when he extended the committee.

As you recall, the charge was to carry out

oversight of further Department of Defense investigations of

any incidents of exposure to chemical or biological weapons,

and to follow up on the implementation of the rather

extensive recommendations that we did make in our final

report in January of 1997.

Staff, I think, have worked very diligently and

very effectively over the last 10 months, in keeping on top

of both the DOD investigations and in keeping on top of the

progress the departments have made in addressing the various

recommendations that we made in that report.

Today we will walk through the draft document that

we have in front of us, which addresses those. I don't

intend to read this document aloud.

I will take it page by page, briefly indicating

what we are discussing, at least, on that page, and ask for

any comments, additions, changes, anything any member of the

committee wishes to say on any aspect.

I will not start with the executive summary. We

will save that until the very end and can discuss how much

we want in that executive summary. Right now it is very


Page one, then, is merely an introduction. It

sets forth that we were established. It sets forth that we

did a report in January and that this special report is in

response to that charter.

Is there anything else that anyone feels should go

into the introduction before we launch into page two, when

we start right in with the review of the implementation.

MS. NISHIMI: I just want to remind the committee

that recommendations and findings of the special report will

be printed as an appendix. That is why you don't find

continued reference throughout the document to them.

MR. RIOS: There has been some discussion about

maybe adding something into the research.

DR. LASHOF: We will get to it page by page.

MR. RIOS: What I am suggesting as something the

staff might want to discuss is that there may be something

that we want to add insofar as the introduction is

concerned, either a paragraph or a couple of sentences,

having to do with some of the issues that we are going to be

discussing in the research section.

I know that some of the committee members have

felt that perhaps we want to add it in the introduction as


Maybe now is the time to discuss it, or we could

do it when we get into the research section, however you

want to do it.

MS. NISHIMI: I would prefer to march through the

document as it is, section by section. If there are

additional things that need to be put into the introduction,

then revisit it.

MR. RIOS: Then get into that at that point?


MR. RIOS: Okay.

DR. LASHOF: On page 3 we start right in with the

implementation. We discuss the fact that the plan is given.

Is there anything that struck anybody on page 3 that they

want to comment on?

It is, again, sort of an overall introductory

statement in the weight of the implementation.

We then move right into the specific aspects. The

first one is the outreach. We recognize the progress DOD

has made in outreach and the VA.

We recognize the activities of Jesse Brown in

going out and meeting with Gulf members. So, anything there

that strikes anyone or anything that was omitted?

We describe the clinical working groups workshops

that we have heard about. We discuss some of the risk

communication efforts that have been made.

MS. NISHIMI: You are up to 5 now?

DR. LASHOF: Yes, I am up to page 5. We take

cognizance of the fact that the deployment of U.S. forces to

Bosnia gave them an opportunity to test some of our pre-

deployment and in-theater risk communication.

Are there any additions, corrections, concerns on

page 5?

MS. KNOX: Do we want to add anything about their

response to the tick-borne encephalitis and their informed

consent here, or do we want to make?

MS. NISHIMI: That is covered under the use of the

investigational products.

DR. LASHOF: It does come up.

MS. NISHIMI: It is not really outreach, I don't


DR. LASHOF: When we come to it there, if you

think we need to say more about it than we do, we will come

back to it. Let us move on to page 6.

We come to the medical and clinical issues.

MR. CROSS: At the top of the page there, we talk

about comprehensive risk, communication program. It says

the effort should receive heightened priority.

Do we want to put some kind of a deadline on that

or a time frame?

MS. NISHIMI: Joe, is it your assessment that you

could do that?

MR. CASSELLS: It is possible to do that. The

original response to the recommendations when we made them

was to have that plan in place by the first of May of this

year. Of course, that slipped.

If the committee wished to set a date, it could.

It seems to me the heightened priority would accomplish the

same thing.

MR. CROSS: Even a time frame. If you just read

it quickly, it leaves it open ended.

DR. LASHOF: I think that is a fair point. I

mean, we asked for May -- they said they were going to do

May. They missed that date. We are now up to September.

Do we want to say, should receive heightened

priority and should be completed before the end of this


MR. CASSELLS: Or by the end of this year?

MR. CROSS: Would you want to list the original

projected completion date of May of 1997?


DR. LASHOF: Did we have it earlier on a previous


MS. NISHIMI: When we discussed the whole program,

just before the recommendation.

DR. LASHOF: Okay, medical and clinical issues.

We note with approval the government's plan for implementing

the recommendations in the interim report and the provision

of care.

We heard some yesterday about the efforts in

primary care and in case management. They are moving in

that direction.

You will note in your draft that on line 19 and 20

there is a parenthetic update with additional information

from September briefing, as appropriate, would be added.

Does anyone on the staff want to comment on what

they think, from what we have heard yesterday, that they

expect to add at this point?

MR. CASSELLS: I think based on testimony

yesterday and answers to some of the questions on the part

of the staff and the committee, we might want to address

ourselves to the case management strategy that the VA is now

undertaking and relate that to the problem of Gulf War

veterans and their access to medical care.

This is particularly since we have noted in the

past the problems with follow-up care.

DR. LASHOF: Yes, I think it would be worth adding

something to that effect.

MR. RIOS: What about the idea of maybe -- I don't

know if it is in this section, but someplace making it

perfectly clear what now appears to be the government's

position on how to take care of all -- what was it?

One of the gentlemen who testified yesterday said

that this is the government policy.

MR. CASSELLS: That was Dr. Rostker's statement in

the afternoon. I am not comfortable that Dr. Rostker could

speak for the Veterans Administration.

MS. KNOX: I think Fran Murphy stated the same

thing, though, in the morning session.

MR. RIOS: What is the policy of the government,


MR. CASSELLS: I think we can make a statement as

to what the policy is, but I would not want to rely

specifically on the words used yesterday afternoon.

MR. RIOS: Maybe something just to clear that up.

MR. CASSELLS: Yes, we can do that.

DR. LASHOF: Anything else on page 6?

MS. NISHIMI: Before we move off page 6, do you

want to address the issue that Joe raised, which is the case

management primary care issue or not?

DR. LASHOF: I think it would be worthwhile to

note with satisfaction or commend the efforts, to proceed

with case management and primary care, and urge that

priority be given to assure that every ill Gulf War veteran

have a primary care or case manager to coordinate or oversee

their care.

I think that is such an important issue to a

patient whose illness is not clear cut, and whose treatment

isn't clear cut, that they get that kind of care.

I think that has been one of the problems for VA.

I think we have understood it. They said they are moving,

they are up to date on that, and their goal is to get 100

percent under it.

I think we should make comment that that is a goal

and that we urge that that be accomplished. Okay, anything

else on 6? Okay, on page 7.

MS. NISHIMI: Seven begins the breakout within the

medical and clinical issues section. Generically, we

address the clinical issues. As you notice from the draft,

we culled out two specific areas, medical surveillance and

then the use of investigational products.

This is still under the medical and clinical

issues, but they were new issues -- they were issues that we

felt deserved fuller treatment in this section.

DR. LASHOF: I think the medical surveillance, of

course, is one of our forward-looking things. If you

remember, in our initial charge to our initial efforts, one

was to have a forward look, not only to analyze what had

gone on in the Gulf, but make recommendations as to what the

future should do.

In medical surveillance, that is one where we have

taken a forward look. We summarize here the DOD finalizing

a directive on medical surveillance policy for deployments,

and we identify what the directive requires.

I think that is fairly thoroughly presented and it

goes on to the top of page 8. After presenting that, we

basically say we approve of this thrust, but note that there

were some problems in Bosnia, despite that.

Let us stop for a minute there and see if there is

anything that should be added.

MR. CROSS: It says DOD is to publish that

directive in September. Do we know if that is going to


MR. CASSELLS: Yes, I fully expect that to happen.

The instruction actually to implement this has already been

signed. Usually it occurs after the directive being signed.

We expect the directive to be signed on time in

this month.

DR. LASHOF: We note then, as I mentioned, on page

8 the special difficulties. We reference the GAO report and

then we just have a note on the vaccine, that we discuss

that matter later in this document. So, we will come back

to that aspect.

Is there anything anyone else sees on page 8 that

they want to comment on, add, subtract?

On page 9, we go ahead and make a recommendation

to DOD about placing priority on the pre- and post-

deployment medical surveillance.

Does anybody have any difficulties with anything

in that recommendation?

I will pause whenever we get to a recommendation

and give you a chance to look at it before we pass on.

The next item, then, is on the use of

investigational drugs. Here we go back and point out that

during the Gulf we had pure distigmine bromine and botulinum

toxoid vaccine, and that they were investigational.

We review the problem of the FDA interim final

rule and the waiver, and we review that information, and the

fact that the committee was concerned two-fold, that the

status of the FDA's reaction related to the rule and DOD's

medical record keeping in theater. We found that both

needed improvement.

We then go ahead and discuss the status of the

interim rule. As you know, we have been pushing FDA over

the past 18 months on this issue.

