Wednesday, October 18, 1995

9:05 a.m.


Committee Chair
School of Public Health
University of California at Berkeley
Berkeley, California
Professor of Chemistry
California Institute of Technology Pasadena, California
Center for Bioethics and Trustee Professor of Bioethics
University of Pennsylvania
Philadelphia, Pennsylvania
ADMIRAL DONALD CUSTIS, M.D. (RET.) Senior Medical Advisor
Health Policy Department
Paralyzed Veterans of America Washington, D.C.
Chairman and Chief Executive Officer Federal National Mortgage Association Washington, D.C.
Clinical Assistant Professor
College of Nursing
University of South Carolina
Columbia, South Carolina
Ethel H. Wise Professor and Chairman Department of Community Medicine Mount Sinai School of Medicine
New York, New York
Georgetown University School of Nursing
Washington, D.C.

San Antonio, Texas
ANDREA KIDD TAYLOR, DR.P.H. Health and Safety Department United Auto Workers Detroit, Michigan

Department of Veterans Affairs
Designated Federal Official

Department of Defense
Committee Staff

Defense Intelligence Agency
Committee Staff
Under Secretary of the Army
Department of Defense
Department of Veterans Affairs
Committee Staff
American Legion
The National Gulf War Resource Center
National Veterans Legal Services Program

6 P R O C E E D I N G S
MS. WOTEKI: Good morning, everyone. May I have your attention, please?
I am Catherine Woteki, the Designated Federal Official for this Presidential Advisory Committee on Gulf War Veterans' Illnesses, and among the duties that I have are officially calling to order and closing each of the committee's meetings.
So at this point, I declare that this meeting is now in session.
CHAIRPERSON LASHOF: Thank you, very much, Cathy.
I am Dr. Joyce Lashof, chair of the
Presidential advisory committee, and it's my pleasure to welcome everyone to this, the second meeting of the committee.
We held our first meeting in August at which we, I think, received a good orientation to the issues and problems that we will be addressing over the next year and a half.
We are committed to making sure that the

7 Government is doing everything that it needs to do
not only to learn the cause of illnesses that are occurring among Gulf War veterans but also that they receive appropriate care and information as rapidly as it is obtained.
This, our second meeting, will be devoted to a series of issues that we've identified that we wish to explore, and in subsequent meetings we will be taking up a series of special issues for the next coming months.
We are expecting an additional member of the committee, who did miss our first meeting, and I will introduce him to everyone when he arrives.
Our opening session, the first session,
will deal with clinical issues, and I will open this by turning to Marguerite Knox for the report on the subcommittee meeting on clinical issues that was held on September 18th in Charlotte, North Carolina.
Marguerite, would you update us on that meeting?
CAPTAIN KNOX: Good morning.

8 The full committee met initially in
August of this year, and at that time we agreed
that we would have subcommittee meetings to address specific areas and concerns related to Gulf War illnesses.
I am pleased to report that the first of these subcommittee meetings was held on September 18th in the city of Charlotte, North Carolina. This location allowed veterans from the Southeastern region to participate in public testimony.
The purpose of the subcommittee was threefold: one, to gain information about access to care for Gulf War veterans; two, to identify predeployment screening procedures among active duty personnel as compared to the Guard and Reserve components; three, to receive public comment from Gulf War veterans and their advocates.
In preparation for this meeting, the staff held discussions with the Department of Defense and VA officials in an attempt to ensure that the testimony presented was targeted to the specific

9 areas of interest of the subcommittee.
Members of our committee who participated
on the panel were Dr. Elaine Larson and Dr. Donald
Custis, and I invite both of you, Dr. Custis and
Dr. Larson, to feel free to make any comments at the end of my remarks.
I would also like to recognize the
committee staff that were present: Robyn Nishimi, Holly Gwin, Joe Cassells, Carol Boch, Tim Phillips, and Mike Kowalik. I commend all of the staff for ensuring that the meeting was a success.
We had three presenters that were on a panel in the morning. The first of those was Dr. Frances Murphy. She represented the Department of Veteran Affairs, and of the three panel members in the morning, she most accurately addressed the issues in question: eligibility requirements and access to care for Gulf War veterans.
The VA eligibility requirements and
compensation rules relating to illness are very complex, so complex indeed that even Dr. Murphy had difficulty verbalizing a clear understanding of

10 eligibility requirements.
As chair of the subcommittee, there are
several key points from Dr. Murphy's presentation
that I would like to highlight.
One is that veterans who served in the
Gulf War need only to have served 120 days, not 180
days, to be eligible for VA care.
Second, priority care was initiated in
August of 1992 following the cessation of the
ground war which ended on February 28, 1991. The definition of priority care that she gave was simply care given to veterans that does not require a, quote, "means test", end quote, to justify the care. Priority care did not extend to pharmacy copayments.
Veterans are entitled to a history and physical exam. The diagnostics included in this Phase One exam were complete blood count, a Chemistry 7, a urinalysis, and a chest X-ray.
In order to receive Phase Two, veterans have to be referred by a physician. Phase Two exams are performed in the following cities:

11 Houston, Texas; Los Angeles, California;
Birmingham, Alabama, and also Washington, D.C. The second presentation was made by Major
Edwin Matthews, who identified himself as the Director of the Department of Defense's Comprehensive Clinical Evaluation Program. He and Colonel Curt Kronke, who was the third presenter, addressed access to care for active duty soldiers in one brief sentence, and that is that all active duty soldiers have readily available health care.
Major Matthews stated that 26,000 soldiers
have been added to the Persian Gulf War registry, and 18,000 have received evaluations. Neither gentleman, however, addressed the issue of active duty soldiers who continue to give public testimony stating that they are concerned that their years toward retirement might be jeopardized should they ask for treatment.
Of interest in the Phase Two exams, he stated that of those who had sleep studies, 40 percent were abnormal and were diagnosed as having physiological sleep apnea.

12 Colonel Kronke discussed the difficulty
that physicians have in evaluating patients with
physical symptoms with no identifiable cause. His presentation was very similar to the first that we had at the August meeting.
The afternoon presentations were given by Lt. Colonel Patti Hamill, who works for the Office of the Assistant Secretary of Defense for Reserve Affairs, and Lt. Colonel Karen Price, the Acting Chief Nurse of the 300th Combat Support Hospital in Columbia, South Carolina.
Each addressed the predeployment screening procedures, which revealed very little or no uniformity among the services. They talked about the screenings that the soldiers underwent before they left for Desert Storm. Most of these were a systems review of a history, so if the veteran did not disclose information concerning the problem, that was not discovered because no physical exam was given.
There were hearing and vision screenings that were performed, a dental screening.

13 Eyeglasses were made for soldiers, and corrective
lenses were also made if you required those for your protective mask.
At this time, vaccinations and medication prescriptions were also given to soldiers.
Lastly in the afternoon, we had 14 public testimonies that were given by veterans and/or their advocates. The testimony represented veterans from four States: North Carolina, South Carolina, Georgia, and one from Missouri.
In summary, there were several themes that rang out in the public testimony.
The first of those is that veterans are very disgruntled over the, quote, "priority care", end quote, which requires them to wait a reported waiting time of anywhere from three to ten hours for an appointment.
Second, veterans repeatedly voice that they are depressed only because they are physically ill and they are unable to perform their activities of daily living.
Third, veterans are very weary at the lack

14 of compassion and the misunderstanding displayed by personnel in both the Department of Defense and the
VA Affairs.
And finally and most importantly, veterans are earnestly looking to this committee to relieve them of the bureaucracy that's involved for each to receive decent health care, decent health care in exchange for leaving their families and loved ones to free a country that most have never heard of, the country of Kuwait.
So I open this now to Dr. Custis and Dr. Larson, if they want to add anything about the committee meeting. Please feel free.
DR. LARSON: I would just like to reiterate the strong sense of frustration that we heard from the veterans and particularly with regard to waiting times and so forth.
I don't think that's unique to this group. It's even not unique to the military. I mean, a lot of us wait a long time for health care.
But I think the issue here is that one can predict after any kind of a conflict that there are

15 going to be problems, physical problems, associated
with being involved in the war, and one can
anticipate the need for sort of revving up the response mechanisms available, so that the larger volume of predictable need for health care can be addressed. And I think that is one thing to look for for the future.
ADMIRAL CUSTIS: I have little to add. We continue to hear, in spite of reassurance from the representatives from DoD and VA, of veterans who encounter personnel in the clinics that are disinterested or ill-informed about things that the veterans are anxious to learn.
I am reminded of--remember the movie, Cool Hand Luke? There was a witticism in that movie that found its way into American jargon: "What we have here is a failure to communicate." It's a phrase, when applied to given situations, can be funny, or it can be sad, or even in some circumstances it can be rather tragic.
I think the veterans who are exposed to something less than caring service in the clinics

16 are obviously not only sick, but they're
discouraged, and they're resentful.
I think it's time for the committee to
visit some of the sites, some of these clinics, and
learn from firsthand experience exactly what the process is and to study some of these case reports.
One of the things that we hear repeatedly
is the misunderstanding regarding priority service in the clinics. And it occurs to me that I might say a few words about that specific issue.
There are approximately 26 million veterans in the United States. Only 11 million of them have some entitlement to VA health care. All veterans are eligible for care, but only 11 million of them have some form, some partial or complete entitlement to care.
Those 11 million are included in what's called the core group or so-called Category A. Category A consists of service-connected veterans, veterans that have ailments directly related to their service or who are rated for compensation because of a service-connected disability, but have

17 some other problem that they are being treated for.
In addition to those service-connected
veterans, there are non-service-connected veterans
who are given care by reason of the fact that they are medically indigent. They are identified as being so through a means test.
In addition to those two categories--and incidentally, the non-service-connected veteran who receives care because of medical indigence, is clearly entitled only to hospital care--their entitlement to outpatient care is restricted to circumstances that would obviate--if they were seen in the outpatient--would obviate hospitalization or care given post-hospitalization. Except for those two circumstances, they do not have any access to outpatient care.
In addition to these two categories, there is another miscellaneous group of veterans that have entitlement to care by law. It includes such individuals as ex-prisoners-of-war, individuals who suffer from Agent Orange exposure, and the Persian Gulf veteran who has illness falls into that same

18 category.
Their priority rating, however, is defined
as one that there is no need for a means test
clearance. Except for waiving the means test, the Persian Gulf veteran has no higher priority than anyone else. As a matter of fact, their priority is second to some of the individuals in Category A.
I think that's all I would have to add,
CHAIRPERSON LASHOF: Thank you very much. The discussion is now open for committee
members generally to ask further questions of Elaine, Don, or Marguerite Knox.
Are there any questions that any members of the committee have at this point?
[No response.]
CHAIRPERSON LASHOF: Don, I would like to ask just in relation to this term "priority care", talking about communicating, it seems to me it's a bad term. I wonder how it originated and what one would do to get the VA to reconsider the use of that kind of a term, because "priority" does imply

19 priority. And this is clearly not, and it's a classification.
I would also think it might be helpful to
get a better understanding of what type of
screening is necessary to be declared medically indigent. How indigent does one have to be to be eligible for care?
ADMIRAL CUSTIS: I could make a guess at that. It's been a while since I had those exact data. Dr. Frances Murphy is in the audience, though, and I'm sure she has that figure in mind.
Is she here?
DR. MURPHY: What was the question again? CHAIRPERSON LASHOF: Would you come
forward, Dr. Murphy?
ADMIRAL CUSTIS: The criteria that form the means test exam.
DR. MURPHY: Let me provide that in writing to you, since it is complex, and it changes on a yearly basis.
ADMIRAL CUSTIS: Incidentally, that means test cap changes each year with inflation.

20 DR. MURPHY: Right now, the income--
CHAIRPERSON LASHOF: If you could get to the mike right quick?
DR. MURPHY: Right now, the income--excuse me; once I get the technology down we'll be fine.
For non-service-connected veterans to
qualify for Category A care or entitlement to health care within the VA, the income level is currently $20,469. But again, that is recalculated on a yearly basis, and it is also dependent upon the number of dependents that that veteran has.
So for a married veteran, there is
additional income added to that $20,000 for each dependent, and the numbers are given to you on the sheet that I've just handed Dr. Lashof. This was also provided to the subcommittee in Charlotte.
I'd also like to provide some
clarification to a point that Dr. Lashof just made. "Priority care" is not a term that VA
chose. It's actually legislative language, and it's used as a term for both Persian Gulf veterans, Agent Orange veterans, veterans who were exposed to

21 ionizing radiation. So in order to change the use
of that term, we would have to change the language in law.
CHAIRPERSON LASHOF: Well, let me just follow up, if you don't mind, here.
I recognize that our laws sometimes put language in. But is it necessary in VA communications to the veteran to use the language in the law?
Does the law require you to use that language, or is that language that you can use internally and translate it into something more meaningful to the veterans?
DR. MURPHY: We actually do put out a benefits book that translates this for every veteran. But it refers back to the original law and the original terminology.
It's really a special eligibility for care. It entitles Persian Gulf veterans who were potentially exposed to an environmental toxin or a toxic exposure in the Gulf to care for illnesses that could possibly be related to that exposure.

22 Illnesses that are clearly not related are
not covered under this legislation. So again, it's
a very complex group of entitlement regulations. But it does need to refer back to the original law. We like to refer to it as a "special eligibility" rather than "priority care", frankly.
CHAIRPERSON LASHOF: Thank you very much. MR. RIOS: Let me ask members of that
committee: Apparently you had over ten veterans testify?
MR. RIOS: What was the--I'm beginning--is it the sense that the common complaint or the common--I guess the common thread to everybody's complaint--that maybe that the medical establishment within the VA just has either an insensitivity, an unwillingness to take their complaints seriously, or that the technology or the medical knowledge of whatever it is that they're continually complaining about is not there?
What is the common thread, or is there a mindset in the medical establishment within the VA

23 that just doesn't take them seriously, or what
would be the common complaint?
ADMIRAL CUSTIS: Are you putting that
question to me?
MR. RIOS: Any of you.
ADMIRAL CUSTIS: You know, in my career--I
spent a full career in the Navy. After World War
II, I spent ten years in getting my training and in private practice, and then I came back into the Navy, and following retirement spent eight years in the Veterans Administration.
And I insist that I saw the best of medicine and the worst of medicine in all three categories of care.
I think the VA health care system provides a tremendously high quality of care, and there is also some of the worst medicine practiced.
I don't think there is anything unusual about the VA health care system in that respect. You will find the same thing in private practice. You will find the same thing in the military medical systems.

24 I think what we see here is a sampling of
those veterans who have been exposed to the worst
of care. And it's unfortunate, but it should not label the entire system as being a poor quality health care system.
DR. LARSON: Let me just say, I think the concerns were of two types.
One was a concern about not being heard or taken seriously, of being labelled with a psychological problem when there were physiologic symptoms.
And the second concern was a lack of responsiveness, a long waiting period, that kind of thing.
Those are the two major concerns: the extent to which their symptoms were taken seriously and were sort of predetermined with a label and the lack of responsiveness of the system.
CHAIRPERSON LASHOF: Thank you very much. I think we will move on to our presenter
this morning, and we can return to this after the staff do their--make some report and comments on

25 the staff work that has gone into this.
But before I call Lt. Colonel Patti Hamill
to the table, let me introduce Jim Johnson, who has
now joined us. We are happy to have you here. And I wonder if you would just sort of say a word or two about yourself and introduce yourself to the whole committee, and we in the committee will introduce ourselves to you at the break.
MR. JOHNSON: Thank you. I don't mean to delay the proceedings in any way. I am very pleased to be here.
I am the Chairman and CEO of Fannie Mae, the largest source of home mortgages in the United States.
Prior to that, I've done a number of different things, including serving in the Government for just a four-year period, from '77 to '81, when I was the Executive Assistant to Vice President Mondale.
Previous to that, I've taught at Princeton and been in business and done this and that.
But I must say that I am very pleased to

26 be a part of this proceeding. I think these issues
are extraordinarily important issues. I think the responsiveness of the U.S. Government to these tremendous concerns that people have is very important, and I am pleased to be a part of it.
Thank you.
CHAIRPERSON LASHOF: Thank you, and we are pleased to have you here today.
Lt. Colonel Patti Hamill?
Lt. Colonel Hamill has been asked specifically to speak to the issues of mobilization and predeployment issues which we did not cover in the North Carolina meeting.
LT. COLONEL HAMILL: Good morning. I am being joined this morning by Dr. Chip Patterson, who is the Deputy Director for Scientific Affairs at the Office of the Assistant Secretary of Defense for Health Affairs, and also by Dr. Kenneth Block, who is currently the Commander of the Army Health Clinic at the Pentagon and during Desert Storm served as the Commander of the MEDAC and health activity at Fort Meade, and he will address--Dr.

27 Block will address--some of the clinical issues as
you get questions, and Dr. Patterson will address the things related to the comprehensive clinical evaluation program.
What I'm going to do is go through, and some of the issues for the panel members previously are going to be repeated, because as we tried to get more detail for you, if I don't repeat it, the rest of you will get lost. So some of it is repetitive for you, and I'm sorry if that gets very boring.
Thank you for the opportunity to address the committee concerning the policies governing the medical assessment of the ready Reserve at the time of Desert Storm and the implementation and effectiveness of these policies during Desert Storm.
The Department is aware that you desire details on, one, the number of Reserve personnel who were medically screened and found unfit for deployment and, two, the medical problems and conditions that rendered them unfit for deployment.

28 As you know, during Desert Storm, the
services were rapidly deploying forces--active,
Guard, and Reserve. Their focus was on moving units and, in some cases, individuals that were mission-capable to where they were needed, whether it be in Southwest Asia, other overseas locations, or within the continental United States.
The process of calling Reservists to active duty parallelled a busy highway with a series of traffic lights that members had to go through. Reserve personnel were processed through a series of screenings throughout the preactivation, activation, and deployment stages.
First, Reserve personnel and/or their
medical records were screened for significant medical problems by the either administrative or medical personnel, depending on what was available
in their individual units at home station; in other words, before they were even called to active duty, as a precursor to that call to active duty.
If no problems were identified that impacted their ability to do their jobs--in other

29 words, not that no medical problems were
identified, but that no medical problems that would impact their ability to do their jobs--they were placed on active duty. So there was a prescreening that was conducted. Those with significant medical problems that would impact their ability to do their jobs were not activated; they were left at home.
Depending on the specific procedures of the service, those members were either put into another evaluation process for separation from military service or attached to another unit for management during the window of Desert Storm. Those with short-term problems were deferred.
Documentation of the actual number of
Reserve personnel who were left at home varied depending on the individual services and what kind of data records they maintain.
Upon arrival at the mobilization station or station of initial assignment, personnel underwent another medical review to determine if they were medically qualified for their specific

30 job. This screening, conducted by medical
personnel, also included a medical records review and a statement of current health from the member. If medically cleared, they traveled to their duty assignment, either in the United States or a deployment site, where a final screening was usually completed immediately before deployment.
Since again the primary focus was to move
these people quickly through the screening process and to eventual deployment, the specifics on those who failed to move really weren't kept consistently. They really kept much better details on those that were going forward, so we'd have an accounting of who deployed.
Even where files on specific medical problems were maintained, after five years, nobody can find them. And I talked to the action officers that maintained those files, and they can sit there and say: We had a computer database that reflected it. And they can show me one sheet of paper to prove that the database was there. But the databases weren't retained once the war was ceased

31 and these members were released from active duty.
Policies governing the medical assessment
of the ready Reserve are aimed at routine
assessment, annual review, and predeployment. As stated in my previous testimony to the subcommittee in Charlotte, North Carolina, the physical standards for Reserve forces are the same as for the active duty force.
A periodic physical examination was
required to be performed at least every four years in all Reserve forces, Reserve components, to document the members' health status and compliance with those physical standards. These standards are set out in DoD Directive 13-3218 and in three service regulations, and they're very similar.
In addition to each periodic physical, each service requires more frequent examinations for such purposes as flight physicals, attendance at school, or for members who are 40 years or older.
Department of Defense policy clearly states that members of the ready Reserves are to be

32 screened at least annually to provide a force that
meets each service's wartime standards of mental, moral, professional, and physical fitness, so that members are available for active duty.
Ready Reserve personnel are required by both law and DoD to submit a certificate of physical condition annually. All services have established specific policies to accomplish both the periodic and the annual requirement.
For instance, in 1994 at least 600 Reserve component members of the Navy and Marine Corps were identified who, under these policies, possessed a medical problem which required their removal from military service. Using the Navy and Marine Corps rate, it is probable that more than 2100 Reserve members in the other services were identified and separated due to medical problems during 1994.
I got that number from a DoD policy book where numbers are reported as a routine personnel code. If the member chose not to reenlist, it would be listed as a non-reenlistment versus a medical problem, but he may have been barred from

33 reenlistment by virtue of medical, but it would
just have been that he failed to reenlist. So the numbers are probably half of what the real number is.
Additional medical screenings for Reserve component members begin at the time of call to active duty and continue throughout mobilization and movement to overseas location or deployment.
During Desert Storm, the Department of
Defense issued specific guidance following already existing Department of Defense directives that all members of units and individuals ordered to active duty were to report within 24 hours or as specified in their orders unless physically unable to do so. Delays were authorized for members who were hospitalized, convalescing or being evaluated for retention.
Servicewomen who were pregnant could be activated, but not deployed, and those members who were in their second or third trimester could be deferred; in other words, left at home.
The very small number of Reservists who

34 were HIV-positive were not mobilized.
Nearly one-quarter of a million Guardsmen
and Reservists were activated for Operation Desert
Storm and Desert Shield, the largest activation
since the Korean War. About 106,000 Reserve personnel were deployed to the Persian Gulf theater of operations.
The Army--now what I'm going to is
individual service specifics, since you wanted some details previously--the Army activated approximately 143,000 Reserve component members; 77,000 were deployed to Southwest Asia, and 13,500 were deployed to other areas outside the United States, and the remainder were assigned within the continental United States.
In addition to the peacetime periodic exam and annual certification, all activated Army National Guard and Reserve personnel underwent medical screening at home station and at the mobilization or deployment site.
In October of 1990, the Army issued specific guidance for home station and deployment

35 medical screening during Desert Storm.
At home station, Army National Guard and
Reserve personnel were to be screened for medical
problems or histories which would delay movement or prevent mobilization or deployment. Personnel with conditions, to include second and third trimester pregnancy which would restrict mobilization or deployment, were to be deferred from movement to the mobilization station.
Reserve personnel were asked to supplement their military medical files with civilian health records or health care provider documentation whenever necessary to clarify the medical condition.
At the mobilization station, all military personnel underwent preparations for overseas movement, which included completion of an individual history form, an update of the report of medical history to include the health care provider review, a review of immunizations, HIV status, and a final validation of their medical and dental status.