We summarized that on page 10. Then we note that

in July, in the testimony before the committee, the FDA did

identify for the first time in seven years the specific

steps and the appropriate time frame to address the issue.

Then we review the steps they have taken. We

conclude that despite some dissatisfaction before, we now

feel that they are acting appropriately and adequately

responding. We make a recommendation.

MS. NISHIMI: The recommendation basically goes to

the issue of continued forward progress. In this case we do

make a specific recommendation the staff feels would be

adequate for rule-making purposes for FDA to make decisions

about this.

They were somewhat imprecise in how long it would

take them to complete their plan they laid out in Buffalo.

We didn't want imprecise to turn into seven more years.

MS. KNOX: Was this date consistent with what they

had told us? I know they had several things they were going

to do, but did that give them time to do that?

MS. NISHIMI: They had landmarks sort of through

the end of the year, and then it was kind of we will see.

So, we felt that a year from now, or nine months from the

end of their plan was adequate. Would that be a fair

assessment, Joe?

MR. CASSELLS: I think it is quite adequate,


MS. PORTER: They indicated that they might need

to have a conference, depending on the nature of the public

comment that came in on the request for comment. That would

take up more time.

That is over a year from now. That seems to be a

generous time frame in which to complete this.

DR. LASHOF: I agree. I have reviewed their

proposal, and if they don't need the conference, they should

certainly beat this by a considerable amount.

If they do have that much comment and have a

conference, this allows that time. All right, any other

comments on page 11?

We then move on to the sticky problem of medical

record keeping and investigational products during

deployments. Any comment on the problems there? They have

acknowledged them.

Now this is where we do bring up vaccine; right?

MS. PORTER: Right. This entire section is really

as a result of testimony that came to light in Buffalo on

the tick-borne encephalitis vaccine investigational new drug

application, the study that was ongoing in Bosnia.

DR. LASHOF: I want you to take a look at lines 14

through 19 and see whether that captures what we need to say

on this and whether anyone feels they need to say more.

MS. PORTER: There was some discussion among the

staff about the use of the word abysmal.

MS. KNOX: I appreciate that word.

DR. LASHOF: You make a point that that is

unrelated to the waiver of informed consent because they

didn't need it.

MS. NISHIMI: They didn't seek a waiver. This is

just performance in the conduct of an investigational new

drug application.

DR. LASHOF: Do you remember the testimony we

heard from FDA on this? Okay, we go on, after using the

term abysmal failure. We then go on and describe what the

problem was.

That continues up through the top of page 13. In

fact, we go on through page 13 discussing the capabilities

for evaluating investigational products during deployments.

It is a difficult thing to do, I think.

MS. NISHIMI: I would like to call the committee's

attention to the bottom of the page, lines 22, 23 and 24,

which was one of the issues that Mr. Cross raised about

informed consent generally, and whether the committee is

comfortable with that language. Does that work for you,


MR. CROSS: Yes, that is fine.

DR. LASHOF: Go to top of page 14. We comment

further on this area and then come up with a recommendation,

recommending that they seek independent evaluations of their

policies and practices.

MS. NISHIMI: If you recall, General Parker had

indicated at the Buffalo meeting that they were forming an

internal task force or working group to look at the clinical

trials during deployment issue.

The staff view was as presented here, that they

should seek an independent evaluation. Is there a problem?

DR. LASHOF: Any problems with that, any

additions? Art, do you have anything to add to our

discussion here?


DR. LASHOF: We continue on now to discuss the

review. We noted that in the interim report we commented on

the major epi studies being well designed and appropriate.

We made further recommendations of other studies.

In the final report we said they had been responsive to the

recommendations of our interim report but the problem

remained in a couple of areas, and we made new

recommendations there.

That continues on to the top of 15. In

particular, we note the most recent round of competition for

new research proposals. We talk about the feasibility of

the epi studies.

MR. CROSS: In light of the VA presentation

yesterday, are all these figures still accurate, or does

that need to be reviewed?

MS. NISHIMI: No, they are accurate. Staff was

pre-briefed to get the numbers.

DR. LASHOF: Okay, lines 10 to 18, we comment on

the amount of money that has been allocated to the different

-- that is what you were asking about, Tom, are those

numbers correct.

Is there anything anyone wants to say further

about this research which has been, I think, quite

responsive to our recommendations that we gave in our

January report.

MS. KNOX: I would like to add a statement. Maybe

in line 8 -- this is what I wrote out last night -- because

the amount of data from either humans or animals on low

level exposures are minimal, it is our belief that the

above-described research addresses the inconclusiveness or

unlikeliness that we identified in our final report of

January of 1997.

It is hoped that the research may clarify the

conundrums surrounding Gulf War veterans illnesses. I think

that would fit nicely after line 8 on page 15.

DR. LASHOF: Either there or consider whether it

would be a better fit after line 18. At line 8 we have

outlined what we recommended. From lines 10 to 18 we

outline what they are funding as a result.

MS. KNOX: Either one.

MS. NISHIMI: Eighteen would probably be the one.

I can take it from the transcript.

DR. LASHOF: As you know, you will have an

opportunity to comment on this, the redraft.

MS. NISHIMI: What we will do here is incorporate

the comments using the red line function, so that you see

where the change was made, and then ask you to return it to

us in a quick turn around.

MR. RIOS: Maybe this isn't the time to mention

this, but I know some of the members were concerned about

the initial report using the term unlikely insofar as the

connection between the low level exposures and the long term


I am just wondering if this is something -- the

staff may want to consider mentioning something in general,

either to clarify that here or in the introductory part of

this second report.

DR. LASHOF: I thought we handled that in the

January report by pointing out that there were uncertainties

and that the research should address those uncertainties.

I thought what Marguerite just read addressed


MS. KNOX: Do you want me to read it again?


MR. RIOS: I thought Marguerite addressed it very

effectively. Read it again.

MS. KNOX: It says, because the amount of data

from either human or animal research on low level exposures

is minimal, it is our belief that the above-described

research may address the inconclusiveness or unlikeliness

that we identified in our final report of January 1997. It

is our hope that this research may clarify the conundrums

surrounding Gulf War veterans illnesses.

DR. TAYLOR: I really like that. The only point I

think Rolando is trying to make is that maybe somewhere

else, that in the preamble something similar to that is


MR. RIOS: I am just suggesting that is something

that perhaps you might want to consider in the introduction

as well.

MS. NISHIMI: Yes, I would argue that the

introduction should just lay out who we are, that a similar

type of statement be put in the summary.

MR. RIOS: The summary would be good, and you may

want to run that by --

MS. NISHIMI: The committee will get the entire


DR. LASHOF: You will get the whole draft. You

will have a chance to have that run by you, I guarantee.

MS. KNOX: I guess I would just be interested, is

there anyone now who has any dissention with that, with

adding that.

DR. LASHOF: Adding what?

MS. KNOX: Adding the statement. Is there anyone

in disagreement?

DR. LASHOF: The statement you just read at this


MS. KNOX: Right.

DR. TAYLOR: No, I think it is good.

DR. LASHOF: I gather everyone is satisfied with

that. Whether we feel it will fit elsewhere as well, we

will have to wait and see. I won't commit myself to that at

this point.

DR. BALDESCHWIELER: I think one do make some

repair to the actual structure of the sentence and the


MS. NISHIMI: They have it on the transcript. We

will be able to work on it.

DR. LASHOF: Anything else on page 15?

MR. CROSS: Yesterday I had made a note that there

were no respondents to research dollars on epidemiology

feasibility studies.

DR. LASHOF: That was on just the epidemiologic

feasibility study of carrying out epidemiology of the

veterans who were at Khamisiyah.

The other epi studies are ongoing and are

excellent ones. It is just, can you really identify those

who were close in at Khamisiyah, that you could assume were

exposed. Is there a feasible way to identify that group and

carry out epidemiological studies.

As I understand it -- staff, correct me if I am

wrong -- what we heard yesterday is that they solicited

proposals for that. They got none. In the absence of

getting it, they then went back to the medical follow up

agency that is based at the Academy of Sciences, part of the

Institute of Medicine now, I believe, and asked them to

submit a feasibility study.

I think that is quite appropriate. They will

either come up with yes, it is feasible, or it is not. If

it is feasible, then they will proceed to put out an RFP for

people to do the study, outlining the elements that they are

supposed to have in it.

Similar things were done with Agent Orange, to try

to get the best study possible.

MR. CROSS: I don't know if you want to mention

that, that they are taking steps to do that.

MS. NISHIMI: So, mention that they didn't get any

and this is what they did to address that. Sure.

MR. CROSS: Don't get me wrong. I am comfortable

with how they are proceeding.

DR. LASHOF: Page 16. We proceed about discussing

the fact that there was competition and external peer review

and how essential that is to good work.

We heard yesterday that there was an awarding of

something -- did we get the exact amount of money awarded


MS. NISHIMI: Outside the broad agency


DR. LASHOF: There was an award outside the broad

agency announcement.

MS. NISHIMI: There has been a total of $6.5

million, $3.4 million to Dr. Hyman at the directive of the

Congress. That was an earmark and separately appropriated

funds were provided for that.