36 The medical and dental status was
documented, but the final decision on deployability was not made by the medical provider, but by the commander of the individual unit to which the member was assigned. And there were instances where the commander overrode the recommendations of the medical providers.
The Army monitored the number of non-deployable personnel, both active and Reserve, on a
weekly basis throughout Desert Storm. This
provided a snapshot of the actual number of non-deployables at that point in time.
A cumulative count of the number of people
who were not actually non-deployable was not
maintained. In other words, on Friday of every week, they submitted a report that said--and they did it installation by installation for the Reserve population and unit by unit for the active duty
population--it said 200 to 400 people were non-deployable. The next week, the number was fairly
constant, but it could have been different people, because the previous people were fixed and now

37 deployable. So they didn't do a final count of
exactly how many people were non-deployable.
A Department of the Army Inspector General report estimated that approximately 1100 Guard and Reserve personnel ultimately could not be deployed for medical reasons. Specific information on the actual type medical conditions was not maintained.
However, discussions with the individuals
who participated in this process indicated that the medical conditions precluding deployment included things like pregnancy, diabetes, asthma, seizure activity, cancer, cardiac disease, broken limbs, recent automobile accidents, things that we would see in any other everyday activity.
The Army Surgeon General's Office stated in April of 1991--and this is a quote: "There was no indication that there were larger percentages of non-deployable Reserve component soldiers than that of the active component soldiers."
The Naval Reserve I'll cover next. More than 18,800 members of the Naval Reserve were activated: some 6650 deployed to the Persian Gulf,

38 and another 2700 deployed to other areas outside of
the United States. More than 41 percent of the
activated Naval Reserve members were medical personnel.
During peacetime, in addition to the periodic physical exam, Naval Reserve members are required to sign an annual statement indicating any health status changes which required hospitalization or absence from school, duty, or civilian occupation; care from a physician in the last 12 months; any prescription medications taken in the last 12 months; and any physical, family, or mental problems which might restrict performance on active duty.
Upon activation, Reserve Naval personnel reported for duty at a Naval Reserve Center where medical records were reviewed by Medical Department personnel. Members whose physical was less than 12
months old completed a new statement saying--indicating if there were any health status changes
since their last exam.
Members with changes in their health

39 status and those members who had not had a physical
exam during the previous twelve months were placed on orders for completion of a physical exam only before reporting to active duty. Only those members who were qualified for active duty remained on active duty; the remainder went home.
Medical personnel were individually screened by phone prior to being called to active duty to verify, one, that they were in a good health status and, two, that they could perform the mission that they were needed for to be done. So that was a very aggressive prescreening effort. Only those members who were fully qualified for active duty were activated.
Upon arrival at the deployment station, immunizations were updated, and the members' dental and HIV status were once again reviewed. As in the case of the Reserve components of the Army, any member with a medical problem identified was referred for a more in-depth medical assessment prior to deployment.
Navy records indicate that approximately

40 414 personnel did not move from the Naval Reserve
unit to the mobilization station. The reason
included members who were hospitalized,
convalescing, pregnant women in their second or
third trimester, and a very small number of HIV-positives. In most instances, screening at the Navy
Reserve Centers was very successful, and very few members were identified with medical conditions at
the deployment site.
I spoke to the officer that maintained that computerized database, and he said there were less than 200 at the very end of the war, which included people returning, that he could remember that were on that list that he was tracking as far as what time to remove.
The medical conditions were the exact same medical conditions that the Army identified: people that had asthma, diabetes, people that had been recently diagnosed with cancer.
There were people who came that were healthy on arrival and then two weeks, all of a

41 sudden, started with symptomatic problems: cardiac disease; and a lot of routine non-battle type
injuries; you know, they fell off the truck; they twisted their foot; they fell in a drain hole during PT; some of the routine things that we all
do if you go out and start doing physical activity. The Marine Corps Reserve. The Marine
Corps activated 27,670 and deployed 11,815 Marine Corps Reserve members to the theater of operations. In addition, 2020 were deployed to areas outside the continental United States. This was, by far, the largest percentage of any Reserve component that was activated.
Marine Corps personnel complied with the Department of Navy policies and procedures for peacetime and deployment medical screenings; there wasn't a special Marine Corps screen.
However, the Marine Corps Reserve is like the Army and frequently processes through the station of initial assignment before they went to their deployment site, and they were again screened at that site. Specific data on Marine Corps

42 members who were non-deployable was not available.
I couldn't find where somebody may have squirreled it away.
Air National Guard and Air Reserve. The Air Force activated 34,536 Air National Guard and Air Force Reserve personnel and deployed approximately 8900 to Southwest Asia and another 6400 to other overseas locations.
Air Force regulations require members to be medically qualified for worldwide duty. Medical status was monitored at the local level during monthly drill periods. These peacetime screening procedures were aimed at identifying personnel with medical problems before activation and are decentralized to unit level.
At home stations, members were assessed for a current physical exam and the absence of conditions which would restrict duty performance. If medical problems were not revealed immediately prior to deployment, the members' immunizations were again updated, and their HIV and dental status was reviewed.

43 The Air Force documented almost no
personnel who were unable to deploy. The reason
for this directly related to the home station screening as well as their peacetime mission level.
During peacetime, wing support missions
and their peacetime training missions where they are routinely doing active duty missions essentially, they tend to have approximately two people for every billet, so that the likelihood of finding someone who wasn't fit to go was slim. So the had a pattern adjusted to control the numbers that would fall out. A centralized file which documented specific numbers of non-deployable personnel was also not available.
In summary, each of the services has specific policies for periodically assessing the medical fitness of its members against established physical standards during peacetime and verifying their status prior to activation and deployment.
The experience with medical mobilization
procedures during Desert Storm has led to improvements in the mobilization process, as well

44 as our monitoring of the medical status of the
Reserve force during peacetime. The routine and predeployment processes are, when properly implemented, effective in identifying members with significant medical problems before deployment; however, this system is constantly being modified and improved.
Since Desert Storm, many mobilization and deployment policies have already been modified. The frequency of routine exams is now every five years with increased emphasis on the annual certificate of physical fitness.
All components now include dental
screening as part of the annual medical screening and conduct dental exams as part of the periodic physical exam.
The Department of Defense is completing a rewrite of its revision and retention physical standards policies and separation review procedures for members who do not meet physical standards.
The Navy has modified its medical
examination policy and requires all members to sign

45 the necessary medical condition form annually.
The Army has modified its mobilization
guidance to formally reflect those procedures
developed during Desert Storm, and the Army has also created a standardized form to improve the quality of the annual certification of physical condition.
Our experiences during and since Desert Storm have caused modifications to our system which we feel have improved the assessment and monitoring of the medical status of the Reserve forces. We continue to strive to improve all processes which will increase the readiness of the Reserve forces.
This concludes my portion of the
testimony, and I think we'll all just entertain questions.
CHAIRPERSON LASHOF: Thank you very much. Are there question of Lt. Colonel Hamill
by the committee?
DR. BALDESCHWIELER: One question: Can you give us a feeling for the rough percentage of Reservists that were not qualified for active duty?

46 LT. COLONEL HAMILL: The largest number I
have heard related to that was 10 percent. The
average number was below 5 percent. The Marine
Corps said approximately 1 percent.
When I could get data like on a monthly--one of the reports from the Army was a monthly
report, and it was less than 3 percent. And the
Army had the largest number, because their mission is slightly different. And they also had the largest CONUS-based support mission.
So the one issue that is important to remember here is, is that even during Desert Storm in some instances we activated non-deployable people purposely in order to support the CONUS-based mission, because even though the member may
not have been fit to deploy, they were fit to do their mission, and we needed them within the States for the same type of job performance. So the non- deployability issue does not always render the member not contributing to the military forces.
DR. TAYLOR: I have a question. You
mentioned that the databases were not retained.

47 You're talking about those that were non-deployable?
DR. TAYLOR: So there was no followup on those individual Reservists, or what happened there?
LT. COLONEL HAMILL: If you'll remember what I said, each of the individual services put those people either into another unit for management where some of the conditions we left people home for, where they had a car accident the week before and they broke their arm, and so they put these people into a temporary holding position until they were fit. Others were automatically processed and separated during Desert Storm.
It was complicated to do that during Desert Storm by virtue of the fact that our routine administrative procedures were geared towards deployment versus routine separation, and there was something in effect called "stop-loss", which said you don't have anybody leave.
So a number of them weren't separated

48 until their next quadrennial review, at which point
if the member fails to meet the standard and a determination is made that they can't do their job in relation to the unit position they're in, then they've been removed.
So it varied by service.
MR. JOHNSON: What was the average length of time that Reservists served in the Gulf?
LT. COLONEL HAMILL: I'd have to get that for you, sir.
MR. JOHNSON: Any estimate?
LT. COLONEL HAMILL: Most of the Reserves started deploying over, if I remember right, in the December--November/December timeframe. I think that's when you went. And then the last group we sent over were immediately before the January timeframe, the first week in January. We tried to hold them in the States until after Christmas, aggressively tried to do that for families' sakes.
And then people continued to deploy over
through March, and then people started returning home in the March/April timeframe.

49 So probably four to eight months.
MR. JOHNSON: If you can get that, I'd
like to have that.
LT. COLONEL HAMILL: Everybody's initial
orders, the Reserve orders started at 90 days.
When we went to partial "mobe" in January, everybody's orders were switched to 180 days. So that was the window of time. But I can get the actual timeframe; we've got that.
CHAIRPERSON LASHOF: Any other questions? MR. RIOS: Yes. Let me ask you: Each
branch had different procedures that were followed insofar as evaluating deployment or not; is that correct?
LT. COLONEL HAMILL: That's correct.
MR. RIOS: And were the differences in procedures--did they lead to differences or higher percentages insofar as determining that so many of these people were not deployable?
Did you notice any difference insofar as percentages because the of the procedures that were followed by a different branch?

50 LT. COLONEL HAMILL: The Air Force had a
fewer number of people who were non-deployable.
When you look at the percentages based on the
numbers, because the numbers vary significantly--you know, 140,000 down to 23,000--the percentages
were very consistent; I mean, really consistent.
The Air Force probably had the fewest
number that were clearly identified, but that's
tough to tell. Because of the way they do their assignment practices, it was pretty well hidden. So their lower percentage number may have been directly related to their assignment processes versus an actual lower number of people that were having problems.
MR. RIOS: Okay. I don't have any followup questions.
CHAIRPERSON LASHOF: One of the other issues that I think was asked of you at the Charlotte meeting is: Prior to deployment, the servicemen were given pyridostigmine bromide, a certain number were, and, of course, some received anthrax and botulinum vaccines.

51 Do we know, was that done for everyone?
Was it a select number? Do we have any data on how
many actually received the pyridostigmine bromide and how many received both anthrax and botulinum vaccines?
DR. PATTERSON: The numbers that I'm aware of are that approximately 8000 individuals received the botulinum toxoid vaccine, and about 120,000 received the anthrax vaccination.
The pyridostigmine bromide would have been issued based on operational requirements and threat. I'm not aware of an actual percentage of those individuals. That really would have been issued by the commanders for pyridostigmine bromide. We can try and get that information for you.
CHAIRPERSON LASHOF: I think that would be of interest.
What were the factors that influenced who got botulinum vaccine and who got anthrax, since only 8000 received botulinum, and 120,000 anthrax? On what basis was the decision made to give some

52 one and some both?
DR. PATTERSON: That was based on
operational requirements and perceived threat,
information known by the unit commanders.
Not everyone would have necessarily been--would have been at high risk for exposure to
chem/bio weapons, and so the reason why you have a smaller number is that that was the number that
were deemed to be at risk for possible exposure. CHAIRPERSON LASHOF: Could you elucidate
what were the factors that were used to determine that the risk of anthrax was greater than the risk of botulinum and why some would be at risk for anthrax but not of botulinum?
DR. PATTERSON: It would depend perhaps where you were located geographically. Potentially, if you were far forward, in the area of operations closer to a military threat. Not everyone was positioned far forward. You had individuals located at fixed facilities in Saudi Arabia in contrast to units that were operating in Iraq where exposures might be potentially higher.

53 CHAIRPERSON LASHOF: Well, when was the
decision actually made to give the vaccine? Where was it made, and when was it given? Was that not at deployment status, not until later than they were off in the field?
DR. PATTERSON: There was a process in place in the early stages of deployment for possible use of these vaccinations, but the actual administration of these vaccinations, the decisions to decide who would receive those, were made later on in the course of the conflict.
CHAIRPERSON LASHOF: Can anyone else elucidate that? It's not clear to me.
DR. BLOCK: I agree with Dr. Patterson. I was the commander of Fort Meade, which mobilized about 4700 troops, Reserve and active component, and we patriated approximately 4500 troops.
During the mobilization process, the
vaccines that were administered were standard vaccinations that everyone receives, not PB or
anthrax or botulinum. Those--my understanding is, that decision was made in theater.

54 Is that correct, Dr. Patterson?
DR. PATTERSON: Yes, sir.
DR. BLOCK: That was made in theater,
depending on the location and the military
intelligence at the time.
The commander--and I saw some of you shake
your heads when Patti was reading that some people, although medical personnel recommended that the
people not be deployed, that the commander overrode that--that is the prerogative of a commander, as Dr. Custis will attest to in his career.
In the Navy, the commanding officer, quote/unquote--and please don't take this as--just take it as I'm saying it--is "supreme", as it has to be; we're not a democratic organization in the military. And the commanding officer has to complete his mission.
He is responsible--he or she is responsible--if a medical officer, as I am, makes a recommendation, which in the Army is a profile and in the Navy may be limited duty recommendations, the commanding officer makes the decision whether

55 or not to accept that recommendation, based on the
need of the mission.
So that was one of the things that I
noticed that you all were a little confused over,
either confused or shaking your heads about, that we were being unfair. But the commanding officer, however, if there is a problem that occurs, the commanding officer is responsible.
But as far as vaccinations, we did mobilize the 4500 people. We did a screening form, because, as you know, in military medicine, military medicine is participatory medicine. We assume that you're telling us the truth; we assume that when we ask you a question, that you are filling out that SF-93, which all four services, all three Medical Departments issue--the SF-93 is the history form; the SF-88 is the physical examination form, and that is standard, as a standard form os--we fill that out, and that was gone over by a physician, a physician's assistant, or a nurse practitioner, who was trained to hone in on certain questions, and we have that packet with

56 us.
So if the individual Reservist or active
component person had a medical problem, that should
come to light.
We also at Fort Meade had the medical
record from the Reserve units for the individual.
Now is that always up-to-date, 100
percent, because we have M.D. soldiers, and the Reservists basically train one weekend a month, and sometimes every little issue does not get into the medical record, and that's why we had the face-to-face interview with every deploying soldier or--well, we did soldiers obviously, but the airmen and
the Marine Corps I'm sure did the same thing. CHAIRPERSON LASHOF: Where might we get
further information on the factors that would make
a decision as to give botulinum versus anthrax?
I mean, both are biological weapons. And if you think a group is exposed, that there is a potential for biological, I'm having trouble trying to visualize the basis on which one would make a decision that they would be subject to anthrax but

57 not botulinum and vice-versa.
And the difference in the number that
received anthrax versus botulinum, was this really
a medical decision, or was it because one is a more experimental vaccine and required a waiver and other things influence the decision?
DR. PATTERSON: We will provide you some additional information on that, Dr. Lashof.
questions? Elaine?
DR. LARSON: Just for clarification, could you tell us what the standard vaccine--you said everybody got the standard?
DR. BLOCK: The standard vaccines
include--we look at your tetanus toxoid, not as a vaccine, but we did a tuberculin PPD. We did the intermediate strength, of course. We did the tetanus toxoid. We gave--I think we gave the meningococcal vaccine, as they do in basic trainees. And I can't tell you--but these are approved, routine examinations to all individuals.
And we used for the standard, as Patti

58 read in her message, we have accession standards to
the military which are extremely strict. And then we have retention standards which are applied during the periodic physical. We use retention standards in the federalization of the Reservists and the mobilization of the active component forces.
DR. LARSON: So the only standards were tetanus and meningococcal and making sure they're up with their--
DR. LARSON: --their PPD, okay. Everything else was not as consistent or--
DR. BLOCK: Administered by the field. DR. LARSON: Yes, okay.
DR. BLOCK: By the theater.
DR. LARSON: Okay, thank you.
CAPTAIN KNOX: I think that the flu shot and the typhoid and also gammaglobulin for hepatitis A was given to most soldiers who were deployed to the Middle East.
DR. BLOCK: That's correct. I'm sorry.