DR. LASHOF: Let me stop you there and point out,

I asked about that also yesterday. That money had been

appropriated a number of years ago, had not been released

because there was not an institutional review board approval

for the studies he wanted done.

We were now informed that there is an

institutional review board approval -- two of them. Now the

department felt that they could release the money. I think

that is appropriate and required under the legislation.

There is no need to question that.

MS. NISHIMI: Then there is $3.1 million across

two projects, about $100,000 is my understanding, looking at

the question of mycoplasma as the committee heard about


Then as Dr. Rostker mentioned yesterday, funds

appropriated to Dr. Haley, not under the VAA.

DR. LASHOF: My assessment from what we heard

yesterday -- I would like to know if the committee as a

whole agrees -- that the funding for the mycoplasma does not

fall under research and is an appropriate sole source effort

to confirm and train people on the use of this new

technique, and determine whether that new technique is, in

effect, an appropriate technique to be utilized.

Since he is the developer of the technique, this

would be a logical sole source, non-research use of funds.

MS. NISHIMI: It wasn't just to Dr. Nicholson. It

was to other independent labs.

MR. CASSELLS: Yes, Walter Reed and other labs.

DR. LASHOF: Yes, but to work on that technique

that he had developed.

MR. CASSELLS: That reduces the total figure of

$100,000 to him.

DR. LASHOF: The other part, we were told -- and

here is where I have to admit there seemed to me difficulty

in this question of peer review, or some statements

concerning the fact that it was done without peer review of

the -- the previous proposals had been peer reviewed.

They took out of a bigger proposal those parts

that they thought the peer review had approved. I don't

know how you do that. I found that very confusing


So, I think our reiterating the fact that research

should be peer reviewed is important. So, I want you to

take another look at the bullet there and see if you want to

say anything more.

DR. CAPLAN: I have two things that I might want

to say about that section. On line 10, I guess, in the

recommendation with respect to the process to assure that

the highest quality science is funded, I would like to see

some language -- I don't have it in my head -- that it is

not just that the highest quality science is funded, but

that it is able to find credibility because it has gotten

through peer review.

It is just look it is done and people can accept

it or quarrel with it, but it affects the way it is


I think we saw that happen with some of the

controversy around some of the stuff that has been supported

that may or may not be within the strict bounds of what has

been peer reviewed.

So, somewhere up there, to assure credibility.

There is nothing worse than getting into a fight after the

fact on a non-straightforward peer reviewed thing of what do

we make of this. That undercuts trust. So, we are back

into that problem again.

I think the other comment I would make is on the

18 to 20 lines. I am not happy with the sentence here. It

says, funding on a non-competitive basis to address narrow

scientific questions that could appear suddenly.

I have this image of things jumping off sides of

streets as questions. The idea that I would look at here is

that it is fine to support pilot inquiries or preliminary

inquiries, and we want to be flexible about that. We

understand that.

Then, we should be moving quickly toward

competitive peer review, et cetera. So, it is just

sharpening that up. I think what they want to get is

flexibility for the preliminary, the new thing, the I got a

big idea, I want to move it along.

MS. NISHIMI: Demonstration project type thing.


DR. LASHOF: I also thought that it might be worth

putting in something sort of along that line, that I had

thoughts about, not precluding calling for proposals to

address specific issues, or even, under some circumstances,

sole source solicitation, sort of the kind of thing that was

done with Nicholson.

Add that peer review of proposed research should

not be abridged. You can call for sole source. You can

have it targeted to address a specific issue. But the

actual proposed research should be peer reviewed.

MR. CASSELLS: That is in fact what they are doing

with the medical follow up agency proposal with regard to


DR. LASHOF: That is right. That is a typical

example of that. I think taking recognition of that, what

we are saying here doesn't preclude that, would be very


MS. NISHIMI: Right, I think we know how to


DR. LASHOF: Anything else anybody wants to say at

that point? Okay, then let us move on to coordination. The

activities of the coordinating board we take note of. We

take note of the Presidential Review Directive. We feel

that they are addressing that recommendation well.

Any additions, corrections or changes to that


DR. TAYLOR: I think we have to at least recognize

that they responded quite well to our recommendations on


MS. NISHIMI: I noticed that was missing, the

generic, we commend the department. I actually had made

that notation. We made that in the other major section. I

am glad you caught that.

DR. LASHOF: Thank you. Now we move on to the

oversight of chemical and biological weapons investigations,

which has been an ongoing problem between us and DOD.

We begin by just the introduction to that, saying

what is the President's Executive Order and what the

supplemental letter report showed what we said on that in

our supplemental report.

We point out that we were going to emphasize three

broad areas that surround it here, the first of which are

the technologies. Well, the three areas we are going to do

are the technologies, the doctrine and the investigation


On page 18 we proceed to get into the discussion

of the technology and where we stand on it.


MS. NISHIMI: There was a separate kind of kit for

the water. The 256 A1 is mentioned earlier.

DR. LASHOF: Line 15 talks about the 256 A1.

MR. TURNER: 256 is an error. It is 256 A1 for

the water.

DR. LASHOF: Also, just a section that really just

describes the technology and we review what we recommended

in the interim report.

We talk again about our concerns and on the top of

page 20 we come up with a recommendation.

DR. CAPLAN: I have a comment on that

recommendation. I found myself wanting us to say somewhere

in that recommendation that part of what that group that we

are calling for should do is not just assess the capacity,

but examine the procurement process by which deficient

monitoring and equipment wound up in the Gulf.

I would like to see a little more look back about

how it came to be that things were so easily thrown off by

the conditions that they encountered, in terms of having

modern equipment.

MR. BROWN: I think this is a group point. I

think even if this group that is described in this

recommendation were put together, and looking at the best

technology that the world could put together, that really,

from what we have heard the last days, wouldn't necessarily

be sufficient to assure that it was implemented properly.

DR. CAPLAN: In other words, what I would like to

see them do is -- and this may be hard, we may get the group

that bought the original set of stuff -- but if we are going

to look back, I would like to know, not that they tried to

invent what didn't exist, but that they made clear to the

veterans how it was that they could be sent into the

battlefield theater with assurances of accuracy in detection

that weren't possible.

I am not going to ask them to invent what can't be

invented, but I do want to know why promises about the

sensitivity and specificity of this equipment, given its

cost, were not accurate.

That is a matter of trust. We have got people out

there saying, I detected this, my vehicle detected that,

nobody believes me.

Now the response might be, no, you are wrong, the

equipment is no good. How do we get there?

MR. BROWN: I think many people have reacted that

way. You get the impression, listening to the description

of how this equipment worked from representatives of the

Department of Defense, that it was pretty awful.

MS. NISHIMI: I think we can handle that look back

so that we can do better. Then we will insert that.

DR. BALDESCHWIELER: I think there is a useful set

of lessons that could be learned that should be incorporated

into the report.

DR. CAPLAN: John and I were talking last night.

You reminded me -- if you let me steal this thunder a little

bit -- just this notion of looking to make sure that we

think it is a bad idea to blow up ordinance that is


I mean, part of that should be to -- part of that

is the procurement process.

MS. NISHIMI: I would put that more toward


DR. CAPLAN: Maybe that doesn't fit here.

MR. BROWN: We deliberately divided this into

technologies and doctrine and we identified problems in both


DR. BALDESCHWIELER: There is a technology issue,

I think, that is associated with unmarked munitions as well.

I think there are ways of determining what is

inside fairly simply.

MS. NISHIMI: I think the staff knows at least

where to take this and then we can run it through the


DR. LASHOF: Maybe John and Art can talk further

about specific technologies and what your thinking is on

this, John. We would appreciate that.

Then we move on into doctrine. Here we are

talking about the kinds of issues you just raised.

MS. NISHIMI: We can make Art's point about the

demolition activities.

DR. LASHOF: We then pick up the doctrine that we

discuss in detail, or at some level, as the in theater

documentation and records management.

We identify things like, that they weren't

required to keep the fox tapes. Then we comment on the fox

vehicle operation, detection and confirmation. Then we

point out that some of the doctrine for confirming is almost

impossible on a battlefield.

The idea that before we believe anything that fox

says, we have to stop for 20 minutes and so on, leaves us

not in a very logical position, and we make that point, I

think, quite clearly.

Then we go ahead and comment on that current

doctrine addresses only exposures at higher levels, and that

we need to address the question of detection of low level


We make one recommendation concerning doctrine, to

address all the issues that we have just raised. Does

anyone have anything they want to add, subtract, et cetera,

to the recommendation there?

MS. KNOX: Help me understand something on page

21, lines 1 through 8, where it talks about the fox


In that last sentence where it says that,

moreover, doctrine is clear that unless a full spectrum

analysis is conducted, detection should be dismissed for

lack of confirmation.

We are disagreeing with that; is that correct?


MS. KNOX: I don't know that that is clear, that

we disagree.

MS. NISHIMI: Okay. So, something along the line

such as, the series of events was impossible to follow.