59 That's correct.
DR. LARSON: That's what I'm trying to do,
is get a picture of everything.
CAPTAIN KNOX: I was at a fixed facility
and received the anthrax vaccine. So I don't know
what the determining factors were. I knew that it was very--it was dependent upon what decision the commander made and the availability of the drug.
CHAIRPERSON LASHOF: Well, if there are
any guidelines that were given to the commanders to help them make this decision, it would be useful for the committee to have those. So whatever further insights you can give us as to the basis on which those decisions were made might prove helpful.
DR. LANDRIGAN: Yes. Could you tell us what system existed for recording vaccine complications and then in what form those data might be held today?
DR. BLOCK: You mean immediate? We, of

60 course, observe people once we give them vaccines.
Thank you for filling that in. But we, of
course, observe people once we give them the
standard, which is routine medical practice. I can't tell you anything other than that from the IGG and the flu, typhoid, and meningococcal vaccines, if people--a lot of people have vagal reactions, pass out, the standard people thing that everybody else does. But as far as complications-
DR. LANDRIGAN: Yes, I was actually--I
wasn't thinking so much of the immediate stuff, because those usually don't carry any long-term implications; they are just an acute reaction to the event of vaccination.
But how about fevers; how about more serious untoward events? For example, in the case of measles vaccine, which I know you weren't giving, one child in ten or a hundred thousand has a neurological reaction, that sort of thing.
DR. BLOCK: That should be--we keep a field medical record on every individual. Actually the individual keeps the record. That system was

61 revamped after the war as well. But we keep a chronological record of medical illness, every time
you go to the corpsman or the physician or whatever, and those should be recorded on that.
That is supposed to--the idea is that
makes its way back to your deployment station and
makes its way back to your permanent medical record if there are any complications. That's the records system that we use.
DR. LANDRIGAN: So I infer from what you're saying there that it's recorded, one hopes,
for the individual, but it's probably not cross-calculated-- DR. BLOCK: Statistically?
DR. LANDRIGAN: Right. In other words, if
there were 8000 people that received a vaccination, there's really no simple way that you can go back
to the records and say that X of these folks developed complications beyond the immediate six hours?
DR. PATTERSON: I would generally agree

62 with that conclusion, Dr. Landrigan.
MR. RIOS: Maybe each of you could respond
to this.
When you were going through these
operations or these procedures and decided to give these vaccinations, was it your understanding, your personal understanding, that there was a potential for exposure, or was it commonly understood that there were some chemical agents out there and we needed to do this, or was it more of an understanding that there were some agents in the theater of operations that we had to protect our troops, or was it that: Well, maybe there will be some?
I mean, what was your personal
understanding of how you were approaching this? DR. PATTERSON: The decision to administer
some of these vaccines, specifically anthrax and botulinum toxoid, were based on operational concerns and operational threats. Not everyone
would have had the same risk of potential exposure. I'm not aware of any information which indicates

63 that there were actual exposures or documentation
of existing threats. But it was the risk, and that kind of a risk determination would have been based on such things as military intelligence and other sorts of related information.
So as I understand it, the decision to administer these specific vaccines were based on the information that operational commanders had and on potential health threats.
MR. RIOS: Dr. Hamill?
LT. COLONEL HAMILL: At the time, I was at Forces Command at the time, which is the Army Headquarters for mobilization, and sitting there, I was moving people forward.
But in sitting in on the meetings, I would have to agree with Colonel Patterson; it was a real operational fear. It wasn't "we're going to do this because". I think there was a definite concern that they were going to be at risk, and that's the only reason they went through the steps they went through to get approval to use it, because it was an immediate--I think they really

64 thought there was a concern and did not want to
subject their troops to undue risk.
DR. LARSON: Just for clarification, I
have here a copy of an active duty soldier's
immunization record, and he received meningococcal, gammaglobulin, typhoid, the TB TINE test, tetanus, no flu, but, you know--and then in January, he received A-1 on the field, and then in February A-2.
Was there a set way of marking which immunization agent was A-1 and A-2?
These were added later. He was given these in the field, and I assume one is probably botulinum and the other is anthrax. And in this case they were added later.
Our understanding is that not all the forms had these two immunizations added to their records later. So two questions:
First of all, what was the proportion of times when the shot records were updated with these two immunizations?
And the other question is: Is there a

65 standard way that you can recognize that A-1 is X
and A-2 is Y agent?
DR. BLOCK: Do you actually have the
standard form or is that just--yes, it is. Is that
a typewritten sheet, or is that the standard form that we have in the medical record?
DR. LARSON: It's the little yellow-- DR. BLOCK: Oh, you have the yellow card. DR. LARSON: Yes.
DR. BLOCK: The official immunization record is a standard form just like this size, and it goes in the medical records. If the medical record were sent--if the patient had his--excuse me--if the soldier or the service member had his medical record, then that would be annotated there.
It is not required to annotate in the
yellow form every immunization. Most soldiers or service people do carry them, however, in a Ziplock bag to keep them dry and carry them on their person. So if that thing is available, it is updated at the time the shot is administered. Otherwise it might not get annotated, or it might

66 get annotated on a chronological medical form. We
also do that when we administer vaccinations in the routine status.
DR. LARSON: Well, again, let me--
DR. BLOCK: This is routine.
DR. BLOCK: In a mobilization status, this might not get annotated.
DR. LARSON: Let me repeat the two questions. One is: What's A-1 and what's A-2? Do we know what those are?
And then, secondly, yeah, I'm still unclear about whether the official record--because we heard different information on that at the first meeting, whether that was always added or not?
DR. PATTERSON: I'm not aware that there was a specific code for vaccinations, and that's one of the things that we can look into and add to our response to you, Dr. Lashof.
I think as Dr. Block indicated, if forms were available, enough forms were available, in many instances it was documented. That was not

67 always the case.
LT. COLONEL HAMILL: Army members do not
take their military record with them. They took a
small sheet of paper that was a synopsis of their military health record. And I can look at that form to see if there was a space for you to record it.
But what they did is, they took their health record, synopsized the health record onto a one-page form, which was a test form at the time, and then they took that forward with them. So that form would have to make it back, and I'm sure that's where it was documented.
I do know that I heard back that many times when the immunizations were given in theater, they documented them on a unit list. And so as the members came through, they annotated that the member had received it, because these people didn't carry their little shot book with them or anything else to record it, and in order to facilitate getting it done, it was recorded on a unit roster, and then I don't know if they ever made it--you

68 know, if they ever got to that individual, because
they took one sheet of paper--I mean, it was one sheet of paper that Army members deployed with.
So I don't know how they latched those two
together later. So I don't know if there's an answer to your question.
DR. LARSON: Well, I think we appreciate the fact that during a war, you know, things have to get done, and you do them however is needed.
All we're trying to do, I think, or all
I'm trying to do, is understand whether the
procedure was standard across units, and it sounds like it wasn't.
And then another thing that I think wasn't standard across units was whether or not the individual personnel member was told what they were getting.
In this case, for example, this person did not know what he was getting. Other people said they were told. So that's another thing that wasn't standard across units.
I'm just trying to understand and clarify

69 that. Thanks.
DR. TAYLOR: I guess the other thing
that's not standard is also the documentation that
was actually given. Is that what happened
LT. COLONEL HAMILL: Each of the services
did it differently. Air Force members took their
health records. So my guess is that Air Force members, you're probably going to find it documented because the record was there.
Army members did not take their health
record because I think we can all understand that you've only got so much space in a rucksack, and if you're going to be moving forward, you're not going to worry about your little pink medical record. You're going to be more concerned about dry socks and some food.
So I think that's the variant. And then the Marines are very similar to the Army personnel. They didn't take their medical record forward with them.
So I think it depends. The documentation

70 depends on the service and the mission of the
individual service at that point in time and where they were in the engagement when they received the immunizations.
I do remember that some of them were pretty far forward at the time they received it from the rear area where you were forward to provide services of that extent. So it may be, you know, that they weren't consistently documented.
But I know that it was--remembering what
the Army did when they came back, I do know that they said that they maintained troop lists of who got what. So I think that at the time they were
aware of who got what, so they didn't double-immunize. And it was usually done by unit, you know,
the 345th got it, because they were trying to keep track of large numbers of people moving in different directions very quickly.
CHAIRPERSON LASHOF: Well, at this point in time, if the soldier or a veteran wanted to find out whether he got or didn't get or what he got,

71 would there be a way for him to do so, if it wasn't
in the record?
Would the unit list allow him to write to
some central point and say: You know, I think I
got certain shots, and I really want to know whether I got anthrax or I got botulinum?
DR. PATTERSON: It might be possible; it
may not--I'll be quite candid with you--due to the fact that there was documentation done on different types of forms--in some instances, medical records; in some instances, troop logs. It might be possible; it might not.
DR. BLOCK: The alpha roster--the alpha roster for the Army, which is the unit roster--in most cases when things are documented, you put a checkmark or perhaps in this case an A-1 or an A-2 would go down next to the soldier's name.
Whether or not that comes back is
questionable. Everything, if possible, is supposed to be brought back with the PAC, with the personnel action people. That's supposed to be back when the unit deactivates or demobilizes. And that's the

72 only way we could check into that, I guess, is
going back unit by unit to see if they have that information. If it were checked off, theoretically, if possible, it should come back with the unit when it demobilizes.
CHAIRPERSON LASHOF: Okay, thank you. Phil?
DR. LANDRIGAN: Yes. Looking towards the future, not the past, is there any consideration within DoD to having a computerized medical record?
Immunization is a good place to start, and
it's actually--the technology for this already exists. The French have it. And in this country, it's being tested in some areas in California.
I'm aware of that mobilizing, to try it
out in East Harlem where I work, so that in a situation where people have multiple providers in multiple sites, they carry what amounts to a bank card with them, a "smart card", plug it into a computer, hit an access code, and the record pops
up. I think the technology probably does exist. I don't say it's cheap to implement.

73 DR. PATTERSON: As a result of some of the
lessons learned from the Desert Storm experience,
we're currently attempting to develop a
comprehensive surveillance program for deployment. A component of that would be an enhanced
capability to document clinical care, vaccinations, during the deployment phase; to have ambulatory care encounters during the deployment phase, to have that linked in a database with what happens when the individual comes back. It's kind of a continuum process to assess and document the deployed member's health status.
So we are looking at that, sir.
DR. BLOCK: We currently have the new ID card that many of you may have seen. And on the back, there's a bar code, and then there's whatever this is in computer language. And this reproduces this identically; everything is standardized.
In the last three years, the Office of the Secretary of Defense, Personnel Readiness Group, was looking into--and that's always been part of the thing: Should we put the medical record,

74 should we put the personnel record, as a little
chip on here, or should we put it on there and it--the decision--this is more of a national security
type decision, because once all of your information
is available, you're extremely vulnerable if you're captured or if the card is lost or something, medical problems and personnel problems, because personnel problems include current assignments.
So that's--I think that's a security issue
that the Department of Defense will have to rectify.
CHAIRPERSON LASHOF: If there are no more questions, I'd like to thank you very much for your testimony, and we would look forward to the answers to the questions that you weren't able to provide today. Thank you very much.
At this point, I'd like to ask Dr. Joseph Cassells of the committee staff and other members of his staff to come forward and brief the committee on their activities in regard to clinical issues. They've been hard at work.
DR. CASSELLS: Good morning. I've been

75 asked to confine my remarks to about five minutes,
and I'll try to keep within that timeframe.
As you heard from the report of the
committee meeting that was held in Charlotte in
September, there were a number of areas that the committee itself, I think, needs to address or might want to address in terms of recommendations to be made as part of the interim report or the final report relative to access to care and to predeployment procedures.
I won't go into those suggestions right now, but they are available to you on Tab B of your book.
As far as the clinical activities future plans, following up precisely on access to care and the issues that were raised there, we plan to begin a series of site visits both within the Department of Defense and within the VA health care systems in order to familiarize ourselves with the access procedures at the initial access points, as well as at the referral centers, so that we have our own understanding of what takes place and the kind of

76 information that's available, the physical
examination that is given at both the initial access point as well as the referral center, the lengths of time involved in waiting, and the length of time that it takes to get from the initial access to point to the referral center and into the system that way.
We also want to conduct a series of focus groups to evaluate attitudes toward access, toward outreach, and any possible disincentives to report illness that Professor Knox alluded to in her opening remarks. We may be able to get different sorts of information by going to the focus groups, specifically both active duty and Reserve, that we do not get by committee and staff visits to the access points in our review processes. We think those are important.
We also, in association with the Research Group on the staff, plan to continue our review of the clinical syndromes themselves and the risk factor evaluations that have been suggested as possible causative factors for Gulf War veterans'

77 illnesses. These will include both infectious
disease agents as well as toxicological agents, chemical agents, psychological stress and its physiological sequelae.
One of the things that we have discovered certainly in Charlotte and in both the public testimony in the August meeting was how very, very concerned veterans' populations are that they are too often being brushed aside because their illnesses are either considered to be trivial or to be psychological in their basis, and therefore they feel stigmatized and that they are coming up against insensitive approaches to their medical problems. We need to look at all of these putative causative factors.
We also want to revisit further the predeployment procedures and the processes that the services are going through. They say that when implemented properly--and that was Lt. Colonel Hamill's statement this morning--that they are effective in screening out non-deployables.
We need to look very much more closely at

78 the predeployment procedures and the fact that the differences across the services and the differences
in paperwork, the differences in documentation, the absence of documentation, and importantly quality control in order to see that what the policy is, is being implemented the way that the policy has been set up to go.
We also want to do as part of our access to care a review of the records-keeping processes within not just the predeployment procedures, but within the clinical activities themselves related to the Gulf War veterans' illnesses and the various registries.
Finally, we want to address ourselves to what we know and what we need to know and what we should do in the future in deployments of this sort about preventive measures and diagnostic tests that need to be taken in order to better prepare our active forces and Reserve forces in the event that they are being mobilized for another activity such as the Gulf War.
In a nutshell, that is what the clinical

79 staff support is going to attempt to do within the
next several months to better inform the committee of what possible recommendations you might want to consider.
CHAIRPERSON LASHOF: Thank you very much, Joe.
Now it's open for committee discussion as to, one, are there other things that you would like Dr. Cassells and the staff to look into? Are there specific issues you want to raise regarding the plan that he's outlined?
It's a fairly inclusive and comprehensive approach to this problem and should serve us well. But we are open now for general questions and additions, suggestions, comments.
DR. LARSON: Joe, you didn't talk too much about specific case studies. What do you have in mind for that, or what's your feeling about that, and how useful do you think it is or not?
DR. CASSELLS: As you'll notice in your briefing book, there's a question mark beside "case studies", and that's because we have not yet

80 decided exactly how we want to approach or if we
want to approach specific case studies.
Coming out of our focus groups and coming
out of our site visits and randomized record
reviews at each of those activities, we may decide that we have the information that we need in order to address these specific topics.
But in the event that we do not feel satisfied and think that we need to go to specific cases, then we will determine what those cases should be and how best to approach gathering that data.
It's very much a ball still in play. CHAIRPERSON LASHOF: Don?
ADMIRAL CUSTIS: In terms of your focus groups, do you intend to handle the logistics, or are you going to contract for that?
DR. CASSELLS: It is our intention to contract that to people who are accustomed to doing that sort of work and do it well.
DR. BALDESCHWIELER: A question either for

81 you, Joe, or for Don.
Does the VA system ever run internal
controls; that is to say, with an analytical lab,
for example, you typically send through a blinded sample periodically where you know the answer, and to test whether a complex organization and system is really working?
Does the VA ever do that? Do you ever run through a blinded patient and see what happens?
ADMIRAL CUSTIS: You must remember I'm
dated; I retired from the VA some ten years ago. But the answer is: Yes, they certainly
do, not only internally, but also they contract for PSRO review on a continuing basis.
Also parenthetically, the VA has recently had a program, a focus group pursuit, that has been very revealing.
DR. BALDESCHWIELER: I'm not sure whether this is feasible. But can you, in fact, inject into the system at the patient where you know--you
know, what the pathology is, what the diagnosis is, and see what happens? It seems to me that would

82 be a logical kind of test.
DR. CASSELLS: Dr. Murphy, do you want to
comment on that?
DR. MURPHY: She's not sure.
DR. CASSELLS: I don't have the personal
knowledge, John.
CHAIRPERSON LASHOF: It's a clever idea,
John. I've not see it done in any of the quality-of-care, medical care programs that I'm familiar
DR. MURPHY: I'm unaware that that program
is actually ongoing in the VA at this point. It certainly is not, to my knowledge, ongoing in
Persian Gulf programs.
Certainly even our Deputy Secretary, who
is a veteran himself, has shown up at a medical
center and requested care, and that's certainly a good test of the system, especially since he may not have been recognized when he came in through the emergency room.
But in Persian Gulf programs we have not

83 done that. We have just completed a directive to
do quality control and a self-assessment on the Persian Gulf registry program to assess the completeness and the quality of the examinations that are being done and the thoroughness of the evaluations on a symptom-specific basis. So we will have that information for you in the spring of 1996.
CHAIRPERSON LASHOF: Thank you. Are there other questions for Joe or other comments or suggestions?
MR. RIOS: Let me say I think that John's suggestion is a good suggestion. I know when I came out of the military, I had a--I was hurt in Vietnam, and about 17 years after I served in Vietnam, I started having some hip pain, and I had been--I had a 30 percent disability when I came out.
And I went, and my pain seemed to be increasing and increasing. I went to the VA, and they said: Well, you know, you seem to be doing fine. And they decreased my disability from 30 to

84 20 percent.
I said: Well, thanks a lot.
So people said: Well, you've got to keep
going if you still have that pain. So I went again several years later, and they said: Well, you seem
to be doing fine, and they reduced my disability from 20 to 10 percent. So I thought maybe I shouldn't go back anymore; maybe they'd say there was nothing wrong with me.
But anyway, I kept going. And I did have considerable pain, and they kept saying: Well, take these aspirin. And they'd prescribe aspirins and so on.
Finally, it occurred: Well, maybe I'll got to a specialist. And I did. And the specialist took some X-rays, and the VA had X-rays as well, and the specialist said: Well, you've got chronic arthritis in your right hip, and you need to start taking Indocin; which is something that the VA never determined. They just said: Well, keep taking aspirins.

85 So, I mean, it was like a case study. I
went, kept going back, and they never could decide,
could figure out what was wrong with me. One trip to the specialist and some X-rays, and they said: You need to get on Indocin. Now I'm still on Indocin, and I can function pretty well.
CHAIRPERSON LASHOF: Okay. Well, John? DR. BALDESCHWIELER: Let me ask along the
same line. Are there other quality control actions that the VA takes; that is, sort of a routine injection of controls into the system to see how its working?
I mean, if so, what are those, and can we get access to them?
DR. MURPHY: Clarify for me what you mean by "injection of controls". We have a very large quality management program in VA, which encompasses not only total quality management and CQI procedures, but also looking specifically at, you know, quality assessments related to various disease categories.
Each medical center, according to the

86 Joint Commission on Hospital Accreditation, goes
through a whole series of quality management procedures. And VA has performed very, very well under JCOHA review. And we'd certainly be happy to share those results with you.
This is done by individual hospitals at the local level. But we do have a compilation of national standards also.
We don't routinely send patients in to test the system. And I have a little bit of a problem with that suggestion. I mean, how are you going to subject somebody to diagnostic testing that might be necessary when they don't really need that?
I think that there are some ethical questions there, and I would not recommend that.
DR. BALDESCHWIELER: Do you have any way
really of determining the--in diagnostic tests, we refer to the sensitivity and the specificity of the test; that is, the probability of detection and the false positives and the false negatives--do you have any way really of assessing that in the

87 overall system; that is, when a patient comes in?
What is the probability that the diagnosis
will really reflect the underlying pathology or the possibility of a false positive or a false
Is that kind of data acquired and assessed
DR. LANDRIGAN: This is one of the great
challenges in clinical medicine. And for a long
time, there was no systematic calculation of Type 1 and Type 2 errors in diagnosis.
I think this began to change on a
systematic basis about 15 years ago with the development of what's come to be known as clinical epidemiology. People at the medical school at McMaster in Canada are given a lot of credit for having first developed this on a formal basis.
But now, in fact, it is possible for many
standard diagnostic tests to look up in textbooks and databases what is the predictive value positive of that test, what's the sensitivity, what's the specificity, in good hands.