DR. LASHOF: Don't we have, at the top of 22, we

say, in the midst of combat, during the marine breaching,

such a series of events was impossible to follow. Doctrine

was incompatible with the battlefield use of the fox vehicle


MS. KNOX: Yes. I just think that last sentence

rebuts what we said at the top.

MS. NISHIMI: What I could do is actually move

that down to the bottom.

MS. KNOX: That is what I am thinking.

MS. NISHIMI: Then I don't have to repeat it.

DR. LASHOF: Thank you. Now we address the

question of the investigations, which has been a more sore


We summarize briefly that in our final report we

call for openness in oversight activities and independence.

MS. NISHIMI: That became us.

DR. LASHOF: That became us. We then go on to

talk about how they have expanded significantly their

resources to address those.

You have been hearing for several meetings now the

narratives they are preparing, their efforts to be more

open. We comment on the modeling.

We take up this question of who gets notified of

what, and we make a recommendation along that line, pointing

out that it is important to notify people who think that

they were under the plume, that they were not under the

plume, as well as telling people who were under the plume.

MR. RIOS: Would it make sense at this point --

again, I don't know whether it should go here or maybe in

the summary, to clarify what the government policy is.

Joe, do we understand now that the government

policy is that if you are sick and you served in the Gulf

War, there is a presumption that your illness is due to

possible exposure?

MR. CASSELLS: They don't make that presumption.

They don't rule it out. The eligibility for access to care

is not dependent on anything other than having been present.

MR. RIOS: Is that something that vets are

notified about?

MR. CASSELLS: It seems to me we would address

that in the earlier issue, where we talked about what the

current government policy is relative to Gulf War veterans.

MR. RIOS: There has been no change, then?

MR. CASSELLS: There was a change in the window

for access from two years to 10 years.

MS. NISHIMI: We made note of this.

DR. LASHOF: That is under medical clinical. Here

we are talking about notifying you, whether you might have

been exposed or whether you would have been unlikely to have

been exposed.

MR. RIOS: Does it make sense to notify them,

insofar as what the policy is, the government policy?

DR. LASHOF: That should be addressed in outreach.

The staff might go back and take a look at whether the

outreach adequately addresses that question of whether all

the Gulf War veterans know that they are eligible for 10


DR. CAPLAN: It may be, if I can piggy back onto

just what Rolando is asking, whenever a communication goes

out from the Department of Defense on plumes or anything

else, it might be appropriate in that communication to tell

them what their eligibility is, regardless of whether they

were standing under the plume or not, if they are sick.

MS. NISHIMI: Those do. They do.

DR. CAPLAN: I am just sort of saying, keep doing


MS. NISHIMI: They do.

MR. CASSELLS: Dr. Murphy has just corrected me on

one point. The eligibility for access to VA medical care is

not restricted to the 10-year window. That is only related

to compensation.

DR. TAYLOR: It is ongoing.

DR. CAPLAN: If you could just repeat it again.

Whenever you talk to vets, tell them.

MS. NISHIMI: They do.

MR. RIOS: My concern is that sometimes I get the

feeling that the veterans are not completely aware as to

what the government policy is now.

MS. NISHIMI: That is why we believe that the

notification should be expanded. That is what this

recommendation goes to. Then they do get told what the

current policy is.

DR. LASHOF: Okay, anything else on this aspect?

Now we come to the question that you have heard us belabor

yesterday and previous times about objective standards.

I think it has been staff's view, as they have

expressed here, and certainly the committee's view as we

have listened that things like best evidence, preponderance

of evidence, which have changed from common sense, still

leave us fairly subjective.

MS. KNOX: Let me ask a question about that

notification process the DOD does. How are we evaluating

that indeed those people who were in those units are getting

that letter? Are we checking on that in any way? Are we

evaluating that process?

MS. NISHIMI: DOD, as part of its process,

updates, I think weekly, what the status is of the X

thousands of letters that have gone out, how many have come

back, how many now they have been able to recontact.

Yes, you can tell how many went out and how many

have come back due to insufficient addresses and how many

they have been able to recontact.

My assessment is, in following the numbers, that

it is well within, if not better, frankly, as well as

delivery as measured by what you get back, from what one

would expect for a mailing of that size.

DR. LASHOF: Are we ready to move on into this

area of objective standards, then?

I wonder whether, in the preamble before we get to

our objective standard, we want to make -- I am not sure

whether it fits there or later -- that they are putting out

narrative reports.

We might not say how long it takes to get

narrative reports, but have we taken recognition of the fact

that they are trying to put out narrative reports and, in

those reports, present the data on which they base their

conclusions, even if they have not given objective standards

to tell us how they reached their conclusion?

MS. NISHIMI: I see what the deal is. We

mentioned the standard without measuring how they are

reaching the standard through the case narrative. We could

add intro text to that.

DR. LASHOF: Yes, something to explain the case

narrative approach and why they feel that is addressing the

openness and so on.

Then the actual recommendation we make about that

starts on line 20 on page 25 and goes on over to the top of

26. Take a couple of minutes and let you all read it once

more, in view of all the discussion yesterday, and tell me

whether you --

DR. CAPLAN: One thing I think we have to be

careful about here, just watching language closely, since

this one is a language fight, we talk in this section about

objective standard and objective criteria.

Robin just put on the table the need to capture

process as part of what this is. I think what we are

talking about is an objective standard that consists of

verifiable criteria and process.

That is really what we are looking for, what is

the criteria and the process. There are three witnesses,

there is the taking of testimony.

So, what I would like to see us do is, if we keep

saying objective standard they keep rebelling and saying,

well, there is no yes/no.

I think what we want is verifiable criteria plus

process. So, it is saying, that is what we want to see is,

you lay those out. Then we will know how you get to the

magic moment of common sense judgement on a case narrative.

MS. NISHIMI: What I tried to do with process is

the next section, which was bias and fact finding and


Perhaps what should happen is that should flip

first and then proceed to standards. Is that what I hear?

DR. CAPLAN: It is almost whatever we say in here

in the recommendation and the lines that go before, we seek

an objective standard. That consists of verifiable criteria

and a different kind of process determination. You put it

there all the time.

MS. NISHIMI: I think we can capture that and then

reverse the --

DR. LASHOF: I think that is a good point. You

really do need to reverse the order and discuss fact finding

and bias and then put the recommendation at the end of that

part of the discussion.

MS. NISHIMI: Then that actually captures the case

narrative because that is discussed here. That makes great

sense. Thank you.

DR. LASHOF: In fact, the whole section here.

MS. NISHIMI: Organizationally, it fits quite


DR. LASHOF: Then we get down at the bottom of

page 26, which of course we all talked about earlier

highlighting three examples to illustrate our concern.

I found a little confusion between the three

examples and the three aspects that gave us concern. I

think what we want -- you might even reverse that sentencing

and say the committee is concerned about DOD's

predisposition to -- and then list those three things.

Then say, we cite three examples to illustrate

this concern, or these concerns.

MS. NISHIMI: I could set down the examples in

bullets, too.

DR. LASHOF: Then the examples could be bullets.

So, here are the things we find deficient and here are

examples that support that deficiency.

That discussion then, and the examples, go on

through page 26 and 27, and on to page 28. Let me stop for

a few minutes and let you all look at that part and tell me

whether you are all satisfied with where that stands.

I stop here to give you time to look at that again

because it is an important aspect in reaching one of our

major recommendations.

MS. KNOX: I just want to commend staff on those

paragraphs. I think they are excellent, just the discussion

about DOD's reluctance to admit there were chemicals in

theater for six years. That whole process, she did a very

good job of that.

MS. NISHIMI: Thank you.

DR. LASHOF: Thank you. I concur entirely. That

leads us, then, on page 29, to a major recommendation,

asking the government to -- first, to ask the international

security council to develop a plan, whether that should be

the security council, or to just ask the President or the

White House.

MS. NISHIMI: That would probably be more

appropriate, that the White House should.

DR. TAYLOR: Then give some examples?

DR. LASHOF: I think it is probably better to let

the White House decide, whether it is science and technology

or where. I find the structure of the White House too

complex to say who should do what over there.

MS. KNOX: I think there are several places in

here where we recommend a certain office to look at things.

Maybe we should delete those recommendations and just allow

the White House or the Executive Branch to make that


MS. NISHIMI: Some of them are things that are

already being done at places, though. It makes sense to

target those directly. This is sort of something new,

develop a new plan.

Since the recommendation essentially says there

needs to be a step back, we had no one to step back within

the agencies on this particular one. We could take a look

at all the other recommendations and see if they fit that.

DR. LASHOF: That would also mean taking a look at

lines 14, 15 and 16 here, which we said in short, we give

four examples. Do we want to give the four examples or do

we want to leave that at the White House.

Robin, do you have any feelings about, on lines

14, 15 and 16?

MS. NISHIMI: I don't have a strong feeling about

giving examples or not.

DR. CAPLAN: I don't like giving examples. I

would like to sort of say leave it over there.

DR. TAYLOR: They still make the decision. This

just gives them advice.

DR. LASHOF: All right, we will leave the four


DR. CAPLAN: I do have a style suggestion, though,

a point of anguish about page 29. I would like to see this

recommendation split into two parts, the one that is on line

three --

MS. NISHIMI: I thought about that after I read

the length of the recommendation.

DR. CAPLAN: The second one is a separate one. It

is a key one for us. I personally don't believe that they

would have admitted chemical weapons if we hadn't been here.

They are not doing it now.

We basically say they have to have someone

external to them. Let's really feature that.

MS. NISHIMI: I came away with the same thing

after I read it for the 10th time.

DR. LASHOF: So, we will have two recommendations

here. I think the second recommendation can't really begin.

You are going to have to rework the wording there to put it

in a better form.

DR. BALDESCHWIELER: What is the second


MS. NISHIMI: The first one is lines one through

three, as Art said, which is essentially the first sentence.

Then the second one would be recaptured. Obviously, this is

follow on, so the intro verbiage would have to be changed


The second part would be the bulk of that, and

moving up the public accountability aspect, which is what I

heard Art say.

The last sentence, to ensure public

accountability, would then serve as the intro for that

recommendation, is what I heard.

DR. CAPLAN: Exactly.

DR. BALDESCHWIELER: Okay, I follow it.

DR. LASHOF: If you get down to line 13, 14 and

15, that would be the beginning of the second bullet and

would precede the sentence that begins, with strong


DR. CAPLAN: Structured that way, the only reason

I was agitated slightly about the examples we were giving

about the types of oversight that could be there, I just

don't know if those groups have any veterans on them or have

any "public" members on them. I just don't know.

Since we are asking for public accountability and

oversight, I don't want to just give them a list of groups

that don't have what we want.

That is what my problem is. I don't mind

suggesting for instances, it is just --

MS. NISHIMI: I think we know how to recapture

that, yes.

DR. LASHOF: Any more questions or comments on

that aspect?

There are some comments at the bottom there on

credibility. We speak positively as to the efforts of ATSD,

Assistant to the Secretary for Intelligence Oversight on the

top of page 30.

Here we are commenting on the work of Mitre. You

were given a summary last night. I am not sure how many

were able to digest it.

MS. NISHIMI: You weren't actually given the

summary. You were given a chapter.

DR. LASHOF: I am sorry, not summary, a chapter.

MS. NISHIMI: If after reading that you have

comments pertaining to this, if in the next go-round you

could make those comments, then we will work it again.

DR. LASHOF: If you could get the comments in

before the next draft goes out, that would be much better.

I would suggest that you take a good look at that chapter

and see whether you feel comfortable or want changes,

additions or deletions from that paragraph one through nine.

MS. NISHIMI: Keep in mind that that is one

chapter out of a document that is about two-and-a-half,

three inches thick.

DR. TAYLOR: I am sorry?

DR. LASHOF: There is a document that is about

this thick. All the staff have reviewed that document, a

classified document at this point.

All the staff have clearance. All the staff have

reviewed it and all the staff are unanimous that the

paragraph here at the top of page 30 reflects their view.

So, what we were given was a redacted chapter,

which is one small chapter.

MS. NISHIMI: Actually, it was fully declassified.

It was redacted for Privacy Act purposes with the exception,

I believe, of about two paragraphs.

MR. TURNER: Of classified material?

MS. NISHIMI: Of classified material.

MR. TURNER: The substance of the chapter you have

fully reflects the substance of the classified version.

DR. LASHOF: We then go on to credibility and

commitment. There is no question that one of the things

that has plagued all of our activities and all of the

previous groups that preceded us and will probably plague

those who follow us is the problem of credibility.

That is not limited to this situation, in terms of

the public and government these days, but it is beyond our

scope to get into the broader credibility.

We have tried to address the problem of how we can

deal with the credibility of the government efforts around

this particular issue of Gulf War veterans.

I commend you to take a careful look at the

wording between lines 12 through 20, because that forms the

basis of the final recommendation we make.

MS. KNOX: I have a question about this

recommendation. The sentence, for benefits and future

research purposes, starting on line 20, of the available

scientific evidence regarding associations between illnesses

and service in the Kuwaiti theater of operations --

DR. LASHOF: You are now on page 31.

MS. NISHIMI: I want to go through the

recommendation in detail, if we could focus on the actual

precise wording.

DR. LASHOF: I was just going to say, I was giving

you time to reread page 30 and top of page 31, because it is

the background that leads to the recommendation. Then I

will carefully go through and read the recommendation.

MS. NISHIMI: So, are there any questions then?

DR. LASHOF: Do you want to make some further

comments about the material on page 30 and the top of 31?

MS. NISHIMI: I just want to make sure that the

committee is comfortable with the lead-up to this final


What the staff has tried to do in this section on

credibility and commitment is to point out that the well has

been poisoned in essence, and that the government's

credibility continues to be questioned and continues to


The committee would conclude that the credibility

gap between the public's views of the government's efforts

to address concerns and the reality of its initiatives

cannot be bridged without a more bold policy action.

That is to say, we have been making incremental

progress in policy refinements. They have been important.

But the committee would conclude that this incremental

progress is not going to be enough to address the pervasive

perception that the government lacks a commitment to its


Is the committee comfortable with that lead-in?


MS. NISHIMI: John, is the committee comfortable

with the lead-in, the text leading to that recommendation.

DR. LASHOF: Is there anything to be gained or

does it make it less useful to try to put some context about

the fact that there is a general problem of credibility

concerning government and the public that is a much broader

issue and is one that we cannot solve, nor necessarily any

action that we can take will solve all of that context.

But, specific to the goal, we have to move ahead

and do whatever we can to bridge that.

David, do you think comments of that sort would be

helpful or not, at this stage in the report.

DR. HAMBURG: First of all, there is intensive

social science research going on at the present time about

that problem, and particularly looking at sophisticated

survey research which shows that there has been, since about

1974, a rather massive decline of public confidence, not

only in government -- this is a very interesting point --

but in other major institutions, and not only in the United

States but in the democracies of western Europe as well.

There is a context of broader distrust of

government and other powerful institutions that goes beyond

our scope, but presumably influences the attitudes that

occur in the context of Persian Gulf War illnesses.

It may well be that we should recognize, at least

in the sentence, that is part of the context. It is

certainly conceivable to me that, no matter what we

recommend, that that context is so powerful that such

distrust will continue and perhaps even grow.

However, within our context, we should address

what we think is sensible to address it, to try to make

initiatives and efforts regarding the Persian Gulf War more

credible than they have been in the past. We should try to

do that.

The question is whether we recognize the larger

context. Personally, I would rather have a sentence or two

to recognize that, because I don't think the attitudes of

the public toward the Persian Gulf War can remained

uninfluenced by the larger context of distrust that exists

out there. It is well known to exist.

MS. LASHOF: I think that is a very important


MR. RIOS: To me, one of the problems with this

particular issue is that it took so long to get the

information out as to what happened, that five-year gap is

probably a factual matter that has fed into the public


The only suggestion I would have is that if you

want to add some meat to it here, you might want to refer to

how long it took to get the facts out.

MS. NISHIMI: The timeliness factor.

MR. RIOS: Especially when you are dealing with an

issue that is so hard to pin down and the research is so

limited and has so many shortcomings.

MR. TURNER: Something along the line of the DOD's

delays and denials have fed the public mistrust, or

something like that.

DR. CAPLAN: One other line of introduction to the

recommendation that I would like to see staff consider, and

again, I don't have the sentence in my head right now, but

if we think about our own existence and we think about the

fact that many veterans have come to lots of hearings and

told us about different problems and issues they have,

whether they have been frustrated or not, I think we have

been seen as a court of last resort, or a sounding board.

If they want to have credibility on this, part of

the problem is that people have come to the committee and

tried to tell us about their health problems of get heard

seriously or get their views heard about whatever they think

the cause might be of their illness.

That impact of hearing lots of people come makes

us understand the depth of the credibility problem and also

highlights the problems that standing institutions don't

seem to have been up to the task of meeting those concerns.

We have spent a long time hearing people come here

and say, will you hear us or will you pay attention to us.

Whether we did a good job of that or not, we will see.

That is part of the reason that credibility thing

is persuasive in my mind.

MS. NISHIMI: I am not sure how to capture that.

DR. CAPLAN: We heard too many times from too many

places unhappiness with existing institutions and approaches

and systems and it weighs on our minds and it has got to be

dealt with, just because those voices were so insistent.

MS. NISHIMI: Okay, I will take a crack at it.

DR. LASHOF: I am ready to go to the

recommendation unless anybody has anything else they want to

put into the introduction to the recommendation.

Our recommendation calls for the Department of

Veterans Affairs should work with the Congress to establish

a permanent statutory program for Gulf War veterans


The committee envisions legislation that directs

the government to contract with the National Academy of

Sciences or other appropriate scientific organization for

periodic review, for benefits and future research purposes,

of the available scientific evidence regarding association

between illness and service in the Kuwaiti theater of


The object of such an analysis should be to

determine statistical associations between service in the

Kuwaiti theater of operations and morbidity and mortality as

well as whether a logical biological mechanism exists,

whether research results are capable of replication and of

clinical significance, and whether the data withstands peer


Based on the external evaluation, the Secretary of

Veterans Affairs should make a determination of a

presumption of service connections or publish reasons for

not doing so.