88 I don't know. In different organizations,
VA among them, I'm sure, when they are put through
JCOHA, are tested in at least some crude surrogate ways as to how they measure up, these testing systems aren't perfect.
DR. BALDESCHWIELER: I was really raising the question in the broader systems sense; that is, when a patient comes into the system, what is the chance that you'll truly find out what the problem is?
DR. MURPHY: I'm not aware that that information actually exists either in the civilian sector, VA, or DoD.
In general, the kind of quality control information or quality management information is tracked on a procedure basis; you know, what is the outcome for a prostatectomy, for instance, or how well do we do in diagnosing a particular disease entity like diabetes?
But actually putting patient with an unknown diagnosis into the system and deciding how likely it is they are going to come out the other

89 end with the diagnosis, you know, I think has some methodological problems. It depends on what the
diagnosis is and what the symptoms are as to how well the system will perform.
I think we get back to some of those issues when we talk about Persian Gulf veterans in specific, because we know that the majority of Persian Gulf veterans who come to medical care do get conventional medical diagnosis. Some of them don't get diagnoses and have undiagnosed illnesses or unexplained conditions. And I think that that is also the case with other patients, non-Persian Gulf veterans. And I think that that is an area that has not been well studied in clinical medicine.
CHAIRPERSON LASHOF: John, the only other answer I would give to this question and quality of care--and I suspect the VA follows it, as do others--is that you do do reviews of surgical pathology and how closely the surgical pathology relates to the diagnosis before the surgery, how many normal appendices you take out versus how many

90 diseased and so on.
There also are critical protocols that
have been developed for a number of diseases, and
you can check into quality of care as to how often a patient with a particular complaint gets a clinical protocol as designed by some of the quality-of-care studies.
And it's an area that's evolving in medicine and has been growing really fairly rapidly in the last ten years, I would say.
ADMIRAL CUSTIS: That is true, Joyce. Still there's more rhetoric than product there.
CHAIRPERSON LASHOF: I suspect. I'm not
as up to date on what's actually happening on the clinical scene these days.
DR. CAPLAN: Joyce, just to come to this issue, I think we need to distinguish between consumer satisfaction about getting clinical access to VA care and the quality of the care that's provided.
Some years ago, I was on an Institutional

91 Review Board, a Human Experimentation Committee,
that approved various experiments, and I decided that I would be a subject in one of them, which involved putting in a nasogastric tube, which we told people on the forms was a minor discomfort.
I think I may be the only subject who actually came from the Board that approved it. And some of what's being asked is to do that kind of check.
But I think it's not the quality of services outcomes and so forth. I think what I hear from many people is that they have problems and roadblocks from the telephone call and all the way through.
And so what I'd like to suggest is that you try to give us an overview about not so much about the quality of care, although that's obviously of interest, but also the access issues in terms of how well this system performs relative to what HMOs or other health care organizations do to measure their consumer satisfaction.

92 In Phil's spirit, looking forward, it
would be nice to make recommendations about how to
make some of these operations more user-friendly. There is enough grumbling that they're not, and I think it would be useful to be able to compare to some extent VA against other health care institutions and how they go.
So I'm not opposed to sending a sample through--I even think you can go it ethically for certain kinds of things--to see what happens. But it's more on the access side than it is on "are they accurately diagnosing the illness" side.
DR. MURPHY: And actually those are issues
that VA has already taken up as part of its reorganization.
Dr. Kenneth Kaiser has just joined us this year as our Under Secretary for Health, and he is committed to improving access to care.
We have new performance standards for access and appointments for both primary care and subspecialty care. And, you know, we also have new performance standards both at the network level and

93 at the local hospital level.
So I think that some of those issues are
already being dealt with within the system, and we
expect to see some improvement and hope that the veterans' comments will reflect that.
ADMIRAL CUSTIS: Is it not true, Frances, you are headed toward an enrollment system with capitation budgeting, an HMO/managed care approach?
DR. MURPHY: You know, there is--VA has
proposed some change in the eligibility rules, and hopefully that will simplify the kinds of eligibility issues we talked about with priority care for Persian Gulf veterans. But those, in fact, have not yet been passed by the Congressional representatives.
So all of that is still in the planning stages and up in the air, Dr. Custis.
CHAIRPERSON LASHOF: Back to that issue of priority care, you know, part of the confusion clearly is, when you're told "priority care", you think you're at the head of the line.
And the question is: How long is the

94 line, and how much does it vary in different parts?
And, Joe, I would just ask whether you
will be able in your work to try to find out how
long it takes from the time that somebody wants care to when they can get an appointment and then how long they wait once they've gone for an appointment, how the system is working from that point of view.
DR. CASSELLS: Yes, that is one of the things we intend to look at, both how long it takes to get into the initial access place, as well as the waiting times for appointments, whether it's a block appointment system where everybody comes at 8:00 a.m. and then they get seen however it happens, or whether it's an individual appointment system--all of these points.
CHAIRPERSON LASHOF: I think it is time for our break. So let me thank Colonel Hamill and Joe and Dr. Murphy for their help and testimony this morning. Thank you.
We will resume at 10:45.

95 CHAIRPERSON LASHOF: This session we are
going to devote to issues of declassification, and I'd like to open this session first by turning to Ms. Holly Gwin, our Deputy Director and Counsel for the committee, who will make some brief remarks, and then we will call upon our witnesses, Colonel Ed Koenigsberg and Mr. Paul Wallner.
MS. GWIN: I just wanted to tell the committee members that Jonathan Tucker and I started looking at the declassification effort for two primary reasons.
First we saw GulfLink as potentially an excellent outreach tool for the Department of Defense by making records of the Gulf War publicly available, and then secondly and maybe most importantly because it would help us get a leg up on our own investigation of chemical and biological warfare.
And then I just wanted to take this opportunity to thank Paul Wallner, Steve Dietrich, and Chuck Wells for all the assistance that they

96 have given to the committee staff so far.
And I think all of you know in your book you have some examples from GulfLink and so on that the staff has pulled together.
At this point, let me ask Colonel
Koenigsberg to kick off. I think you're going to speak first.
COLONEL KOENIGSBERG: Let me be clear that I am not addressing the declassification part of this, though. The other part of this briefing this morning is on the investigation team, and I am a Director of the Department of Defense's Persian Gulf War Veterans' Illness Investigation Team.
The investigation team initiative was directed by the Deputy Secretary of Defense in March of '95; the team was established in June and is to function for a period of two years under the authority, direction, and control of the Assistant Secretary of Defense for Health Affairs, Dr. Joseph.
Our charter is to integrate and analyze

97 classified, declassified, and unclassified
operational, intelligence, and medical information to explore all reasonable possible causes for illnesses related to service in the Persian Gulf War. We will examine unit logs, command reports, battle damage assessments, supply and logistics records, encampment procedures, and many other types of records, reports, and files. Every classification level and category of information is available to the team.
On our toll-free hotline number, 1-800-472-6719, a "plug", we are soliciting veterans to
give firsthand accounts of events or conditions
that may be related to Persian Gulf illnesses, and we are soliciting theories from health care providers. We will review and evaluate this information and any additional information we develop.
The twelve-person investigation team is multidisciplinary. We have people with medical, operations, intelligence, and support backgrounds.
I am a physician, and my most recent

98 assignment was as Director of the Armed Forces
Medical Intelligence Center at Fort Dietrich.
We also have a pharmacist, epidemiologist, preventive medicine physician, chemical/biologic weapons expert, operations expert, and a special investigations officer. We have a chemical engineer intel analyst on loan from the National Ground Intelligence Center, and expect to have a permanent intelligence analyst soon.
We have a line support officer with command personnel and operations background, a secretary, and an enlisted administrator will join us this month and a senior substantive advisor with a background in research who has been identified.
A large part of our job is to coordinate with other Department of Defense, Federal, and non- Government agencies. The graph that you see over here on the side shows many of these agencies with whom we deal. We are a resource to these agencies, and they are a resource for us.
Not only will we investigate events and possible exposures which may be related to Persian

99 Gulf veterans' illnesses, we are also the primary
conduit for new information from Iraq and elsewhere to help focus the efforts of the clinical and research programs.
Let me give you a little more insight about our process for conducting inquiries and analyses.
As indicated, a high volume of information will come to us from many sources. The DoD alone estimates that up to 10 percent of the 15.9 million pages of operational Desert Shield/Desert Storm documents are expected to have some relationship to health data. We initially evaluated over 9000 pages of documents and reports which were placed on the GulfLink database in addition to a huge amount of material previously compiled by the Department of Defense.
Then there are the other databases we use or will use as they come on line, such as the Environmental Support Group's unit locator file, the Center for Health Promotion and Preventive Medicine's geographic information system, Health

100 Affair's comprehensive clinical evaluation files,
and several of the databases managed by the Defense Manpower Data Center.
Many theories of particular interest for investigation are already well-known, and we have begun to reevaluate them with these new databases as they come on line.
The team does a regular review and
analysis of our 1-800 incident reporting line database, and as of October 16th, we had 419 callers reporting 571 incidents or conditions. Currently there is no clustering by unit, incident type, incident date, or location on the calls that we've received. The information is, however, routinely cross-referenced with other matters that the team is investigating such as the effects of sand exposure, Scud attacks, chemical and biologic warfare target damage assessments, et cetera.
As an example, a caller reported that on a give date he witnessed several dead animals and suspected some unusual terrorist activity in the vicinity of their encampment in Bahrain.

101 We first confirmed the duty service and
Persian Gulf service of the individual through the
Defense Manpower Data Center, Desert Shield/Desert Storm files. We verified the unit's exact location on these dates with the Environmental Support
Center's unit locator database. We will now cross-reference all of this with the Scud attack
database, the enemy chemical and biologic warfare
facility list, the coalition air war battle damage assessment reports.
We will also review documentary evidence such as unit logs, veterinary reports, and intelligence reports to see how all of this fits together. We will analyze whether any of these factors overlay with each other and, in combination with each other or alone, could have resulted in the reports of the dead animals, the unusual enemy activity, or the veterans' illnesses.
We have also checked to see if anyone else from the same unit or other units in the area made similar incident reports for similar dates or locations. We will now check the medical and

102 personnel data files to see if we can find a
cluster of people with similar medical problems from these units or nearby units which could have had a potential for the same exposure.
Now I would like to give you some details about specific areas we are already investigating, which in turn should provide some idea of the wide scope that is involved in this.
A persistent theory is that due to the targeting of chemical and biologic weapons production, filling, and storage sites, inadvertent release of agents occurred.
To determine if there was a potential threat to Coalition forces, we coordinated with the Air Force to get a copy of its new comprehensive database of all airway targets when it is available. The Air Force began compiling this database shortly after the war. It is derived from air tasking order and target lists, which assign specific units to bomb specific target locations. The database, containing data from all services, provides descriptions of the targets, known

103 weather, mission diverts, and bomb damage
assessments. We will link this data with data already released on GulfLink to determine times when possible downwind hazards could have occurred.
In addition, reported incidents of
chemical agent alarms are being cross-checked for possible connection to when the chemical and biologic warfare facilities were bombed. This should give us an idea of whether there were specific instances that could potentially have exposed Coalition forces to chemical or biologic agents.
We are also searching intelligence resources to develop a complete list of actual and suspected CBW production, storage, and weaponization sites which were not targeted or bombed.
As another example of how we are keeping an open mind on the various theories being advanced, we are beginning an investigation of the
hypothesis that one specific military unit may have possibly been exposed to low levels of nerve agent

104 from a bombed chemical warfare storage facility
around the same time as the reported check
The unit was a in a different location
than the check detectors, but the unit and the
check detectors were both approximately the same distance from the possible targeted weapons facility.
Let me mention that we are also investigating the use of insecticides such as DEET and prometherin. It has been suggested that the insecticides could have become more toxic when combined with others or with the pyridostigmine bromide that some soldiers were taking.
We are examining several related issues such as whether it is likely that individuals were exposed to more than one of these substances at the same time. Non-governmental researchers, not our investigation team, are evaluating delayed neurotoxicity. One of the investigation teams's roles is to provide operational and intelligence information to supplement the Government and non-

105 governmental research efforts.
Due to the numerous reports of chemical
agent warning alarms that were subsequently
determined to be false positive, we are investigating the operation and deployment of these detectors.
It should be noted that initial detection alarms are designed to be overly sensitive for a quick response while trading off for specificity. Backup detection equipment is more specific but less responsive to confirm the actual presence and identification of a chemical agent. Battlefield interference also confounds detection capabilities.
We intend to investigate and prepare a
report addressing the military chemical warfare detection capability and specific data on specific reports of alarms.
We are also studying the Scud propellant additive, red fuming nitric acid, RFNA, which is not totally expended before impact. At the time of launch, a Scud missile contains about 8000 pounds of RFNA and 2000 pounds of kerosene. When the

106 missile reaches full speed and the engine shuts
off, there is a residual of as much as 300 pounds of RFNA and over 100 pounds of kerosene. Volatile residual RFNA could have escaped, especially if the missile did not fully detonate, causing a vapor hazard.
When released, RFNA is a reddish brown cloud. It's fumes can be suffocating and poisonous. It is an irritant to the skin, mucous membranes, eyes, and respiratory system. Acute exposure symptoms, which may be delayed up to as much as 30 hours, include dizziness, headache, nausea, general weakness, chest tightness, and difficulty breathing. In some reported incidents, chemical agent alarms and acute symptoms similar to those experienced with RFNA exposure were associated with reported Scud attacks.
Using a list of actual Scud launches and impacts, we will examine these reported incidents to discern if RFNA or another of the substances used in the Scud might have contributed to the acute symptoms of our servicepeople.

107 New information that Iraq has released to
the United Nations makes it clear that Iraq had a
mature biologic warfare program. We are evaluating the effects of identified biologic warfare agents and investigating whether there is any possibility that biologic warfare agents could have been employed or accidentally released through collateral damage.
We also have an investigative interest in silica, especially the fine microparticle size silica that exists in Saudi Arabian sand. Medical research has linked silica exposure to immunosuppression and autoimmune diseases such as rheumatoid arthritis. We believe that silica inhalation and absorption by U.S. troops deserves further research attention.
We are awaiting more data now from Rolls Royce/United Kingdom on studies of silica damage to jet engines on the British Tornado aircraft used in the war, soil analysis data from the United Nations, and a review of CHPPM, or the Center for Health Promotion and Preventive Medicine, soil

108 samples.
Dr. Pamela Assa, an immunologist from Mid-South Arthritis Treatment Center in Memphis,
Tennessee, sent Department of Defense a paper theorizing that vaccine adjuvants could contribute to the Persian Gulf illnesses. A correlation was drawn between the use of silicon vaccine adjuvants and human autoimmune disease, based on silicon breast implant research.
Our initial investigation disclosed U.S.-produced vaccines use only aluminum salts as
adjuvants because of concerns about the safety of silicon-based adjuvants.
There is no evidence that aluminum
adjuvants are related to autoimmune disease, but we requested the Army's Medical Research and Materiel Command review this matter. At the request of the Army, an additional review was conducted by an expert on the staff of Johns Hopkins Hospital. It is the opinion of the Army research and the Hopkins consultant that there is no clinical relationship between adjuvants and the Persian Gulf veterans'

109 illnesses.
A theory on mycoplasma infection was
introduced in veterans' publications and
subsequently in a talk to DoD and VA researchers by Drs. Garth and Nancy Nicholson from the University of Texas. Because the mycoplasma organism is so unique, detection and treatment are extremely difficult. DoD, VA, CDC, and civilian scientists are exploring with the Drs. Nicholson the existence of mycoplasma in Persian Gulf veterans and attempting to determine whether it is possible to intentionally manipulate the organism as was suggested.
The investigation team's part is reviewing related and intelligence and operational data, trying to determine if the organism can be weaponized.
We are investigating the effects of chronic exposure to oil well fire smoke and petrochemicals in general. We will review data on the Kuwaiti oil fires compiled by the Center for Health Promotion and Preventive Medicine, and we

110 are looking for epidemiologic studies of oil
industry workers and oil well firefighters.
The 193rd Air National Guard unit in Pennsylvania, with a high rate of illnesses, is of interest to the investigation team. The unit is part of an ongoing study by the Centers for Disease Control and Prevention. Our investigative efforts to date include coordination of Environmental Support Group and Defense Data Management Center data to determine the demographics and locations of deployed personnel, interviews of deployed personnel, coordination with CDC, and coordination with unit physicians.
Future efforts include further evaluation of the unit's deployment, mission, equipment, in coordination with the Centers for Disease Control.
We are working across a wide spectrum of
information. Many of our investigations will lead to final conclusions and reports to the public. Other investigations will provide avenues for further research, and some, in addition, will produce results useful for planning future

111 deployments.
We are certainly happy to provide your
staff with any further details, if you require, and
I thank you for allowing me the opportunity to
present this information.
CHAIRPERSON LASHOF: Thank you very much,
Dr. Koenigsberg. We will get back to you.
But we are going to move to Mr. Paul
Wallner next and deal with declassification, and
then we will open it to questions for both of you. MR. WALLNER: Madam Chairman, ladies and
gentlemen, good morning. It is a pleasure for me to be here this morning to talk about the Department of Defense's declassification program on behalf of the Persian Gulf veterans' illnesses issue.
By way of introduction, I am the Staff Director for the Department's Senior Level Oversight Panel, looking at Persian Gulf illness issues. That is chaired by Deputy Secretary John White.
The panel provided direction and resources

112 to accomplish the Department's initiatives
responding to the Persian Gulf veterans' illnesses. Its members are the Assistant Secretary for Health Affairs, Dr. Joseph, who spoke to you at your initial meeting; the Under Secretary of the Army; the Assistant to the Secretary of Defense for Atomic Energy; the Assistant to the Secretary of Defense for Intelligence and Security; the Director of the Defense Intelligence Agency; and the Director for Current Operations, Joint Chiefs of Staff.
My job is to ensure that the declassification and investigations team obtain and apply the resources required to implement the Department's initiative with respect to the Persian Gulf veterans.
The declassification program, as you will hear today, have heard this morning, and will hear this afternoon, is only one part of a widespread, integrated, and unprecedented program undertaken by the Department. You will be briefed on medical research investigation from Ed Koenigsberg and

113 outreach efforts over the next two days.
Our declassification initiative is an
important component of the outreach and
investigation programs. Its primary objective is to provide all health-related information to any interested people or organizations.
Underlying this activity is a new attitude established and consistently endorsed by Secretary Perry, Secretary White, former Deputy Secretary John Deutsch, and Chairman of the Joint Chiefs of Staff, General Shalikashvili.
The direction of these gentlemen and others in the Department for the defense, operational, and intelligence communities is to share all health-related information, and where there is any doubt, to err on the side of inclusion. In earlier episodes, I think it's
pretty well understood that we erred on the side of exclusion rather than inclusion.
With me today and to my right are Brigadier General Jack Mountcastle, the Army Chief of Military History and head of the Army

114 organization that is charged with declassification;
Lt. Colonel Steve Dietrich, who is in charge of the Gulf War Operational Declassification Project; and Mr. Chuck Wells of the Defense Intelligence Agency, who led the Gulf War immunization declassification team. They will join me in addressing your questions at the conclusion of the presentation.
Last March, then Deputy Secretary of
Defense John Deutsch directed the expansion of the Department's Desert Shield/Desert Storm declassification program. This action broadened the program to include all records in the operational and intelligence arenas that could be related to potential causes of illnesses among Persian Gulf War veterans.
Prior to this decision, the focus of declassification and public release was on medical information only. That's an important distinction that you need to understand.
The guidance from then Deputy Secretary Deutsch added that these records would be reviewed, investigated and made available to the public to

115 the maximum possible extent.
He also set up the Senior Level Oversight
Panel and the investigation team and designated the
Army and the Defense Intelligence Agency as offices of primary responsibility for operational and intelligence information and declassification projects.
One of the first challenges was to come up with a definition designed to zero in on health-related information while eliminating all documents
that do not pertain to possible causes of illnesses. At the same time, the definition had to be flexible enough to allow for growth as new potential causes surfaced in the course of examinations, research, investigation, and inputs from the veterans themselves.
Within these parameters, the declassification teams are looking at information that is prepared or acquired by the United States on storage, deployment, or use of chemical, biological, and radiological weapons during Desert Shield/Desert Storm and outbreaks of disease,

116 epidemics, or other widespread illnesses that may
have resulted from infections or environmental causes among military forces and civilian populations.
Although this is a little bit long, it has proven to be highly useful in the process of guiding the teams to those documents that are health-related from the millions of pages of information on the Gulf War.
Army and DIA are only two of many DoD and Government producers or acquirers of information on Gulf War developments. As the office of primary responsibility for the operational declassification effort, the Army must guide the Navy, the Air Force, Marine Corps, the Joint Staff, and the Central Command, its supporting commands and component organizations in their review and
declassification efforts. This task is in addition to declassifying their own records. With an estimated 11.7 million pages, the Army Gulf War documents constitute the bulk of operational information.