We believe specific details of such -- I would

suggest the word program rather than arrangement there. So,

I will read it as, we believe specific details of such a

program, for example, the timing, the length of an

individual presence in the Gulf, the frequency of the

scientific review, risk factors, are best left to the

department and to the legislators in developing the program.

I would stop and ask you to --

MR. RIOS: Are we going to keep that

recommendation that the committee envisions legislation that

directs the government to contract with the National Academy

of Sciences, or are we going to leave that up to the White


DR. TAYLOR: We could change that around to say,

contract with the appropriate scientific organizations,

i.e., the National Academy of Sciences, for a periodic


MR. NISHIMI: For example?

DR. LASHOF: Yes, contract with the appropriate

scientific organizations, for example.

DR. CAPLAN: You might even say, contract with an

organization with the appropriate scientific expertise. The

only reason I am watching that language carefully is because

there is this issue of the public nature of NAS meetings and

so on.

That is for another day, but there might be

reasons why in this case what you want might be the

scientific expertise that is available in a particular kind

of a format.

DR. LASHOF: You will note, however, that prior to

the recommendation we state that advisory committees like

ours are not well suited for such tasks.

DR. CAPLAN: Yes, I did.

DR. LASHOF: I don't think another advisory

committee is the kind of thing, primarily because it has to

be an ongoing institution that is going to survey from one

administration to another.

DR. CAPLAN: If the chair wishes to recommend

groups that it should not be, I would be happy to be


DR. LASHOF: No, I think we have handled it in the


DR. BALDESCHWIELER: What is the vision of when

this would come to pass. The recommendation is directed

toward the Congress.

DR. LASHOF: The VA is directed to work with the


DR. BALDESCHWIELER: So, would the VA, for

example, draft legislation?

MS. NISHIMI: In the normal course of events, the

Congress ultimately has to introduce a legislation.

Depending on the particular topic or issue, there can be,

you know, multiple versions, give and take.

So, we don't specify VA should try to find a

member of Congress to introduce its version of legislation.

I don't think that is an appropriate role.

DR. LASHOF: But that is the way it works.

DR. BALDESCHWIELER: I understand. It is not

envisioned that the White House play a role in this.

MS. NISHIMI: Yes. The Secretary of Veterans

Affairs is part of the President's cabinet, so yes.

DR. LASHOF: We could put the White House rather

than the Department of Veterans Affairs, if you prefer.

Clearly the Department of Veterans Affairs does not

introduce legislation that hasn't been passed, reviewed by

the President and endorsed.

No department head goes down and introduces

legislation that the President doesn't give his okay to.

MR. RIOS: John, were you concerned about using

the Veterans Administration?

DR. BALDESCHWIELER: I am just wondering about how

this would work. The earlier recommendation identifies the

National Security Council.

MS. NISHIMI: Right, which is now the White House.

That is because the interested parties, that recommendation

went to the fact that we believed there needed to be an

entirely new oversight plan. That is why the White House.

This is a specific policy and a specific agency.

DR. LASHOF: This requires legislation. The other

did not. The other was something the White House could do

by itself. This is the kind of a program the White House

can't just establish. It has to be legislatively mandated.

DR. BALDESCHWIELER: The earlier recommendation

focuses really on the chemical and biological warfare issue.

DR. LASHOF: Right.

DR. BALDESCHWIELER: Here the issue is tracking

the health issues and the epidemiological issues.

DR. TAYLOR: And the credibility issues.

DR. LASHOF: For the government, not the DOD. This

is designed to assure the veterans that the government will

take an ongoing look at all the data and all the policies

and issues involved that relate to their benefits and the

results of the research and how it could influence that, the

health care, the total aspect, in an ongoing systematic

manner to address the issues that we have all been looking

at before that are not going to come to a conclusion with


DR. HAMBURG: Let me think out loud about what we

are fundamentally trying to do. It seems to me right but I

am a little bit mixed up about how we are saying it.

I think we are fundamentally trying to say that we

have addressed certain critical issues that were brought to

our attention by the veterans and others.

It is very important that these issues continue to

be addressed in an ongoing way for some years to come.

Therefore, some strong mechanism is needed to do that.

Then we are saying that the mechanism created for

the purpose needs to have as much credibility as is human

possible in an atmosphere of distrust.

Then we are saying that to assure that that would

be done, we think it would require legislation.

We are furthermore saying that that legislation

would be most -- the part of the government most pertinent

to that legislation is the Veterans Administration.

Therefore, we are asking the Veterans Administration to take

the initiative to get it done.

DR. LASHOF: Correct.

DR. HAMBURG: I guess it is a logical sequence. I

have some misgivings to us. First, we are an advisory

committee to the President. Is it obvious why we don't say

we recommend to the President that he take these actions

with special attention to the role of the Veterans


Maybe that is just a matter of protocol because we

are an advisory committee to the President. It may not be.

It might be that there are resources in the

government beyond the Veterans Administration that would

have a strong bearing on how well this is done in the


For example, the main capacities of the government

in health, by far, is the Department of Health and Human


I understand that they are not primarily focused

on the veterans. However, their resources have in the past

and could in the future augment the capabilities of the VA

in this respect.

Maybe it is more than protocol to say that the

President should, in fact, mobilize the Veterans

Administration to establish the kind of mechanism we want,

with primary attention to the role of the Veterans

Administration. I am not sure, but I want to raise that


MS. NISHIMI: I think we can sort of capture that.

I do want to point out that in particular one of the reasons

that we want to link back to the Department of Veterans

Affairs is that this doesn't go just to the issue of

research. It also goes to the issue of the benefits.

So, I want to make sure that the committee

understands that. It is not just about evaluation of

research periodically. There is this issue of benefits.

DR. HAMBURG: I am trying to say -- I am not sure

that it is quite adequately said, but you are trying to say

that the ongoing review in the years ahead and the research

would include this implication for benefits.

MS. NISHIMI: Yes, it needs to be tied quite

closely and absolutely to the disability compensation


MS. KNOX: Robyn, on that note, and we are talking

about benefits for veterans, I think we really need to look

at the sentence that says, associations between illnesses

and services in the Kuwait theater of operations.

I think there are veterans who have experienced

stress that were in Germany, that were in CONUS, that would

be included in this legislation as well.

MR. CROSS: I also have a concern with that. I am

somehow in my mind, we are establishing the limit to


DR. HAMBURG: Service in the war.

MS. KNOX: Service in the Gulf War, rather than

limit it to the Kuwaiti theater of operations. If you were

in Germany, you may have taken PB tablets preparing to go.

So, you may have some of the same risk factors, wherever you


DR. BALDESCHWIELER: Let me come back to make sure

I understand what it is that we are suggesting once again.

That either the Executive Branch in some form present

legislation to the Congress to do what; to create a review

committee that meets periodically?

MS. NISHIMI: No, to create a permanent statutory

program. Program means entity.

DR. BALDESCHWIELER: Permanent employees doing


MS. NISHIMI: Yes, people have to administer a


DR. BALDESCHWIELER: So, this is a full-time staff


MS. NISHIMI: Yes, there is a full-time staff

somewhere because someone has to administer the type of

program that Congress would create legislatively as

envisioned here, which directs a contract with -- I am

trying to recapture Art's language -- an organization with

the appropriate scientific expertise, such as the National


That scientific expertise body and staff would

conduct an analysis.

DR. BALDESCHWIELER: In the academy framework, for

example, this would be a full-time staff in the National

Research Council plus an outside expert committee that would

meet periodically?

MS. NISHIMI: Yes, that would be one mechanism

within the academy. It wouldn't necessarily be the same

committee, every two or three years, whatever Congress


DR. BALDESCHWIELER: But there would be a full

time staff with documentation and record keeping.

MS. NISHIMI: Correct.

DR. LASHOF: And a well-established plan as to the

methodology that would be used to evaluate research to draw

conclusions and to interpret the importance of that data on

the issue of benefits as well.

MS. NISHIMI: The committee should know that this

is not unlike functions that the academy already does for

the VA in many respects. It is exactly comparable.

They do it. They evaluate the scientific

information for many things.

DR. CROSS: Suppose that committee ends up

residing in the DOD?

MS. NISHIMI: That is what this recommendation --

well, we don't tell Congress they can't do that, but our

advice is that it go in this direction.

MR. CROSS: Should that be mentioned?

DR. LASHOF: That is why we said, to contract with

a scientific organization. That is an outside organization,

if you will. We can put in the word outside. Congress can

decide to do it any way they wish.

MS. NISHIMI: They can recommend to put it inside

DOD. I don't think they will.

MS. KNOX: Can I just add something further to



MS. KNOX: In the recommendation that we made back

on page 25, I think it was commendable. You say at the end

of that, when the facts of the situation are indeterminant

or ambiguous, you said the DOD decision making related to it

should weigh in the favor of veterans.