117 Similarly, DIA is responsible for their
documents, for those of the four service
intelligence centers, the Central Command and its subordinate intelligence organizations, and the National Security Agency.
Additionally, DIA was required to coordinate declassification and release of documents originating with the Defense Nuclear Agency, the Central Intelligence Agency, the State Department, and the intelligence services of Coalition allies.
In intelligence information declassification, there are stringent requirements placed on each organization for coordination and cooperation.
The investigation team and declassification projects, as you may recall or you may not recall, are unfunded mandates. The people and dollars required to do the various jobs are taken from the services component or agency with primary responsibility for that activity.
For the operational declassification,

118 there are about 100 people working fulltime on the
task. They are from each of the services, the Joint Staff, and the Central Command. Monies for hardware, software, and communication links for the operational entities totaled about $4 million in Fiscal Year '95 and will come to about $4.6 million in Fiscal Year '96.
Because the operational declassification project was a new task, resources had to be taken from other missions and activities of the services.
Except for the Army, which will employ 20
new information specialists for the projects, these totals do not include salaries of military and civilian employees assigned to the task.
Because the defense intelligence community, under DIA leadership, is more integrated than the operational elements and because the vast majority of intelligence information on the Gulf War was already digitized, the intelligence declassification project required fewer resources. They have been able to complete declassification of currently available information in about six

119 months.
32 people were dedicated to this task.
They came from DIA to include the Armed Forces
Medical Intelligence Center, the intelligence components of the four military services, the defense agencies, and the Central Command. Only $50,000 in additional funds was required by the intelligence declassification team.
The Department is taking this extraordinary step of declassifying health-related, operational, and intelligence information for three key purposes.
The first is to openly share information on data on possible causes of illnesses with all interested parties. We estimate that less than 10 percent of the nearly 700,000 military personnel who served in the Gulf War have been or are sick, and that some of their families have experienced illnesses since their returns. The Department's first priorities are to make these people well and to determine what caused them to become sick.
Those groups that might be interested in

120 the declassified information include the Gulf War
veterans themselves and their health care
providers; other Government departments who are working on the problem, such as Veterans Affairs, Health and Human Resources, the Environmental Protection Agency; and the public, including the news media.
Another aim of the declassification program is to assist in identifying health or health-related incidents and events that warrant further examination by the Government or by the medical community.
Lastly, as Colonel Koenigsberg mentioned, the declassification effort is intended to serve as one of the primary resources for use by the investigation team as it responds to specific inquiries.
The process through which the operational and intelligence information is declassified involves five distinct steps. The amount of resources and time spent on each of these steps will vary from organization to organization,

121 depending on the volume and location of the
documents involved, the quantity of the documents that are digitized, and the sophistication of the available information-handling system.
Intelligence had a far easier task in this regard because there were fewer total documents, and most of those were already digitized and centralized. This process has been refined and improved since the intelligence team began its efforts last April, and I expect there will be further enhancements now that the operational declassification project has begun.
The first step in both processes is to locate and identify all documents that might bear on the problem. The intelligence team initiated two data calls to all intelligence producers and
acquirers in the Defense Department. Although most of the intelligence was found in DIA's central database, the team wanted to ensure that all relevant data was located for review and declassification.
The operational effort comprised several

122 data calls to all units and services that
participated in Desert Shield and Desert Storm. With nearly 700,000 military personnel engaged in the Gulf War, this has been an enormous task. Operational organizations are still coming forward with relevant documents or records.
The next step is to compile and digitize this material for further screen. Intelligence had a significant head start in this step because most of their data was already available electronically.
The relatively small amount of intelligence hard-copy documents consisted of miscellaneous
memorandums, background papers, and briefings. Soft-copy information comprises intelligence assessments and reports and a variety of unevaluated reports from intelligence collection organizations.
By contrast, with some exceptions, the bulk of the operational information is in hard copy. These documents are unit or service reports on movement activities, plans, and developments affecting the organization's mission.

123 Nevertheless, there are two factors that
will help the operational declassifiers. One is that there are many purely administrative reports that are not expected to contain health-related information. The second is that a large number of the operational documents are already unclassified.
The third step, and the one most
important, is to determine what information is related to Gulf War veterans health or illnesses. This is accomplished by comparing the reports either electronically or manually to a comprehensive list of topics and subjects. This 13-page list covers a wide range of issues ranging from nuclear weapons to the local insects.
In this step, prioritization for further exploitation will be given to those reports or incidents closest to U.S. forces, to those with the largest number of personnel that could have been affected, and to those of the most serious nature in the reported condition or activity.
For example, a document relating a plan for employing chemical weapons on Scud missiles

124 against a major Allied facility would go to the top
of the pile for immediate action.
A critical part of this step is
determining the originator of the document or
information. In the declassification of Government documents, the originator of the classification is the only authority for declassification of that document.
For intelligence, this is a particularly salient point. Intelligence assessments are composed using multiple kinds of information from multiple originating agencies. Each organization with activity in the information used in a report or assessment must review the document before declassification.
Moreover, intelligence assessments often include data on multiple sources, such as order of battle and physical characteristics of facilities that have no relevance to veterans' health or illnesses.
The fourth step is to prepare the illness or health-related documents or information for

125 public release. Each document is reviewed based on
the requirements of security regulations, the classification Executive Order, the Freedom of Information Act, and the Privacy Act.
Where information in the report falls within the parameters of one or more of these laws, it is excised, and the appropriate regulatory exemption code is inserted in that declassified document.
All of the exemptions and the explanation in the introduction to the intelligence--are explained in the introduction to the intelligence and operational part of the public online database.
The final step in the declassification
process is the public release of the documents. This is being accomplished through the Department's GulfLink database that is accessible through a Worldwide Web home page on the Internet. The address is
Managed by the Defense Technical
Information Center, GulfLink contains studies, research reports, factsheets, press announcements,

126 speeches, intelligence documents, and operational
records. It is easy to use and has both search and browse capabilities. Searches can be done using keywords or Boolean queries.
In addition to the exemption codes
mentioned earlier, a database base description and frequently asked questions on using the systems are included.
Since Deputy Secretary White announced the activation of GulfLink on 3 August, some 6700 pages of intelligence and operational information have been put on the system. On average, there are some 4500 queries against the database each week.
The operational records on GulfLink will include daily unit journals and logs; logistics, supply, medical, and environmental reports. Also in this group will be unit orders and plans, situation reports on operations and activities, and personnel status reports.
In addition to a variety of briefings and publications, the intelligence component includes information from human sources, without any

127 evaluation or assessment; imagery reports;
electronic data; bomb damage assessments; and captured and translated Iraqi documents.
The quantity of the records to be reviewed
in this process is substantial, as I mentioned earlier. In the operational program, which is just getting started, there is an estimated 15.9 million pages throughout DoD. Of these, it is estimated that about 2.2 million pages will need to be manually screened.
The operational elements estimate that about one million pages may be declassified. This estimate is based on expert judgments that many of the records will deal with administrative details or tactical activities and not contain health or illness-related information.
I must remind the committee that these numbers are estimates which will be subject to change as the project evolves.
At this early point, there are some 1000 pages, additional 1000 pages, of operational information that is ready to be placed on GulfLink,

128 and that should happen later this week or perhaps
early next week.
The declassification of available
intelligence documents is essentially complete.
Nonetheless the steps of identification, review, and declassification continue as new information is received, data is uncovered by the operational reviews, and documents are returned from cooperating U.S. and Allied organizations. There were over 2 million pages of intelligence information on the Gulf War. Of this, some 500,000 pages were manually screened, and 6000 pages have been declassified and placed on GulfLink to date.
The Department's declassification program
is a thorough and detailed initiative to share all health-related intelligence and operational information with the Gulf War veterans and the public. We have made significant progress in this
effort since it started last April with the operational now fully engaged. We expect to complete the job before the end of next year.
This concludes my presentation, Madam

129 Chairman, committee members. My colleagues and I
will be happy to answer your questions.
CHAIRPERSON LASHOF: Thank you very much,
Mr. Waller.
Before we go to committee questions, I
would like to ask Holly and Jonathan to make some
comments and tell us a little bit about their work in regard to this.
Jonathan first, then Holly. Jonathan? DR. TUCKER: Thank you, Dr. Lashof. Based on the background information that
was presented to us in DIA and Army briefings on the declassification process, the advisory committee staff has made a number of preliminary observations, and I would stress they are preliminary.
First, it is our impression that DoD's statements to date about public access have tended to overstate the availability of declassified documents. In fact, the vast majority of the reviewed documents from the Gulf War have been
deemed irrelevant to the issue of veterans' health,

130 and of the more than 2 million pages of
intelligence records that were scanned, only some 6000 pages, or about 800 documents, have been declassified and made available to the public on the GulfLink Web site.
The second observation is that the advisory committee staff believes that there could
be more disclosure of information than has occurred thus far. Documents ostensibly declassified have been extensively redacted in many cases with large sections blanked out for reasons of national security or under other FOIA exemptions. Indeed, some of the documents consist of only a few sentences with the rest of the document deleted for various reasons.
Part of the problem in our impression is that after identifying the relevant documents, DoD leaves declassification and redaction decisions to the originating agencies.
A centralized review of decisions to retain classification, in our view, would ensure better consistency in implementing the spirit of

131 the Deutsch declassification order of June 1994.
Third, we believe there is a need for more
background information to help the public interpret documents that have been declassified.
For example, DoD representatives have told
us that they question the accuracy of many
documents now posted on GulfLink. For example, there are numerous raw intelligence reports based on unsubstantiated accounts from human sources interviewed in the field during Operations Desert Storm and Desert Shield.
Yet beyond a blanket disclaimer on the GulfLink home page, DoD makes no effort to explain these misgivings. DoD representatives have told us that this lack of quality control or editorial comment has been intentional in the interest of openness, so that the public can judge the documents for themselves.
However, without a clear explanation about the reliability of the information contained in the declassified material, the net effect of the declassification process may be to confuse, rather

132 than enlighten, the public about their real
Thank you.
CHAIRPERSON LASHOF: Thank you, Jonathan.
Holly, do you have any additional comments you want to make?
MS. GWIN: No. I would like to
participate in the questioning. But no. CHAIRPERSON LASHOF: Okay, fine.
Let me first ask Mr. Wallner if he wants to respond to any of the comments of staff at this point, and then we'll open it for the committee.
MR. WALLNER: Thank you, yes. I'd just
like to say a few words in response to Jonathan's observations.
The process was basically jump-started, for want of a better term, by John Deutsch. And his guidance and that of the rest of the leadership to the declassifiers, particularly the intelligence people, was to get as much out as quickly as possible. He did not want us to establish an elaborate bureaucratic structure that would take

133 five years before the first things go out.
So that's part of the reason why we have
been hurrying with regard to intelligence and part
of the reasons why we've been leaning very hard on the operational side, as General Mountcastle can attest to, to get their program started and do the same sort of thing.
The other thing you need to understand is, the disclaimer that's on GulfLink goes, I think, a little bit further than the point that Jonathan mentioned, which is clearly in there, but it also says that these are raw reports. There is no context put to them. They are reports that need to be looked at in that light. They are not the official U.S. Government or U.S. Department of Defense position; in fact, that position is contrary to many of the reports that are in there.
We knew this going in. The Deputy
Secretary and the leadership of the Department have said we want to share all of this information.
And when I'm questioned about this process and the wisdom of it, even from people within the

134 Department--I had an intelligence analyst tell me
the other day that he was not completely convinced that the policy of sharing all this stuff with the public was the best way to go.
So the point is, if we didn't share it, we would be accused of withholding things. What we've established is a comprehensive logical system to get as much information in both the operational and intelligence community out to the people that are interested in it as we possibly can.
Thank you.
CHAIRPERSON LASHOF: It is open to committee questions.
DR. TAYLOR: I have some questions for Colonel Koenigsberg. It's regarding information that you gave from the investigation team, information that is being currently conducted.
One is regarding the RFNA. You mentioned
that it's an irritant to skin and there are some acute symptoms like dizziness.
Do we know what the long-term effects are,

135 as well as the chemical contents? What is RFNA
nitric acid. It's nitric acid. And like any acid, it will cause skin symptoms.
There have been, so far as we know, no long-term effects of exposure to RFNA. It's all been acute effects that you get.
There have been people that, in the business of working with RFNA, we've gone back to look for and are still looking at to see if there are any reports or studies in there that will show that they have had long-term effects. To date right now, we have not found anything.
DR. TAYLOR: How was this used?
COLONEL KOENIGSBERG: It's an oxidizer for the fuel in the Scud missile. And so it's supposed to be burned up.
But obviously what they do, you have to put more of it in, so that when you get where you're going, you don't run out of gas when you get there. So when they load a missile, they put

136 additional substances in there, so that there will
still be some left at the time when it hits the ground. It's just part of running the missile. We do the same thing with space missiles and everything else. There's always an extra load in there.
DR. TAYLOR: The other thing that you mentioned was that among the phone calls that you've received--
DR. TAYLOR: --that there's no evidence of clusters. Is there any evidence anywhere of clustering regarding exposures to anything at this point, or do you know?
COLONEL KOENIGSBERG: That's basically the whole purpose of what we're doing. We're trying to look for clusters by looking at it.
I think this is the thing that Dr. Joseph has tasked us with in this thing, and he and Dr. Deutsch at the time had the ideas. The medical community was out on one side doing their work and investigation; the operational people were

137 somewhere else doing their stuff. The intelligence
people were doing something else.
And what they saw was, trying to put all
this together, to have access into all these
different areas, and see if by looking and comparing the areas, that we would be able to find clusters, and that's the whole thing that we're looking at.
So, yes, we do go into the database on the telephone calls, and we look for, electronically, whether there is some cluster of things that are coming in.
But right now, we're not seeing it because there's not enough numbers on it. With 400-and-some callers, I mean, we have people from this unit
and this unit, et cetera, et cetera. It doesn't help that much at this point, but it does help us when we start getting into it, and we've gotten some specific incidents off the telephone calls that we use where people call in and say: I was
involved in this. And then we can go out and start looking.

138 We hope to get--as we get more calls, we
have hoped that we'll get more clustering.
DR. TAYLOR: What is the timeline
regarding most of this information that's being
conducted now or the investigations underway? And I'm specifically talking about the chemical agent detectors, whether the capability that's being investigated now will turn up any information that would be useful, and how long will that last?
COLONEL KOENIGSBERG: Well, we'll be doing
that, at least, as I said, for two years.
DR. TAYLOR: Two years.
COLONEL KOENIGSBERG: And that we'll be looking at this material.
A lot of the material will not be coming to us. It's coming to us slowly. And as Mr. Wallner has said, the declassification effort won't end until next December. So a lot of material we won't even have in our hands until next December that we can start working with.
So we work through the things. And the problem is a lot of these theories, whatever the

139 case may be, may not be able to be closed out until
we get all the data in from all these data things. We'll have some theories; we'll have some ideas as we go along; but we won't be able to close them out until we can assure ourselves that there's not some document that we haven't seen yet that might shed light on it.
CHAIRPERSON LASHOF: Thank you. John? DR. BALDESCHWIELER: A question also for
Ed Koenigsberg.
You mentioned the potential effects of silicon and presumably silicon dioxide of fine sand particles.
DR. BALDESCHWIELER: And also silicon in adjuvant preparations?
COLONEL KOENIGSBERG: Adjuvants, right. DR. BALDESCHWIELER: What is the rationale
behind that?
COLONEL KOENIGSBERG: Well, in the adjuvants, the paper that was presented to us, the

140 theory was that adjuvants which are added to the
vaccine material in order to get better antibody response, it slows down the release of the--
DR. BALDESCHWIELER: I understand how an
adjuvant works.
COLONEL KOENIGSBERG: Okay. So what was brought up there was, that there is a study that they were doing on silicon implants in women, breast implants, and that they were seeing some symptoms that were similar to what people with the Persian Gulf illnesses were having.
So the suggestion of Dr. Assa was to look at whether silica in the immunizations was causing the symptoms.
We went back and looked at this. And a good many years ago in the U.S., it was changed over to aluminum salts rather than silica salts to be used. So there is no silica in it.
And so we didn't stop with our research on it. As I say, we sent it out to others to look at. And so far, the answer we've gotten back is that there is no correlation at this point anywhere that

141 anybody has on the aluminum.
Now in the sand, you're talking about
silicosis, and there have been studies on the
systemic reactions of people exposed to sand and silicon and the fact that it does affect the immunosuppression system and that it has been involved in illnesses like rheumatoid arthritis or it has been questioned in the illnesses like rheumatoid arthritis. And I think this is something that needs to be explored further.
DR. LANDRIGAN: May I follow up on that? CHAIRPERSON LASHOF: Yes. Phil?
DR. LANDRIGAN: Usually in the
occupational setting when you think about exposure to sand and the hazards that result from it, as you just mentioned a moment ago, the disease that we're concerned about is silicosis, which, of course, is a fibrous disease of the lung.
And I know that increased incidence of rheumatoid disease has been reported among people with silicosis. But my recollection of the literature is that it usually is seen in the

142 situation of fairly heavy exposure where people
have manifest changes in pulmonary architecture; it's not something that occurs early in the game.
So I wonder in that connection, have you--in
people who are reporting rheumatoid changes,
have you done any sort of systematic chest X-rays surveyed with a B-reader analysis of the X-rays to see if there's any evidence of silicosis?
COLONEL KOENIGSBERG: First of all, the sand in Saudi Arabia is much finer than normal sand. And like everything else, we're looking at it to say: What is different about this?
So when you look for gross pulmonary
lesions and silicosis, the question that comes to our mind is: Do you necessarily have to have it, if the grains of sand are so small? Could there be something different about the way this sand is?
That's one of the reasons why we're taking
a look at the U.K. Rolls Royce study, to see what it did to mechanical engines that's different than regular sand.
The people that came in for examinations

143 under the comprehensive clinical evaluation program
did, as part of their workup--a good many of them have chest X-rays.
Now one of the things that we do is, we're not research people. We're not into the research end of it. So what we will do and what we are suggesting in here is that researchers go back now and take a look at this and see whether there's something there.
We can do the initial investigation. We can tie the initial thing from the operational and the environmental factors that are there. But we're not going off and doing the research. That will have to be done by others.
So this, as well as other things, is being turned over to the research and clinical folks to say: Can you find anything?
We've given copies of what this paper is that you have here to the people in the CCEP program. They know what it is we're looking at it. We meet on a regular basis, because we all work for Dr. Joseph, and we report on these things that are

144 there. And then the clinical people and the
research people can take it back into their areas and turn it into whatever research investigation is needed.
MR. RIOS: Mr. Wallner, does the
Government have any information on whether or not either the Iraqi forces or civilians were exposed during this war to any chemical war agents?
MR. WALLNER: There is some information to that effect. It's in GulfLink. It's some of the unevaluated reports that you have seen earlier.
That does not mean that the Department
believes weapons were used. We do not believe weapons were used based on this.
MR. RIOS: The information that you have is that there were exposures or--
MR. WALLNER: That chemical weapons were, indeed, used during the Gulf War. But it is unevaluated information.
MR. RIOS: Okay.
CHAIRPERSON LASHOF: Let's clarify this.

145 MR. WALLNER: Clarify that? Okay.
CHAIRPERSON LASHOF: This is why the question is raised by GulfLink in looking at it.
In GulfLink, there are specific references
to exposure, and they're in there. But I understood that the Government, the Department of Defense, had looked at those and did not consider that those were valid, and it's been their position up to now, I understood, that it was not used.
Is that position being reexamined in light of some of this?
And I guess the real question on that is to Mr. Koenigsberg and the special investigative team. You mention these in your report.
Are you seriously taking now or
reevaluating the Department's position around biological and chemical warfare?
COLONEL KOENIGSBERG: No, this doesn't--I think what's being misunderstood here is, our work really does not impact on policy until--and the Department of Defense's position--until we find something.

146 We're an investigation team. The
direction I've been given is to look at anything and everything, and I have had no interference from my supervisors or anybody else to say that the DoD position is such; therefore you will not look or you will make it go this way or you will do anything else. It is up to me and my team to decide what we want to look at.
Now obviously everything that we're
hearing here in the 1-800 line, in the press, et cetera, all goes back to these chemical/biologic incidents. So we're looking at them.
But it does not say--it has nothing to do really with DoD's policy. At this point, I would have to agree that I have not found anything; we have not found anything that would change that policy or that position.
If somewhere down the line, stuff came out that was substantiated, then I think DoD is openminded, and my impression of all the people that I've talked to in DoD is that the door is not closed. It's--you know, the position is the same

147 as it's always been. But they put us together;
therefore they expect us to look at it.
CHAIRPERSON LASHOF: What things are you
looking at now that haven't been looked at before? COLONEL KOENIGSBERG: Well, the thing-- CHAIRPERSON LASHOF: I mean, one can
continue to look and look and look and continue to look at the old things.
together a new team, are there things that you're looking at that hadn't been looked at before?
before, we've got for the first time the ability to look at operational data. It's never been available to anybody in any bulk to take a look at and combine it. It gives us a tremendous opportunity to look from the clinical standpoint with what's going on in the CCEP program, what's going on with the VA program, in evaluating veterans, and to try to tie this to what is happening there.

148 As far as the chemicals, biologics,
weapons and this kind of stuff are concerned, this
new database that the Air Force is now coming out with, it will be able to show us weather and wind directions as well as bombing damage assessments, and everything put in one place is going to be a tremendous new tool to be able to use. And we'll have the advantage of being able to use that along with tying it to the things, as we've mentioned.
But we can go back to all these different
databases and pull it in. If we find that a unit was in a certain location and there's some question that they might have been exposed to something, we now are getting the capability to go in and say: What other units were there? What people were in that unit? How many of these people have shown up in the CCEP program? How many of them have had examinations or some kind of diagnosis, or what were their complaints when they came in?
And then try and package that to say: Wait a minute; there's a cluster here; there's something here that has not been seen before.

MS. NISHIMI: Just as a followup to what
Dr. Lashof asked, though, regarding a specific
incident that you discuss in your testimony: Is it fair to say that DoD is essentially reopening its investigation of the incidents surrounding the check detection?
COLONEL KOENIGSBERG: It's fair to say the investigation team is. That has nothing to do with the--
COLONEL KOENIGSBERG: --position of the Department of Defense.
MS. NISHIMI: Right. But you are
reopening the investigation of the incidents surrounding the check detection. That's a fair statement?
COLONEL KOENIGSBERG: We are looking at everything. There are no restrictions on what we're looking at. We are looking at the check detections. We are looking at anything that anybody has given us that had any kind of validity

150 to it; we're looking at it.
MS. NISHIMI: Okay, thanks.
MR. RIOS: Mr. Waller, you said that a lot of these reports, you haven't released them because they are not within context; in other words, you don't want to release these reports because they're not put in context.
Is that a policy decision, that you all have taken the position that you will not release these unless they are presented in a context?
MR. WALLNER: No, there has not been any
such policy decision. And you are misinterpreting "the context".
The context I was referring to was specific unevaluated reports that are on GulfLink. And there has been no restriction placed on us as to what we can release. The guidance from the senior levels of the Department is: Release as
much as is possible that is health or illness-related; let's get more out there than we possibly

151 And that's why there are things out there
in the unevaluated category.
MR. RIOS: And, Chuck, do you have
anything to add to that?
MR. WELLS: Yes, actually. In fact, I
would like to actually address some of the points
that Mr. Tucker made earlier as well.
Yes, you have to understand here that we
have gone to great lengths here. I have spent the
last six months of my life directing the work of 18 people within the Washington area, as well as an additional 14 people worldwide, in looking for every bit of intelligence that was related to Persian Gulf veterans' illnesses or could be related to possible causes thereof.
And so to address some of the--again some of the points Mr. Tucker made, first on the irrelevant data on the GulfLink, I think--and we make a statement in the introduction to GulfLink that there is information that is of marginal utility, particularly the translations of captured Iraqi documents. We admit that some of those are

152 quite marginal to the issue, but we felt again it
was important to put anything that even touched on chemical or biological warfare up on the Internet and make it available to the public. So some of that material is questionable.
But again, when you go to the next point, which is that, okay, there were over 2 million pages of Persian Gulf War-related material that we searched and that only 6000 pages are on the GulfLink, well, the reality is, we're probably only going to have about nine or ten thousand pages
maximum of intelligence data that is illness-related material that will ultimately be on
GulfLink, because we manually searched over 500,000 pages. That's what those 32 people were doing worldwide, is sitting down and looking at each report and making sure or trying to determine whether any information in those reports was related.
Now in the comment where there was not enough disclosure of the information in the reports, some of the finished products that we have

153 in intelligence--and that means assessment or a
final report of some event or some capability that the enemy may have, that we did not release all the information -- the reason we did that is because in many of the situational reports that were produced during the war--and these came from many headquarters, from the U.S. Central Command; they also come from DIA; they came from other government intelligence organizations as well--you have a paragraph that describes the situation with regard to the ground order of battle, the Iraqi ground order of battle.
Then you have a section that describes the naval forces that were active, the air forces, et cetera. We walked down every military capability that the enemy has.
And then you'll find a section that says "chemical/biological warfare", and it will specifically state what was going on with the enemy with regard to that, or it may cover missile activity, Scud activity.
If there was any mention of any biological

154 warfare activity, that paragraph you will see was declassified and is on GulfLink.
If there was any mention of biological
warfare capability in any of the other sections of
those reports, we also declassified and released that information.
So consequently, yes, there are some reports you're going to pull up, and you're going to see all kinds of exemption codes all throughout the document, and it looks like we just went happy with the macro that we use to put those codes in.
But, in fact, that information really is
not related to illnesses. And again, our task, our mission, was to get the information out as quickly as possible and to make it available to the public to the fullest extent.
And I would further argue that, okay, we erred on the side of inclusion. We put out a lot of documents that are borderline. Some people probably can't even figure out why we put these documents out.
But again I would argue there is a

155 process. There is a process for getting additional information from those reports, and that is the
FOIA, the Freedom of Information Act.
By now, identifying documents that have information or potentially have information, any citizen of the United States can request to the Department of Defense to see or have that document reviewed completely.
So in these examples that I've given as the situation reports, any citizen can request that situation report and can ask for the whole thing to be declassified. So they could see the ground order of battle, the naval order of battle, to see if there is any relevance or see if there was anything else there.
I don't think you'll find anything. But again, anyone is welcome to do that.
And also as far as the centralized review of documents, unfortunately again intelligence is rather unique in this, as opposed to the gentlemen on my left here in their declassification effort of operational documents.

156 In intelligence we use sources from
multiple agencies and from multiple governments,
for that matter. For us to declassify any document, we must get the approval of each agency that has an equity in that document. And if it's a foreign government's information, consequently I must go to a foreign government to get release.
If, for example, in those situation
reports, you wanted the entire document released, I would have then been required to go worldwide to get coordination, which probably would have taken six to twelve months at least per document, I think would have been unreasonable, and it wouldn't have been fulfilling our mission to get the information out timely and as comprehensively as possible.
And finally, as far as background
information describing what is on GulfLink, I think that is a valid criticism by the committee.
We have obviously drafted an introduction. We do some explanation of the materials out there. But I think we probably could go even further in providing some additional aids for searching and

157 also maybe to give some examples of the kind of information that we do have on there.
Thank you.
MR. WALLNER: I would add one point to Mr. Wells' discussion.
On the FOIA exemptions and the rights of people to appeal that, that is explained in the introduction on GulfLink, so they know not only what to do, but who to go in each of the services and throughout the Department.
DR. LARSON: First a quick comment on the silicon, and then we'll get on to the maybe more interesting issues about declassification.
I mean, the obvious epidemiologic question is: Do the Saudis who live there have an increased incidence of rheumatoid arthritis and other things?
And unless you believe there is a biologic
reason to think that an acute exposure, as compared to a lifelong or chronic exposure, makes a difference, if the Saudis and the Kuwaitis and those who live in the sand don't have an increased

158 incidence of these problems, I think we can not
worry about that. But I'm sure you've thought about that.
COLONEL KOENIGSBERG: Well, let me comment on that, too.
There's been one interesting thing that came up from one of the people that's doing research on this, and that is the idea of the dress that the people who live in that area wear and the reason that they wear it. It's very interesting.
COLONEL KOENIGSBERG: A lot of the things that have come from the Bible and from the Mediterranean area and the Middle East go back many years, and there's ways of doing things. And there's always been the feeling that maybe some of these laws within Judaism, within Moslemism [sic], are due to some of the health risks.
People out there go around and wear a cover over their face when they're outdoors. They take it off when they go inside, but when they're outside they always have a cover over their face.

159 Our people went over there, and they were
outside sunbathing in the sand, playing volleyball, running around, filling sandbags, doing a lot of
things with the sand that the people over there thought we were crazy.
And I think, you know, it does present a little bit of a different environment.
DR. LARSON: Thanks. Now you've given us a better understanding about why this whole effort is taking a long time, and that was one of the questions, early questions, we had is: Why is it taking so long?
I just want to make sure that we have--we've heard a lot of numbers, and tell me if I'm
inaccurate here.
It looks like we have spent over $9
million in '94 and '95 for those declassification
efforts at least. That doesn't count the personnel in the service. Let me just read them off, and then you can correct where I'm wrong.
It looks like there are about 16 million pages of information, about 2 million of which have

160 been considered to be relevant to health. Those
are the ones that are being reviewed or have been reviewed, and of those, 5000 pages have been, in fact, declassified, which means that 99.7 percent of the information that's been reviewed has not
been declassified, and I assume that's because it's been determined not to be relevant to illness or health.
Okay. The second part of that question is: Your third phase in this declassification effort was to have the organizations or people who have equity in the information to review it.
My question is: They're reviewing it for what purpose? For issues of confidentiality for individuals, for issues of accuracy, or for permission to declassify, in which case right there, you know, they could say no, and that's the end of it?
For example, if you need to get foreign government permission to declassify information about biologic warfare or whatever, well, then, we don't have it.

161 So what is your sense about the extent to
which we have full information? The fact that it's declassified or not may not be the issue. I mean,
it may just be that we can't get it.
MR. WALLNER: Let me answer a couple of questions, and then I'll defer to the experts on the numbers and on the third part.
First of all, the dollar figures you've cited were not for '94 and '95; they were for '95 and '96.
MR. WALLNER: So only about half of that money has, in fact, been spent so far. The rest of it will be spent this particular year.
And I'm sorry if I confused you on the numbers; that was not my intent. I intended to make a clear distinction between the numbers on the operational side and the numbers on the intelligence side. And that's perhaps the best way to explain it.
And I will now defer to Steve Dietrich on the operational side and then to Chuck Wells.

162 MR. WELLS: As far as the numbers on the
intelligence documents, first of all we determined
there were about two to three million documents that are Persian Gulf War-related, okay. This covers all aspects of the war.
After we used--and I think Mr. Wallner mentioned a 13-page list; that was the unclassified keyword list that we used to search the databases; actually the classified list is more like 17 pages of words.
Then we refined that over two million documents down to approximately 500,000 pages.
Then it was at that point, to get the illness-related information out of that 500,000 pages,
that's when we had to do the manual review. We had to have people actually sit and read each of those reports. And then out of that 500,000, we deemed that there was--like I said, it will come out that there's approximately nine to ten thousand pages of intelligence-related information that will be declassified ultimately.
But that doesn't mean we're withholding,

163 you know, 490,000 pages of documents. All that
means is that 490,000 pages of documents may have the keywords that we used to search, but they may relate to another country of the world. It's just that it came up during our search, because we were trying again to get or locate as much of that information that was related to that war at that time and at that place.
And I'll turn it over to Colonel Dietrich. CHAIRPERSON LASHOF: Could I--before you
do, because it is logical to follow through on some of these questions--
MR. WELLS: Sure.
CHAIRPERSON LASHOF: When they were manually looked at to say whether or not it was illness-related, what kind of criteria or guidance were given to all the reviewers, and how standardized was that, and could you share with us
what the criteria were to decide it was illness-related or not illness-related?
MR. WELLS: Certainly. In fact, that was
on of our first major tasks. Obviously defining

164 something that is illness-related, that would be insufficient to give to 30 people and say: Yes, go
at it, find this.
So we wrote a definition, and we coordinated it within the intelligence community, and we also coordinated it with the other military services on the operational side to ensure again we were including or were going to get all the information we were looking for.
That definition is essentially--it's been somewhere abbreviated, but it is included in Mr. Wallner's statement. Essentially it covers five functional areas, which I would describe as biological weapons; chemical weapons; radiological weapons, specifically any nuclear waste material that the Iraqis may have used or any other radiological weaponry of any type that may have played in this.
Fourthly, it covered any illness or
epidemics by either military or civilian populations of either side in any of the countries where U.S. troops were involved, and fifthly in the

165 environmental--flora, fauna, oil well fires,
anything of that nature that could have again affected our troops.
So that essentially is the five broad categories that the definition covered. So all of our personnel who were looking for the information were using that material.
Again, though, one key statement here--and Mr. Wallner made this earlier--is that we erred on the side of inclusion. That was the bottom line. If there was any doubt as we did this review--I've told this countless times to all reviewers--that they were to include the material, and we would then make maybe a further determination later in doing our quality control of the declassification. But nonetheless, we were erring on the side of including the information.
And again, that's where, I guess, we've gotten some criticism that we've put out irrelevant information. But I say it's better to have irrelevant information that was marginally related than to miss some, I think, key bits of information

166 that may have been there.
LT. COLONEL DIETRICH: And, ma'am, the
Army, as Mr. Wallner has pointed out, is just
getting started, along with the rest of the services, in the operational records community. We have a total estimated 15.9 million pages. Of that, the Army has an estimated 11.7 million pages; again the lion's share of that work falls to us.
Our intent, to illuminate or continue what
Mr. Wells said, is to release our documents, review them, and have them released to the maximum extent possible. You will see a document that responded to a keyword search in our automated system, a health-related keyword. You will see that document that will have sections in it made available to the public that do not bear on the health-related issue, and we intend to do that to keep the entire document in context.
DR. LARSON: The second part of my
question, could you just tell us what the people
with equity in the document are reviewing it for--for relevance, permission, confidentiality, et

167 cetera?
MR. WALLNER: No. They are reviewing it--and correct me if I'm wrong, Chuck--but they are
reviewing it because it's the recommendation of the producer of that particular document that it be declassified. We are going back to the originator of that information, that helped us get that document, to say "we want to declassify this". It's your information; you have to say yes or no. So it's a thumbs-up or thumbs-down.
GENERAL MOUNTCASTLE: Sir, could I follow up?
Let me just take a moment, and if you'll bear with me, as the Army's Chief of Military History, I need to put something in the historical context.
A year ago when I was appointed Chief of Military History, our biggest task lay in just completing the Army's history of Desert Shield and Desert Storm, and we provided copies of that to your staff assistant today, because we've just gotten it published.

168 But we had not yet begun the mission that
now is our first priority. Lt. Colonel Dietrich, a
year ago, was floating offshore Haiti on the U.S. Mount Whitney, maintaining our coverage as part of a joint effort to record the operation within Haiti.
So we came to this collectively under the guidance of Dr. Deutsch and now subsequently Dr. White within OSD to ensure that we reached the
points that Ms. Larson has discussed, and that is--and certainly that we have already heard from Mr. Wells--that we include those documents that will be of assistance to individuals looking for information.
And I think one thing that I'd like very much--and the reason I asked to come today--that
I'd like very much for the committee to take away is the fact that we have built a team, essentially from scratch, based around what I think will be a very effective mix of Desert Storm veterans, a number of them non-commissioned officers who represent boots-on-the-ground experience in the

169 desert, who also possess those military
occupational specialties, be it chemical or engineer or explosive ordinance disposal, that will allow us to meld their talents and their personal experience with those key professionals that we have found the money to pay and we've gone out and hired to build this declassification effort.
And we will be the nexus of all of the efforts of the other services, of the Joint Staff, and of the Central Command. We have a quarterly review of those operational records, a specific council that is chaired by the Honorable Joe Reeder, the Under Secretary of the Army, who has just joined us for this morning's session, and we are responsible through him--and, of course, Mr. Wallner--to the Deputy Secretary of Defense.
We take that responsibility as seriously as we do our greater responsibility, and that is to Desert Storm veterans, their parents, and their health providers.
Thank you.
CHAIRPERSON LASHOF: Thank you very much.

170 Mr. Wallner, do you want to add--
MR. WALLNER: I would just like to add--to
try to come to closure on the numbers issue, Dr.
I think--and correct me if I'm wrong,
Steve--that the operational side of the house,
which is just getting started, is estimating--and I can't emphasize enough, this is their best considered judgment--when they get all through with this process, they will probably have somewhere between one million and two million pages that end up being declassified and placed on GulfLink. But that's just a ballpark figure. It could be off by several hundred thousand one way or the other.
Are you satisfied with that, Colonel Dietrich?
question for Paul.
I thought I heard you say that there were reports of the use of chemical weapons in the

171 database.
Now I'm familiar with the reported
detections by various sensors. Could you give me
an example of a report of use and a little bit of background on it?
MR. WALLNER: I will defer to Mr. Wells, unless he would rather defer to me. Go ahead, Chuck.
MR. WELLS: Okay. No, sir, I really can't give you any, because--
MR. WALLNER: All right. Then I can lead the way.
MR. WELLS: Oh, all right.
MR. WALLNER: There are some reports by observers on the ground of unknown reliability, human beings, that would refer to they knew that a Scud missile was launched on such-and-such a date at Allied forces. I mean, that was their view, their opinion.
It has been thoroughly checked out from all other kinds of intelligence information--

172 DR. BALDESCHWIELER: You mean a Scud
missile that was chemically armed?
MR. WALLNER: Yes, a chemically armed Scud
missile. I'm sorry.
I can assure you that the entire
intelligence community thoroughly checked all of
those out at the time that they occurred, and there is no confirmation that any of those had taken place.
But nevertheless that raw report is out there on the database.
And I will tell you furthermore that this came as a surprise, somewhat of a surprise, to Secretary White on a recent U.S. News & World Report article that mentioned that they had looked at GulfLink, and it, in their mind, can--you know, says that the Iraqis used chemical weapons.
And he called up young Mr. Wallner and said: What in the world are you people doing to me?
So I had to explain to him that the nature of this job was, we're releasing stuff even when it

173 tells something that we don't believe is true, even
when it's contrary to the position of the
And as Ed mentioned, we're not closing the
door on that position. There might conceivably be something that makes us change our mind on some use
or activity.
We're not trying to say we've got blinders on, and we're not going to listen to any of this stuff. We're trying to be an objective, integrated, multidisciplinary evaluation of all these reports, and that's the best way that we can do it.
Sorry for being so longwinded.
MR. RIOS: Let me ask you, Mr. Wallner, were there any reports of any Iraqi troops or civilians dying because of use of chemical weapons or because of exposure to chemical weapons? Were there any reports like that?
MR. WALLNER: I don't recall any of those, no.