Can we add that concerning the VA when a situation

is indeterminant or ambiguous to this recommendation?

DR. LASHOF: I don't see how we can here. What we

are doing -- that would be involved in writing the

legislation or helping write the guidelines for the

organization that is established.

MS. NISHIMI: You are kind of far down the tree


DR. LASHOF: I think we have to leave that.

MS. KNOX: Well, you say here the Secretary of

Veterans Affairs should make a determination of a

presumption of service connection, or publish reasons for

not doing so.

Could you add something to that at that point that

would -- as it is now we are leaving specific details to

legislation and to departments.

DR. TAYLOR: Where are you now again?

DR. LASHOF: She is now up at the top of page 32,

lines 2, 3, 4.

MS. NISHIMI: Arguably that sentence should go,

too, because that is farther down the tree, frankly.

DR. LASHOF: If that stays, I suspect your

addition should be added. Whether that statement should be

there, maybe we should remove that and really leave that

kind of an issue --

MS. KNOX: We say based on the external

evaluation. I just think there will always be incidents

that will be indeterminant and we should weigh it in the

favor of the veteran.

MR. RIOS: I kind of like the language there that

says they should make a determination of a presumption of

service connection.

MS. NISHIMI: Presumption implies. We could put

semicolon, our view again is policy decisions of

indeterminant or ambiguous findings should weigh in favor of


DR. BALDESCHWIELER: I guess I am uncomfortable

with that. I am not sure what that means. Weigh in favor

of which, the veterans view on which issue?

MS. KNOX: When you are talking about their

benefits and service connection.

DR. BALDESCHWIELER: In the earlier case I don't

think it makes sense either.

MS. NISHIMI: The staff is going to have to recast

much of this. Why don't we play with both sentiments and

see if we can move forward that way and in the next

iteration you can check it out.

DR. LASHOF: It might be that some of that might

go in the preamble to it, rather than in the program. Even

after the recommendation we could put some of the issues we

think need to be addressed are, something like that, and

leave that open.

MS. NISHIMI: Not part of the bullet. I think I

know where I could take this.

DR. LASHOF: Any other? Are we comfortable, then,

clearly with the point of this recommendation, recognizing

we will see new language that makes it a little clearer.

This is a new program that is being mandated


MR. CROSS: Would it be fair to mention veterans

service organizations in here? At some point they are going

to become a watch dog in a lot of these efforts.

DR. LASHOF: They always are. We don't have to

tell them.

MS. NISHIMI: I think that legislators and the

department are going to hear from many quarters. To single

out organizations versus individuals, no.

DR. TAYLOR: I don't think it would be necessary

in this context.

DR. LASHOF: In a sense we try to capture that in

lines 8, 9 and 10, where we recognize our charge to

Congress, our recommendations urging action by the Executive

Branch, and we hope a partnership among all the concerned

parties can implement this. Clearly, concerned parties

would be veterans, veterans organizations and others.

We recognize that the burden will rest ultimately

with Congress to address the recommendation in legislation.

Okay, we make, then, a final statement about the legacy and

that we hope that this legacy will now also include that the

government acknowledges and does honor its obligation to

care for the men and women who served in the Gulf.

We express our appreciation to the President for

being given this opportunity to serve the veterans and their


Are there any other final statements that anyone

else wants incorporated in our closing statement here at the

end of this special report?

DR. HAMBURG: I don't think it is a closing

statement but somewhere -- it is a concern. I think what we

have now before us I think is generally excellent.

It starts off and goes straight to our mandate for

an extension, these additional months. It is very

businesslike and very well focused.

At the same time, it lacks any concise overview of

our whole mission from start to finish, how we pursued it

and what we hoped would come out of it.

I really think it is important for us to have such

a concise statement of what we were trying to do, how we

pursued it and what we hoped would come out of it.

It could be the preamble, it could be the

executive summary, it could be a covering letter.

I think in a way in a certain sense it is too

bureaucratic to say, the President asked us to extend this

for a certain number of months and this is what we have done

in those months.

We do have some history. In other words, you

could say something like this. We undertook to

comprehensive, systematic thorough examination of all facets

of the Persian Gulf War illnesses with strong encouragement

from the President to pursue all lines of inquiry in an

independent way.

That included trying to get the facts straight

about what happened during the war that had a presumptive

bearing on illness, and also about the insight derived from

research about causes, prevention and treatment of such


We tried to learn from experience of previous

post-war situations and to go beyond them where necessary,

those other earlier wars.

I think it would sensible to say concisely what we

tried to do to fulfill this charge; stimulate departments

and agencies of government and also the national and

international scientific community to address the problems

of Persian Gulf War illnesses in their full complexity.

Finally, as we have just been discussing, that we

try to set in motion a process, both within the government

and outside the government to sustain -- I emphasize sustain

-- this work to promote the understanding and care of

veterans for many years, and to apply the lessons learned

from the Gulf War experience to future deployment.

That is kind of a crude first approximation of an

overview of sort of where we were coming from and where we

are headed.

I believe that we need that somewhere. Whether

that is in the introduction or at the end of a covering

letter, I am not sure.

I would hate to see us send this off without

giving some kind of overview of what this whole thing had

been about.

MS. NISHIMI: I think I could work with that play

around with placement and then you will see it in the next


I understand what you are trying to capture; sort

of the role of the committee in the bigger picture, not just


DR. HAMBURG: Above all, Joyce and Robyn have led

us through this enterprise and I might take a moment to say

how deeply I appreciate that. I think I speak for all the


The leadership we have had, our chairman and the

superb staff is really extraordinary. I have done a lot of

these things and this has sort of had a remarkable quality

of leadership.

DR. LASHOF: Thank you very much, David, for that.

I concur with your desire to see that kind of an overview.

My feeling at this point would be the introduction might be

the most appropriate. We can defer that to see how staff

works on it.

MS. NISHIMI: My feeling would be the transmittal,

but we will work on it.

DR. LASHOF: Okay, transmittal or introduction.

The introduction, we can discuss that.

MS. NISHIMI: I will capture it, put it in there

and then you all decide where you want it.

MR. RIOS: It may make sense -- I think this is

taking off what David said -- to kind of look briefly at

where we were when we started and where we are now, the

presumptions, the government's disclosure, the research that

is underway, where things were when we started two years ago

or a year and a half ago.

MS. NISHIMI: I understand the gist of it.

DR. LASHOF: Do we want to take a moment, Robyn,

to take a look at the executive summary?

MS. NISHIMI: What I would like to do, because I

think there were several important sort of broad topics that

were interjected, is to work that into the summary and then

you will see it in the next iteration.

The summary as it stands really right now is not

an exact replication.

DR. TAYLOR: The executive summary goes at the

beginning of our report?

MS. NISHIMI: Well, what I had hoped to do, but I

don't believe we will now be able to do, was to have this

report, in terms of the summary -- in essence, a summary is

like an abstract of a paper. So, it is all contained on the

first page.

I think there would be a high degree of utility if

we can remain with that format. This is a relatively short

report, it is essentially 30 pages double spaced now. Once

it goes down to a single space type face, it would be


That was my feeling, to try to go for that

abstract format. I think we should still proceed along that

line until the summary becomes as big as the report, which I

hope that it would not. In that case, we would rework the


Yes, I do think it would be useful to have, in

essence, the abstract/summary up front.

DR. LASHOF: Any other comments on the text itself

now? Do you want to tell us a little bit about the process

and time table, Robyn, before we complete?

MS. NISHIMI: Yes. What I intend to do,

obviously, is to take all the comments. Staff will feed in

with the additions and the rearrangements and edits. I

anticipate that there will be no problem getting a revised

version out to you by the end of next week.

Frankly, I could do that by Monday or Tuesday.

DR. LASHOF: That is because you work 24 hours a

day and on weekends.

MS. NISHIMI: It is Friday and the staff probably

would shoot me if I demanded that. So, we will take a few

days and we will get it out to you and ask you to read it

quite quickly, frankly, to turn it around.

Then it needs to go out to external parties for a

review and fact check. I don't intend to send out -- my

intention is to send out a redacted copy -- that is, the

committee's recommendations would not be included.

Those are the committee's words and the

committee's works and, let's face it, we have had a problem

with leaks before. I would do that. There would be a

redacted version sent out for review. Then that would come

back in.

Again, I would impose a requirement on the

external parties that it be a very quick turnaround.

Then one last version would be created based on

the external review. That would go to the committee one last

time. Then it would come back in and we would go through

the typesetting and production process.

DR. TAYLOR: So, it sounds like your projected

date for completion is somewhere near the end of September.

MS. NISHIMI: I believe that if we can get it to

the printer by the end of the first week in October, we will

be able to receive the printed copies to deliver to the

President by October 31, as we were required to do under the

Executive Order.

So, it will demand some sort of immediate

attention periodically from the committee and I appreciate

in advance your attention.

DR. LASHOF: Any further questions anyone on the

committee has to Robyn or any member of staff?

DR. TAYLOR: I just want to say thank you to the

staff for the superb job you have done on this. We have

said this before.