174 DR. LANDRIGAN: Just a quick followup
question on this conversation that's going on.
Apart from deliberate use of these
weapons, do you have any confirmed reports of
exposure that resulted from some source other than deliberate use--for example, Allied destruction of an Iraqi arms depot or something of that sort?
MR. WALLNER: I'll defer to Colonel
My understanding is that we do not have, at this point, any confirmation of those kinds of exposures. But obviously it's another area that we're looking into. We haven't closed our minds on it. If we find something in the investigation that confirms that, we're going to go public. We're going to take it and say: Yeah, this is what we think caused your illness, Sergeant Jones, and let's get it fixed.
DR. CAPLAN: I had some questions for Colonel Koenigsberg.
I'm slightly confused from this meeting to our last meeting about the status of information,

175 about specific units and their deployment.
When we were here last time, there was a
great deal of complaint that it was going to be
tough to get this information, that it was hard to establish. And I'm heartened to see that we're going to go back and look at many causal factors that many folks have looked at before.
But I'd like your assessment about the other end of the correlation.
What sort--what kind of expectation can we have that we're really going to be able to get good correlations about who was where relative to these variables, and how fast?
COLONEL KOENIGSBERG: You're going to hear a briefing from the people from the Environmental Support Group who are putting this together, and I'll defer to them. They can tell you what they're doing, when they expect to finish it up, et cetera. There's some good work being done out there, and the expectation is that we will have a very good database to work with.
DR. CAPLAN: Let me ask you two other

176 things about that.
It seems to me you've got a massive
epidemiological challenge on your hands, and you
went through the resources available to you.
In your opinion now, are they adequate? COLONEL KOENIGSBERG: In addition to the
twelve people we have on our team, we have access and support from the whole community within the Department of Defense. There is no way that the twelve of us can do it. But I think the fact that we can go back to people like the U.S. Army's medical research on infectious diseases out at Fort Dietrich and the people up at Edgewood and Aberdeen that do all the chemical work and the people at other Government agencies that can do it, the people that are working the CCEP program, we go to them; we work with their epidemiologist and their preventive medicine officer. So we have access to a lot of other things.
Sure, it would be great to have a huge team, and we could all do it. But we're working with what we've got. But we've got a tremendous

177 support system.
DR. CAPLAN: Well, one final question:
When you're doing this kind of work, it's often
useful to have some input from the person who's going to try and do the causal analysis in terms of correlating with the search strategies.
What kind of input are you having into what the Army is beginning to do now in terms of its look-see?
We've talked some about the keywords and so forth. Are you satisfied that your--
COLONEL KOENIGSBERG: Well, that was the thing I was going to bring up before, and it's a good question.
And the point that they didn't bring out is that before they started doing all this, their list was run by us, and we, then, have added to the list and the list that's been given the Army.
We have also been at all their quarterly meetings to sit there and tell them what we need. And what we've worked out is that--well, I'm afraid when you hear some of this, you say: Okay, it's

178 just data related to medicine.
It's not. What we've identified is, it's
data related to doing an epidemiological survey.
And so we've asked for things like any toxic
material, any toxic product. How was it moved? That we need the data on. Where was it stored; how was it handled; what was the policy and procedure for doing this; what kind of training was given to people?
So any documents that would go along those lines we've asked for. And they've been very good.
The other thing that we've got going with
them right now in the interchange is that as we get into a study and if we're looking at a particular unit, then we can go back to them, and they will put it close up to the top of their list, and they'll bring it up, because it's going to take them all this time to do it.
So we go back and say: Look, an incident has occurred. We're interested in looking at this particular unit and what happened to it. We need all the logs from this date to this date on that

179 particular unit. And then they will go through
those logs and give them to us.
So it's not a static system; it's moving.
And we do have an input to it.
MS. NISHIMI: Actually since we're
discussing specific incidents again, I want to
return to your testimony.
You indicated that you were, quote,
"exploring" with the Nicholsons their hypothesis
that a genetically modified mycoplasma might have been used as a biological warfare agent.
Can you explain to me what you mean by the word "exploring"?
COLONEL KOENIGSBERG: What I said was that the researchers are exploring with them. We're looking at one particular inference that he has made or that they have made on this, and that is the fact that this could have been a manipulated organism and that it could have been spread that way by somebody. And we are looking at that aspect.

180 The research people will have to look at
whatever he's saying about mycoplasma. They're the experts on what mycoplasma can do or can't do.
They're the experts on what blood tests would be done, how do you use the PCR testing and whether it's adequate or not.
We really don't have the expertise, and we're not the researchers.
MS. NISHIMI: So you're doing your exploring--and it's still not entirely clear to me
what that means, but we can discuss it on a staff-to-staff level--but would it be your role, then,
based on what your explorations yield, to make a recommendation to the research team that they then perhaps fund research in this area? Would it be
PGIT's role to make that recommendation? COLONEL KOENIGSBERG: On this particular
issue, I don't know that that would be a fair thing. On some issues that we come up with, we may make a recommendation to go back and say: Yes, we think that there's something that needs to be explored further.

181 In this one, I see our role as more of a
supplement. We can come up and answer part of the question of what has been asked on this. We can
give that to the research people and then let them factor it into their decisions on what they're going to do.
MS. NISHIMI: So the role of the investigation team is never to make recommendations for what types of research?
COLONEL KOENIGSBERG: No, I didn't say that. No, ma'am, I didn't say that.
MS. NISHIMI: Then how do you distinguish between what kinds of incidents you may or may not make recommendations for?
COLONEL KOENIGSBERG: If it's something that we come up with in looking at all the data, that there's nothing--that if we don't see research going on in a particular area, we may recommend that research be done.
If people are already looking at this, we will try and supplement what they're doing, to give them the intel on the other data.

182 What we've found is that some of the
research that goes on, that people do not have
access; they don't have the classification clearances and such that they can get some of this data.
So what we do is, we round up the data and get everything that we can released, so we can give it to the research people and let them take it from there, if they're looking at this already.
Now if they're not looking at it, then if we come up with something as a suggestion, we can go back and suggest to the research people that they do look at it.
CHAIRPERSON LASHOF: Along that line, what is your relationship--I mean, you're related to all of those--but how much input do you have into, say, the epidemiologic studies?
Does your investigative team actually review the protocol and the issues and questions being looked at in the "epi" studies and then advise on those, or is that not your role at all?

183 referring to the epidemiologic study that's being
done with the CCEP, and that's one of the major ones that's going on--
CHAIRPERSON LASHOF: No. I don't consider the CCEP an epidemiologic study. That's a clinical study--
COLONEL KOENIGSBERG: Well, they do have people that are doing that.
CHAIRPERSON LASHOF: --but it's not an epidemiologic study. But we've taken that up with CCEP, and we will proceed on that.
I'm thinking more of the whole research plan that has a whole series of epidemiologic studies that are being done by different units throughout the country, which we'll be delving into later. And I don't expect nor want you to delve into those. We have a separate session just on that and some other special subcommittees on that.
But I'm just trying to understand what are
the things that you might turn up in your investigative team, whether those are fed back to cause a change in the protocol or the carrying out

184 of some of the epidemiologic studies.
part of our task, is to do that. And we do meet
with the VA/DoD research people, and we sit in on their sessions. We have been able to feed back information when we've had it available to the epidemiologic studies that are being done. We do this on a regular basis, and that's part of our role.
CHAIRPERSON LASHOF: Other questions? Phil?
DR. LANDRIGAN: Just a quick followup. Down to what size unit are you able to go in your follow-back in regard to specific incidents? Are you able to get down to company, platoon, or are you working in larger aggregations?
COLONEL KOENIGSBERG: In some areas you can get down a lot closer. It depends on the service and how well the records are kept on that.
Some of the problem that you have in
trying to locate where people are and that's been--I guess the ESG people can tell you more about

185 that--has been that a lot of people were detailed
over to other places for a while, came back in. And so even when you get down to the platoon level, you've got a problem, because the individuals were not always with that platoon.
So it does give us a little bit of a problem in trying to find who was there and who was not.
DR. LANDRIGAN: I remember in some of the reviews of the Agent Orange experience, that question came up, because when you looked at large groupings, they were too large to permit precise identification of who had been where when, at least in some instances.
COLONEL KOENIGSBERG: And I think, you know, when we get finished, in terms of an epidemiologic study, there will probably be holes in it, but it may be the best that we can do.
And, you know, what it will do, I hope,
is, if we find something that begins to cluster, it just opens the door to go further.
I don't see what we're doing as the final

186 answer. It's just finding the little opening
somewhere that somebody can then take and run with a little bit further. And then it may be a matter of going back and actually contacting everybody who was in a unit, find out if on that day they were in that particular thing, which here again has holes in it, because the memory of most of us, unless you're keeping a log, I don't know where I was, you know, January 19, 1991; I have no idea. But, you know....
MR. WALLNER: Madam Chairman, I'd like to take a moment and introduce Under Secretary of the Army, Joe Reeder, who is still here, and if you have just a moment, he'd like to say a few words.
Reeder, would you come forward? We are happy to have you join us.
UNDER SECRETARY REEDER: Thank you, Madam Chairman and distinguished members of the Presidential Advisory Committee.
I don't have anything in the way of the

187 specific detail that you've been covering this
morning to add.
I did want to say to you that this
undertaking, our declassification and release of information from the standpoint of the operational documents, is a top priority.
I met several times with Dr. Deutsch when
he was Deputy Secretary of Defense and did not know
when he left whether or not the same priority would be there until about three days after Dr. White took his position. And I have met a number of times with Dr. White.
My responsibility as Under Secretary of
the Army--I'm the Number Two Civilian in the Army--is to oversee this process as it relates to the
operational documents.
As you've been told, that is one of three pieces. It is the largest piece from the
standpoint of mass of paper.
And the reason it fell logically on the Army--and I have the oversight responsibility for
all of the services, in addition to Joint and

188 SYNCOM documents--is because 11, approximately 11
million of the 16 million approximate operational documents are Army.
But we see as a timeline, in response to Dr. Larson's comments, our timeline and our directive from Dr. White has been no later than December 1996.
That's frustrating to all of us from a standpoint of how long it takes. I can simply tell you that I have had experience in these kinds of undertakings before, never of this magnitude. We're talking about documents that normally take
decades upon decades to normally become part of the public domain.
And it has lots of pieces. We will be fully operational in the sense of full speed declassification within the next 30 to 45 days; I believe that's correct. And we have given it a lot of priority by assigning General Mountcastle to oversee the effort.
But the effort has lots of little pieces, and there are parts of it that are frustrating to

189 us because there are bottlenecks in the release.
But the general guidance that we've
received is: If in doubt, declassify. And you
just heard reiterated just a few minutes before: If in doubt on the issue of relevance, it's releasable; it's a document that would be included in the health-related documents.
But we see as our timeline December 1996 for all health-related documents.
I think to review this again after 30 to 45 days when we are at full speed in the process with regard to what our timelines are, how fast the documents are going, will be extremely useful for us and perhaps for the committee.
But if there are concerns, I simply want you to know that it is not for lack of good faith and priority, and it comes all the way from the White House.
Thank you very much for letting me come over and just share a couple minutes with you, Madam Chairman.
CHAIRPERSON LASHOF: Thank you very much

190 for joining us.
Are there further questions the committee
has now? Elaine?
DR. LARSON: I just didn't want us to
leave without sort of looking toward the future,
because I appreciate the massive effort that this is taking; I think we all do. And it seems to be sort of an unprecedented effort toward openness.
The frustration is enhanced by the fact
that it's four years or five years after the war, and it's very hard to, you know, find all these documents, et cetera.
What, for the future, would you--if this effort at openness, if you will, or at making the data that's necessary for the appropriate epidemiologic studies available continues, when we have another war, if we have another war, or if we have other times when the troops are exposed to potential environmental hazards, what have you, what implications does this have for future data
collection, so that we don't have this again, where you're trying to go back and look through 15.9

191 million pages of records four years after an event?
And what can we do as a committee to help
in terms of recommendations?
MR. WALLNER: Let me just say a couple of
things quickly to start off with.
This is the first time that I have been
involved in this sort of effort in my 30-odd years
in intelligence, and I must say it isn't much fun [laughing].
But it seems to me that we need to establish an attitude towards ultimately releasing more and more information from intelligence and operational circles as our future wars are ended.
And with that, I can't tell you any more,
because I simply don't know specific recommendations. Perhaps Mr. Wells and Colonel Dietrich have some comments to add.
LT. COLONEL DIETRICH: Yes, ma'am. Part of the challenge we face is the records management system, the centralized collection of records into a repository. The services could improve their capabilities to do that.

192 The Army's records management system and
its status has been written about and in a preface
to one of the Army's books on the Gulf War, called Lucky War, written by Colonel Swayne, who was the 3rd Army, Army Central Command Historian.
I have an article coming out in Military Review this fall, which discusses the Army's records management system and makes some recommendations for future history, as I call it.
We need to improve our capability to
centrally collect and manage our records.
The Army Historical Program under General Mountcastle is working very hard in this arena. That is the reason that I was deployed as the Senior Army Historian to the operation in Haiti last fall.
We initiated a pioneering collection effort there to help ensure that we collected the important parts of the record, and that was, we initiated a digitized records collections process where we collected all the message traffic, all the situation reports, all of the logs.

193 Everything we could that was being
digitized, we got on diskette; 83.4 megabytes of information, enough to fill about five filing cabinets of paper we brought back on diskette. It has now been downloaded into the Army's digitized archives at Fort Leavenworth, Kansas.
The other thing that we could do to help with the release of the information or making it available to the public would be to have the original classification authorities, immediately after operations, make immediate determinations on what can and cannot be released from their information.
And the reason that we should do this is because some of those original classification authorities and some of their commands vanish after the operation. Some of those commands are created specifically for the operations.
DR. LARSON: Could we get a copy of your manuscript with your recommendations?
DR. LARSON: Thank you.

194 CHAIRPERSON LASHOF: Jonathan? I think
Jonathan had one more question.
DR. TUCKER: I had a quick followup for
Mr. Wallner.
As I understand it, the Deutsch memo--it
was, I believe, June 1994--initiated the
declassification process and used the term "zero-based review", and I wondered if you could explain
the meaning of that term and also whether the current policy is the same as that enunciated in the memo, which was that topics can only remain classified by an explicit decision by the Deputy Secretary of Defense?
Thank you.
MR. WALLNER: That's a good question. My impression, my understanding, to take the last question first, is that that is not the current policy, to wit: Things can only remain classified upon the expressed authority of the Deputy Secretary, in this case John White.
Nevertheless, the guidance from Dr. White and which continues to be the same guidance from

195 Secretary Perry and General Shalikashvili, as we
have reiterated several times this morning: Be inclusive; get as much out as is possible.
And that's what the operators are working
under, as Secretary Reeder mentioned, and that's what the intelligence people continue to work under.
But specifically, I do not believe that that is still extant.
Now the other question was implementation of the June '94 memo, basically.
I don't recall the specifics of that particular memo. But my impression is that it is, indeed, being implemented, and more explicitly with respect to operational information.
We do have, as recently as last August, an exemption from the May 1992 classification requirements as signed by Dwayne Andrews at that point in time. We do have an exemption from those fairly restrictive criteria for declassification for the purposes of Persian Gulf War veterans' illnesses.

196 The release from that authority came to us
from the Assistant Secretary of Defense for
Command, Control, and Communications and Intelligence, the Honorable Emmit Page, and that came in September.
That will enable people like Jack
Mountcastle and others to do some bulk declassification of material as it is deemed appropriate in this process.
DR. TUCKER: Just quickly, the definition of the term "zero-based review", do you have a clear definition of that as it was used in the Deutsch memo?
MR. WALLNER: No, I do not. I think he meant it from a programmatic standpoint; that is, in terms of the dollars and resources, the dollars and people, that are dedicated to these kinds of activities and to declassification and information management generally. That's my impression.
I'm sorry I can't be more definitive on that. You know, I'm sure John Deutsch would be happy to talk to you, if you pick up the phone and

197 call him, and he'll tell you exactly what he had in
CHAIRPERSON LASHOF: Well, thank you very
Let me ask one more question for you not
to answer at this point, but to think about.
And it strikes me that all this effort for
declassification exists because we classify
material; we classify an awful lot.
And maybe we don't need to classify, and maybe you ought to think about--and come back to us at some point, when we're trying to get together our recommendations--your thoughts about what the guidance ought to be on what ought to be classified to begin with and what ought not to be classified to begin with.
I have heard from someone that the
Nuremberg Code was considered Top Secret in some classification file. You know, you certainly will have to declassify less if you classify less.
But with that [laughing]--if you want to comment, go ahead.

198 MR. WALLNER: Let me just say that there
is a new Executive Order on classification and declassification for the intelligence community
that is out, and it is relaxing the rules on classification and on declassification rather significantly. That's a positive step in the right direction.
But we will be happy to come back and give you recommendations on that.
CHAIRPERSON LASHOF: Thank you very much. You can expect further questions from staff as our process continues.
And with that, we will adjourn this session. We will reconvene at 1:30.
Thank you very much, Mr. Wallner. [Whereupon, at 12:38 p.m., the advisory
committee meeting was recessed, to reconvene at 1:30 p.m. this same day.]

[1:39 p.m.] CHAIRPERSON LASHOF: I believe we're ready
to start our afternoon session.
The first part of the afternoon--really
all of the afternoon--is devoted to--all of the
afternoon is devoted to the outreach issues and how well we're communicating with the veterans about the whole situation and their entitlements, et cetera.
And to do that, we have asked Mr. Gary Christopherson from DoD and Mr. Newell Clinton from VA, and they will each address us in turn, and then we will turn to the committee requesting of them, and then we will ask staff who have been doing work on the outreach issue to also comment and ask questions.
So we will start with Mr. Gary
Christopherson from DoD.
MR. CHRISTOPHERSON: Dr. Lashof, distinguished members of the committee, I want to thank you for the opportunity to come and appear

200 before you today and speak to the committee.
I think we are actually the first act in
the three-part play that is going to occur this
afternoon, if I'm not mistaken. So we are going to try and give you a little bit of insight into where, in my case, the Department of Defense is in terms of the issue of outreach and try and answer as many questions as we can.
What I want to do at first is just to indicate a little bit, in outreach here--and I'm going to sort of use a more broader term here--I think we look at Persian Gulf illness.
Again we all understand it's a very tough issue; t's a very difficult issue; it's a difficult issue in terms of trying to make sure we are taking care of both our active duty troops, their families, and obviously our veterans as well. We have an obligation to the American people as well, who are looking at us now in terms of how we handle Persian Gulf illness and hold us to: Do we do it right?
I think we have obviously the commitment

201 in the statement of the President in terms of being
sure we leave no stone unturned. And we in the
Department of Defense take this very seriously, and I will touch a little bit on some of the stuff you've kind of talked about today already, but in a little bit different light.
You asked me to talk about what outreach
is about. And what I've done here is I've taken--probably because of my old training, which is
public health kind of experience, and done it in
that sense of what public health is, if you're trying to do this and approach it as that kind of an issue. And I know a number of you come from that venue as well.
So what we look at, when we look at outreach, we take the broadest sense of the term, which says: If you really want to go out and try and take care of a problem, you go at it from a lot of very different perspectives.
You look at it essentially from the point of view of obviously the tradition of public education; you look at it from the point of view of

202 not just dissemination of information out to
people; you're doing it everywhere from toll-free hotlines; you're talking about how you move your people out; you're talking about how you try to increase access to the system to make it more able to use.
We're talking about research, going beyond the traditional kinds of research that we may be doing in those kinds of areas to find things and deal with issues that may be going beyond.
Those are all part of what we essentially see as, in quotes, the outreach of this kind of effort.
I think what's important to understand--and it will come out, I think, obviously in some of
the questions you'll be asking--is what it is not.
We made a very clear decision early on
that this was not designed to be a sort of a mass education to convince somebody one way or the other
of what was the right answer. What we look at very differently is to try and find a better way to deal with a very difficult issue, which this will not

203 be--it's neither the first nor will it be the last
that we will run into.
So again, our real issue here is how we
best take care of our people, Mission No. 1 from
the point of view of the Department of Defense. And the second thing is, to the extent
that we can sort of unearth what the facts really are around Persian Gulf illness and its potential causes and its potential existence, that is really our role here.
If we do a good job, if we take care of our people, if we unearth whatever facts there are to find in that regard, we believe we will have served our mission well. We will have served our troops, our vets, and the American public.
What you have to look at and what you've started to see some of the pieces of over the last several days, and part of you saw as well in the first meeting that we had with you all, is a sense of what this sort of total outreach effort is like.
It really comes down essentially to about
seven components that we see as, in quotes, what

204 this initiative is for Persian Gulf illness. And
I'm going to cast them in those lights.
The Comprehensive Clinical Evaluation
Program. You've heard it from the clinical
perspective, but let me give you what the outreach perspective, I think, on that is.
Historically when you've looked at things like we've done in the past--and you can look at Agent Orange as an issue; you can look at a lot of other kinds of things--one is a much greater time delay between the actual occurrence, a war or whatever it might be, and the action. Four years seems like a long time, but from a historical perspective, that's very fast. I think we have to look at whether we should do it faster in the future than we are doing it today.
I think you look at the Comprehensive Clinical Evaluation Program, we made a very conscious decision that we were going to reach out and take care of everybody, regardless of whether or not they, in quotes, had Persian Gulf illness. If there was something that had the potential, if

205 it was somebody who served in the Gulf War, we were
going to reach out, find them, treat them, try and figure out what was going on, and go from there. But taking care of our people was the key thing; we would do that.
And that's why we did the toll-free hotlines. That's why we put out letters from the Secretary and a lot of other people and General Shalikashvili. That's why we continue to put the word out that this is the thing we're doing and inviting people in.
So again, the point of view is again of a clinical program that doesn't just sit inside the building, but actually tries to go out and find people and get people in the system and encourage people to come in, rather than just sort of waiting to see whether or not they show up or not.
The second thing--and again, I think part of that thing goes to the question of--the other part of outreach reach is, we learn things.
In the Comprehensive Clinical Evaluation Program, again to emphasize the point raised, Madam

206 Chairman, this morning, it's not a research program
in the traditional sense.
But it is important in the sense that
there's a lot of things that will come out of it,
and there will be useful information to build into a larger body of research and other kinds of things that we're doing that will help inform people about what we've got.
And part of what we're doing in that process is to make sure--letting people know what we find--to the extent that that is useful, with all the caveats, with the external reviews--those kinds of things, to try and get a better and a clearer answer as to what that is.
The second piece of the puzzle. They were talking about and you just had a session this morning on the Persian Gulf investigative team. Again, you have to understand the context of this.
The traditional sense, very honestly, for
us, like the Department of Defense, is to sit back and wait for things to occur and then sort of figure them out, you know, later or not address

207 them.
We took a different tack. When the
Persian Gulf investigative team was created--and
this was created essentially about seven or eight months ago, the idea to fruition--the idea was here--is that we would go out and look one more time at everything.
We would cast the broadest net possible. Everything was fair game. If we had looked at it before, fine, we'd take one last glance at it just to make sure. If we hadn't looked at it before, we now were going to look at it. If we found out new information, we would bind that in.
So again, an attempt to sort of go outside and aggressively try to figure out what's going on out there, to build the body of data that would, in quotes, say: What have we discovered in terms of the potential relationship between incidents in the Gulf War that may have some relationship to exposures, that may have some relationship to illness or not?
And that's clearly what we're trying to do

208 in that investigative team, again not willing to
sit back in what we are trying to do, put out again another toll-free hotline, say: People, if you know anything about that, if you have incidents to report, let us know; if you have theories which you think may have some validity, let us know, and we will do our best to try and chase down all those theories at least that have even a modicum of credibility there.
And that is the tack in that regard there. Again as I've mentioned in two different
places, a toll-free hotline. Again, another active outreach, VA has done something very similar.
And by the way, VA, in general, has also taken a similar approach to ours in the sense of not sitting back, but also trying to go out and find people and try to bring them in.
Again, what you have to recognize is that this is unprecedented in many, many ways; not to say it is perfect, but it is unprecedented, and therefore it's important to set the context for all these kinds of things.