DR. LASHOF: I will give everybody a chance to

make any closing statements. I want to finish the business

aspects first.

Since this is our last meeting, I would be happy

to go around the table and have anybody make any closing

statement they want on any aspect of our work over the past

essentially two years now.

We had our first meeting in August of 1995 and

here we are two years later, 23 meetings later, in September


We will start at Art's end of the table and just

go through. You are not obligated to say a word if you

don't want to. It is just the last opportunity.

DR. CAPLAN: I will just say I was very

appreciative of the chance to serve the veterans community

and to benefit from having such able fellow committee

members and to learn a lot from the staff.

I felt that people really did yoeman's service on

the committee and I learned a great deal from each one of

you and appreciate the chance to have had that opportunity.

MR. RIOS: My comments would also just be

addressed to the veterans. When we started out this

process, the government's position was that there was no

evidence of any exposures to our veterans in that Gulf War.

As we end the process, I think it is clear that

the government has now taken the position that it is very

likely that there were low level exposures.

Tremendous resources are going to be spent on

research, research that was not even thought of before we

started this process.

Also, there appears to be a presumption that if

you are ill, it was probably caused by your service in the

Gulf War.

I hope that the veterans feel that we have served

them well.

DR. BALDESCHWIELER: I would like to add that this

has been a very illuminating process. As so often happens

when one gets together a committee of capable people with a

mandate to look critically at issues, a number of things

turn up that none of us would have expected at the outset to


As one example, I think that the process has

really illuminated some serious deficiencies in the U.S. war

fighting capability with respect to chemicals and


I think those deficiencies should not go

unnoticed, and are a matter of important and urgent future


MR. CROSS: Let me first say that it has been an

honor for me to serve on this panel. I just want the

audience to understand that other than staff here, all of us

have other full-time careers, families and other interests.

Yet, I always found it amazing that the committee

members would show up and put in an effort to put closure to

this issue.

Again, I would like to thank the full-time staff.

I think they did an outstanding job in the background when

obviously the rest of us were out doing our regular work.

I hope I personally added a little insight in

terms of an actual veteran of the Gulf War. I learned a lot

from my counterparts here.

I mentioned it earlier but I need to highlight it

again. This committee does go away. Yet, the sick veterans

and the questions still remain.

I would like to charge the veterans service

organizations. I think you all need to step up to the plate

now and take a couple of swings at this.

There is a lot of -- they have a lot of vehicles

and an organization all among themselves. To be the future

watch dog of efforts in terms of future research, I think

they are key to this whole thing.

Again, to all my counterparts here, thank you very

much. It was a pleasure.

DR. TAYLOR: I wanted to say again, thanks, to the

staff. Also, I work for the United Auto Workers. I

represent workers on their jobs.

I feel your pain as veterans because we have some

of the same problems when we are trying to identify

exposures in the work place.

It is very hard to identify what causes illnesses

in many cases. I want to say I think the government has

responded to our recommendations.

They have done a good job at responding with the

research that is ongoing. I want to caution the veterans

that we may never know what the causes of the veterans

illnesses are.

With all the research that is being funded, with

all the money that is being given, we may never identify an

exact cause.

What we should be concerned with and what I hope

we have learned and what the government has stated they will

do is that they will treat any veteran who served in the

Persian Gulf for their illness.

They will be cared for and they will not go to a

physician in the VA system and be identified or brushed off

as not being a serious illness. I hope that is what we have

learned from all of us, that that actually happens.

Maybe there will be some answers, but again, I

just want to err on the side of caution. There may not ever

be, and thank you again.

DR. HAMBURG: I already expressed the deep

gratitude I feel for our chair and our staff. We are very


Working with this committee has been, as others

have said, a privilege. I have learned a lot.

I want to say a word about the inherent

frustration for us and for the veterans in the nature of

this situation. It flows somewhat from what Andrea just


There is so much that is unknown and so much that

is unknowable in light of present techniques and capacity.

We were bumping up against very complicated considerations

that were terribly hard to sort out, even to a modest


A lot of it is the inherent fog of war, the

classic fog of war. From time to time, I suppose, our

colleagues in the Department of Defense were saying to us,

in effect, look, we were fighting a war to win a war. We

weren't running a school or a clinic or a social service

agency. I understand that.

We pointed out the deficiencies in the record

keeping and all of that. It was awfully hard to know who

was exposed to what, when and where and for how long, let

alone what the consequences of it might be for health.

They are very, very hard problems. Part of it is

in getting the facts straight about what went on during the

war. Part of it is in the research based information to

understand what it would mean for health.

I know that we and the veterans were constantly

hearing about very technical, complex, ambiguous reports

that are very hard to understand and somehow or other you

have to trust somebody to some degree, that the information

available is being adequately analyzed and all of that.

There are inherent frustrations about the known

and the knowable in this experience. Yet, as I think others

have pointed out, we have made an impact, I believe.

I believe we have made a difference, perhaps just

as a stimulus to a lot of good people in a lot of different

places in government and out of government to look harder at

these problems, to apply a great deal of human ingenuity and

dedication to figuring out what happened and what we can do

now about all of that.

I think particularly insofar as we have stimulated

the international scientific community -- and I believe we

have -- there is a real possibility that the insights that

will emerge in five and ten and twenty years time will not

only be helpful to those who served in the Persian Gulf War,

or even to those who serve in future military deployments,

but really to people at large.

For example, the relation of the chemical agents

involved in the Gulf War to insecticides that are widely

used throughout the world is a significant one.

Who knows what other ramifications there may be

that would be helpful to people everywhere. At least I do

believe there is some basis for anticipating a broadly

useful outcome from the kind of work that has been set in


I don't just mean by what this committee has done

at all, but by fundamentally the President's elevating this

to a level of broad public concern, giving us a license to

go hunting in any way we saw fit.

More than that, it was to getting a lot of people

thoughtfully addressing these problems and seeing what could

be done about them in the future.

So, I think there is some basis for supposing that

this has been a constructive enterprise and will have

ramifications for years to come.

MS. KNOX: Gosh, this is an emotional time because

this has been a wonderful two years. There have been a lot

of accolades that have come with being a member, as a

veteran who served on a Presidential advisory committee.

I will say, however, there has been a lot of pain

and a lot of sacrifice.

I do want to thank Joyce and Robyn because they

have shown good leadership. I will say that I have been one

of Joyce's biggest supporters. I have been to every meeting

except three.

I have also probably been her biggest concern

because we have not always agreed on matters, and she has

allowed me to share my opinion about veterans opinions very


So, the Gulf War experience was not a good one for

me. I left a six-week-old baby to serve in the Gulf, to

participate in the 251st evacuation, which was at King

Khalid Military City in Saudi Arabia.

So, this was a pleasure to serve my fellow

veterans. However, I will say, at each public testimony I

felt your pain. I still do.

I regret the fact that research and technology has

not revealed what the causes of many of the veterans'

illnesses are.

I do hope that you will take with you the fact

that our final report -- you know, we didn't have all the

information that we needed and we still don't.

But our hope is that changes in policy will allow

you to continue to receive care and also to get the

compensation and the benefits that you so deserve.

We appreciate what you did for the American

people. Many people don't realize that the freedom that we

have is not free. Your service is very much appreciated.

DR. LASHOF: Thank you very much, Marguerite. Let

me say, as chair, again, I share with all of my colleagues

at the table our gratitude and confidence in the work that

Robyn and the total staff have done.

It has been a yoeman's job. I found it a real

pleasure to work with them on all the issues. I have been

in contact with them every step of the way and yet it is

their work that made our work possible.

So, I join all of those in that. I thank you all

for the thanks you have given to me.

I want to thank every one of you for the

contribution you have made. Each of you have come from a

different kind of discipline and bring to the committee

knowledge and the expertise of your discipline.

Especially to Marguerite and Tom, the veterans in

our group, I know how hard this has been for them, to share

the pain of the veterans, as Marguerite has so beautifully

expressed it.

I know how difficult it has been for her to not be

able to come up with all the answers. I think we have had a

good relationship. I appreciate her support and I

appreciate her being honest and open about how she feels all

the time. That is her role. That is what she should be

doing and she has done it well. Tom as well.

I think everyone has contributed very

significantly to this work. I have chaired lots of

committees in my career. This has been one of the more

fascinating ones among them.

It has been one in which I cannot think of another

committee that has had as dedicated a staff or as dedicated

members to the committee as this one.

I really do believe that, between our interim

report, our final report and this special report, we have

made progress in moving ahead on these very complex issues.

I am not going to repeat them. David said a great


I can't resist closing, as Robyn would probably

expect me to do, that the real dream is to have a day

without war, so that we don't have to face these kinds of

things, and a day in which every one of our citizens is

eligible for health care without worrying about means tests

and special programs.

With that, I turn it back to McGuire to close

this, our final meeting.

MS. MC GUIRE: As the designated federal official

and the President's representative, I would like to extend

the White House's appreciation for all of the committee and

the staff's extraordinary work, and acknowledge all that you

have accomplished. The meeting is adjourned.

(Whereupon, at 10:48 a.m., the meeting was