209 So we're putting out toll-free hotlines in
Parade magazine and The Mercury, Army medical
documents, and anyplace else we can put the word out--leave and earnings statements--to all our soldiers. Again, we're looking for any kind of vehicle we can to get the word out, to say: Here's something that's going on that can help you and can benefit you in that regard there.
Press conferences by the Deputy Secretary, press conferences by the Assistant Secretary for Health Affairs, again more and more ways to try and reach out to try and do that.
Another part of the outreach is the declassification. And it is an outreach in the sense of trying to put out information.
Rather than waiting for someone to file an FOIA request, it saves time to get the information out, to be aggressive, out, and that was partly in the issue of declassification, to move and to move quickly, and we're still looking and trying to make that all work as perfectly as we can.
And the questions that you raised this

210 morning are good questions that we will be thinking through as we try to make this a better and better
kind of arrangement and watch that delicate balance in terms of what we release and how we release it.
But the other part is to say, is how
should we make it available?
And we made a decision very honestly that we would not just, in quotes, stick it in bunches of boxes over in a corner and say: If you want to dig them out of the boxes, feel free to do so; but decided to go out on the Internet.
And that's a rather major change for us to try and do, which would say: We're going to put it out there; with all the risks and benefits that you all went through in the previous panel about when you do that.
And the decision was to err on the side of putting more out rather than less out, again with all the risks and the benefits that go along with that as well, but again to understand that the clear decision made here was to try and get the information out, to err on the side of reaching out

211 further, putting more information out, and living
with that risk more than the other way around in that regard there.
Research as well, and research is another area we're trying to go out and trying to traditionally do in the sort of inside-the-building kind of research, to going out to external researchers, and we're doing more of that. VA is doing that as well, trying to find ways to get more researchers involved in Persian Gulf illness, again to try and figure out more what the real answers are in all that.
And again, we will keep doing that, and we will keep our commitment going forward in terms of funding that kind of research.
We've also tried to turn to outside buys, another example of trying to get out to people, again not to sort of live within our building, but to also get people outside like the Institute of Medicine and others, the National Institutes of Health and others, to look at--some distinguished scientists as well--to get their views to say:

212 What are we doing; what are we doing well; what do
we need to fix? Again to try and get the--a better job of trying to do what we're trying to do here in that regard there.
And finally, just trying to get
information out as much as we can. Again, the decision was made that we were going to not try to persuade people of what was the right or wrong; we were going to try to get people the information and help them make decisions that they needed to make in that regard there.
And as people know from various kinds of things, that can be tricky as well. This is a very emotionally charged issue. It is not unusual that it is. People read lots of different things into the data one way or the other, based upon what their basic beliefs are. We have to deal with that.
I think the decision we made, it was important to get as much information out, as far- reaching as we could, and that hopefully over time the research, the data, the declassified documents,

213 the investigation team reports will stand as a body
of information upon which people can make good,
hopefully, decisions--better than, hopefully, they've been able to do in the past.
So again, we have tried to do that. So I think, again, once you've looked at it, we've tried to use a variety of mechanisms to reach out, to try and do things that are outside the building, to do things that really the Department has not traditionally done or as timely done as we have done in this case here.
We are going to obviously be looking for more opportunities as well as time goes on to see that maybe, if we can do it again, to try and keep our people, the troops that are still active duty as well as the American public and vets who are no longer with us but still have a very strong list in there and try to do that.
I think in the end we've made a decision that we want people to judge us for what we do, and we'll let the chips fall where they may in that regard there.

214 That's why we're doing that side there.
That's why we're trying to be very honest about it.
It is not always one of the easiest things to do to try and get all the information out into people's hands. We want to try and get to the point hopefully where we have--and people believe we have--taken good care of our troops, that we really have tried to go out and find what the facts are and report them for people to interpret and give people a chance to look behind and say whether they agree or not, so not just to give them, of course, our interpretation, but to give them raw data in a lot of cases as well to try and do that in that regard there.
And I think it's clear--it's a part of the Department and a part of the President that clearly we will leave no stone unturned in search for answers, and we will leave no soldier, airman,
Marine, or sailor with their care unheeded, un-taken-care-of in that regard.
With that I'll end. I thank you again for
the opportunity to appear before the committee. If

215 we can answer questions when the time comes, we'll
try to do so.
Thank you.
CHAIRPERSON LASHOF: Thank you very much.
Mr. Quinton?
MR. QUINTON: Madam Chairman, the
Department of Veterans Affairs followed very
similar approaches.
In essence, our focus was two things, one
to be very timely in the dissemination of
information and to provide assistance to Persian Gulf veterans and enable them to, one, find where to get assistance, particularly in directing them, those veterans, to the appropriate medical facility; the other, of course, to address questions, whether they be from the benefits arena and aiding them to process claims or submit a claim, as well as provide information regarding medical care.
The law required the VA to establish a toll-free system, which we did effective February 2nd. That system was designed to aggressively

216 enable Persian Gulf veterans to not encounter
typical busy traffic that we experience many times through our regular information dissemination process, so it was really designed very carefully to provide a very high grade of service.
We established that in St. Louis with a message tree in four areas: one particularly in the benefits arena, one in general compensation, how to submit a compensation claim, and the other area was in medical care.
Typically the response to that has been very favorable since we started in February. There has been more than 100,000 calls into the center.
It was interesting from our standpoint
that our attempt was to address the needs of veterans and to service them in a different manner.
In essence, the center was established on
a 24-hour-a-day basis, seven days a week, to recognize that the Persian Gulf veteran complement was really of three components-- those from the
Reserve and National Guard as well as active duty--and we wanted to make sure that the information was

217 available not only during work hours, but after
hours, and also to them during their home or leisure hours. So they could call the St. Louis Information Center and avail themselves of the information. We believe that has been very positive.
The other aspect that we did for the first time in response to the Persian Gulf veterans, in looking at the complement of people that made up that group of veterans, we recognized that they were certainly a younger group of veterans than what we're accustomed to servicing throughout our facilities in the VA.
Because of that, we offered access to information through a computer network. Really the VA online system came on line at the same time as did the telephone information center. Our response to that was also--their response to that was also
very favorable, and we believe that it offers our--enables us to provide service to veterans that we
never did before.
We have--our report shows a significant

218 number of people access information through the use
of computers during late hours, weekend hours. We show nearly 112,000 access-to-information and exchange-of-information, basically downloads of different types of material through the computer network.
And I will restate again, that was the first time within the VA dissemination process that we really introduced the use of computers as an access-to-information/exchange device to veterans.
On the telephone toll-free system, our
experience as of October 12th shows a total of 102,000 calls that went into the information center.
And interesting at the center, our concern was that we provide a high grade of service, so it was designed that people were able to get the information and then move to where they could get assistance, whether they moved to a regional office or a medical center, was really our intent.
So the message tree is intended to direct them to where they can get assistance, in addition

219 to providing general benefit information.
It is interesting to note that that
system--of the 102,000 calls that we had received
as of October the 12th, 18,000 of them were intercepted by an operator; that is, the veteran wished to speak to a person. The other 80,000 calls, we believe that the information tree that we established provided the type of information where the person then could go to a regional office for claims information or to an appropriate medical center for medical care.
And that's really the way that we intended to provide the service. We want it to be very responsive and make it available 24 hours a day.
It is also interesting to note our concern to make sure that access was always available. Of the total attempts made to reach the VA, there were only 300 times since we opened the information center that we believe or we have records to show that a veteran accessed the center and either hung up or decided not to go through the information tree or to move on throughout the message system.

220 We believe that's very significant.
In other outreach areas, we are continuing
through the Veterans Health Administration to
disseminate the semi-annual newsletter that has very similar information to that that's available on the toll-free system.
Through our transition assistance program, the same information is available through counseling in group sessions with members of the
armed forces. Before separation, either in pre-separation or pre-retirement briefings, they are
reminded of services and means by which they can
acquire these services through the VA system, which is provided at most military facilities.
So in essence, a service member can receive the information through many, many sources: the toll-free service, the computer bulletin board, the VA newsletter, or through face-to-face briefings at the military facilities.
Since February, the volume of the calls, the level of activity has decreased. The indications are--from our tracking of that--would

221 suggest that the veterans since February have been
able to submit claims to the Veterans Benefits Administration, or they have been able to pursue health care through one of the VA medical facilities.
We are showing the average number of calls per month in the neighborhood of 9000 calls, which is a significant decrease when we started being 22,000 calls. The trend has continued to go down over the last five months.
Again, this further suggests that we believe the veterans that were a part of the Persian Gulf population are pursuing claims or they are receiving health care through one of the facilities.
Because of that, the number of attendance at the information center in St. Louis has been reduced. It is attended eight hours per day; however, the toll-free and the automatic means is still available 24 hours a day, so that people can still avail themselves of the same information through recorded messages or through the personal

222 computer bulletin board.
Since the activation of the toll-free
information center, as well as the enactment of the
law, we record 51,174 people on the Persian Gulf registry.
The other note is in terms of disability compensation claims since March of '95. We show granting 20,000 disability claims of which 51,000 that were submitted were denied.
In the environmental hazards disabilities, 859 were granted; 5961 were denied.
Those are claims from a total population of Persian Gulf War veterans of 832,000 service members, and that number represents 112,00 from Reserve and National Guard, as well as 447 service members who have since separated since the ending of the Persian Gulf War.
We will continue the outreach effort in all phases to include the transition systems program that we believe to be very effective. It provides a one-on-one consultation and counseling with service members before separation. That is

223 normally done 180 days prior to separation from
active duty.
The toll-free information center will
continue to be available, as well as the personal
computer bulletin board. The personal computer bulletin board is updated whatever we have a change of information or additional information that is available. People are notified of the change upon alert when they log onto the system to direct them to the particular issue that has been changed.
We believe that represents a very
effective approach, our forward approach, to providing information to our nation's veterans and provides the very best grade of service in terms of access to the VA and directing them to where they can receive care, whether it be in benefits or in health care.
Thank you, ma'am.
CHAIRPERSON LASHOF: Thank you very much. Questions?
MR. JOHNSON: Mr. Quinton, could you just run through those numbers for me again: total

224 number of veterans, disability claims, claims
approved, environmental claims, claims approved? MR. QUINTON: Yes, sir. We show the total
number of disability compensation claims, grants were 20,604. Additional claims that were filed that were not granted were 51,711. So the total number of compensation claims would be approximately 72,000 claims.
MR. JOHNSON: And the total number of veterans?
MR. QUINTON: Well, the total number of veterans, active duty and theater, was 832,750. Of that total, 112,000 were National Guardsmen and Reservists. We show, since the end of the Persian Gulf War, 447,000 have since separated from active duty. So those numbers are important to us from the standpoint of our transition assistance outreach program, which tries to provide information to service members while they're on active duty.
The interesting thing here, we were very concerned about Reservists and National Guardsmen

225 and the impact on family and felt that they would
need to access the VA from their home, and thereby the need to have the personal computer access as well as the toll-free number and to keep it 24 hours a day.
Information was provided through certainly DoD to avail the same types of information, but the focus here and why we tried by these categories was particularly from the Reservists/National Guard, which would be separated from the military and would come to us through different means. And we wanted to also see the number of people--we're always concerned about the number of separations to make sure that we track those people during our transition assistance programs.
MR. JOHNSON: What were the numbers again on the environmental?
MR. QUINTON: The environmental hazard disabilities, we show 859 claims have been granted, and 5961 have been denied.
MR. JOHNSON: And what's the criteria for environmental hazard claim acceptance?

226 MR. QUINTON: I don't have it right now,
but certainly Dr. Murphy is here from the VHA, and
she may be able to answer that. I don't know
myself. But I can get that answer for you.
MR. JOHNSON: Or if the Chair--is it okay to pursue it?
CHAIRPERSON LASHOF: You may pursue it. DR. MURPHY: The environmental hazards
claims are claims whereby a Persian Gulf veteran has identified that he or she feels that their illness or disability is related to an exposure
that occurred in the Gulf. So it's a self-identification. Because of the, you know, some of the
unique characteristics of those claims, they've been centralized at five different--excuse me--four different regional offices, so that they get special attention.
MR. JOHNSON: What can you tell us about the 5961 that were denied? Any patterns to the denials?
DR. MURPHY: The Veterans Benefits

227 Administration is really the organization within
the VA that handles that, not either Veterans Assistance Service or VHA, which is where Mr. Quinton and I are from respectively.
But my understanding is that in looking at those claims, there are a variety of reasons why they have been denied. Either they did not have an illness or a disability that occurred during military service or was documented in military service, that they did not have a disability
documented, or that the claims were not well-grounded. But for more information, you might want
to hear directly from the Veterans Benefits Administration, the Compensation and Pension
MR. JOHNSON: I would think that for our purposes it might be interesting to ask our staff, in cooperation with the Veterans Benefits people, to do some review of--these are all asserted to be Persian Gulf-related, right?
MR. QUINTON: Yes. The claims are--as Dr.

228 Murphy said, we track the claims, and we keep them separated by category. In this case, all claims
from the Persian Gulf were--are tracked. I'm sure the information is available, and I would be glad to pursue it and get back to the committee. I simply am not versed to discuss it, but I can get it and get it to the committee.
CHAIRPERSON LASHOF: Yes. Thank you. I mean, our focus today was on outreach, so it's not surprising they wouldn't have that kind of information.
MR. JOHNSON: No, not at all. CHAIRPERSON LASHOF: And compensation is
somewhat beyond the scope of this committee. But
it clearly is within the scope of this committee as to how one determines that environmental hazards did lead to disability and the basis of that and what are the veterans claiming they were exposed to and what disability they are claiming.
So I think we will have staff do a
thorough followup on that.
MR. QUINTON: Thank you.

229 CHAIRPERSON LASHOF: Other questions?
DR. CAPLAN: Yes, for Mr. Christopherson.
I was looking at--listening to your
statement, and I noticed that education really is
the first thing that you talk about in the outreach area. And then I'm a little startled to see that you disavow a mass education campaign.
You know, I spend a lot of my time
thinking about informed consent issues. And sometimes when information is presented in the informed consent context for therapy or research, it looks like someone is driving up a big dumptruck and unloading information. It's sometimes called the "truth dump", in fact.
It seems to me in this setting with people deployed all over the place, not having access to the usual means of communication, plus fears about what does it mean to come forward, what does it mean to identify, a mass education campaign is precisely what might be expected.
MR. CHRISTOPHERSON: Yes. Let me--what I

230 was trying to clarify is, there would be people
that who would suspect that we might do nothing but a mass education campaign. I was trying to sort of--
DR. CAPLAN: I may be one of those.
MR. CHRISTOPHERSON: Right, right. I was sort of bringing it back the other way around, which is to say--is that recognize that that is not what the intent was.
Now but let me go back to the issue of the education.
It is our clear intention--we have been, and we've used all the sort of vehicles--the Department of Defense is different than a lot of other organizations because we're sort of like a big corporation, to some extent, with even a few more things going on.
So the way that we go about educating people is a bit different. We use--for example, we've got things like newspapers that go out through a lot of different vehicles, and we are making sure we get articles out and placed in those

231 to try and again get people up to date with what
the latest--whether it's research findings or
clinical studies or just other kinds of information out there to again educate people what it's about.
The other part was, when it comes time to
try and inform our people at the command level as well as at the troop level that this is the thing we want to see happen--we want people to come in for clinical kinds of things--that we have things like, for example, letters from Secretary Perry and the Joint Chiefs, Shalikashvili; we did that as well.
So we have done those, and we are
continuing to do those things as more and more information comes out. So we are using all the vehicles there.
I tended to sort of downplay that, only because I wanted to make sure that we understood that this was much more than that effort there.
There will be more. As more information
comes out, as we become--have more facts to give people in that regard, again we'll be using more of

232 those vehicles to get things out.
DR. CAPLAN: Let me just followup with one
DR. CAPLAN: --comment on this, because I
want to make sure that I understand the activities
that have been done here.
It's one thing to put out a letter or put
up a toll-free number and say: Call us if you
think you've got a problem. It's another thing to really make a serious effort to educate people about what it is that they might have in the way of symptoms or problems or questions.
DR. CAPLAN: What sorts of things have happened of that nature?
MR. CHRISTOPHERSON: Well, I think a couple things.
In the first place, it's part of the Comprehensive Clinical Evaluation Program, is there's an extensive amount of education and counseling for anybody who comes up with a

233 potential.
Whether or not we find something or
whatever we find, whatever it ends up being,
potentially related to the Persian Gulf or it doesn't become potentially related to the Persian Gulf, there's an education process that goes there with the people who are feeling most immediately affected in that regard there. And we will continue to do those kinds of things.
Beyond that, again part of what we're going to now is, we're really beginning for the first time to have information out there, and that's why we're using--and the way we can do it, as Dr. Joseph has decided, we'll do the release of a study saying: Here's what we've learned. That
thing goes out over The Service Times, The Army-Navy Service Times, to try and get that information
out to again give people a sense of what that is in
that regard there.
The issue of trying to reach people who--
DR. CAPLAN: I can't help it; I have to interrupt there.

DR. CAPLAN: The last time I heard from
Dr. Joseph was a study--I think that was in front
of this group--that said there isn't much in the way of Gulf War syndrome; at least some of the headlines read that way.
MR. CHRISTOPHERSON: That's what the headlines said, but that's not--
DR. CAPLAN: So if I was trying to educate people about what they might want to come forward with, I might find that slightly offputting to say: I have a toll-free number for what the headline tells me doesn't exist.
MR. CHRISTOPHERSON: Right. In the first place, it was a headline, not what the story was that Dr. Joseph put out on the table or what--if you read the press release or the report or whatever in there, that's--I mean, that includes, just to clarify--
DR. CAPLAN: That's more in the spirit of saying--putting the spin there, putting the tools there, so that people know what it is--

235 MR. CHRISTOPHERSON: And it's a fine line
we walk here. We have a need and obligation to put
out information as best we know it, at the point we know it, with all the limitations to make sure that we're not leading people incorrectly down one path or another in that regard there.
And it's a difficult line to walk, and because again different people have different views about where this is. There are people who believe there definitely is a Persian Gulf illness, who are going to go down one path. There are people who doubt that there really is, and there are a lot of people in the middle who are still trying to figure it out. And, by the way, we put ourselves in that middle category; we're still trying to figure it out
So when you put out something that says--a study that says that essentially we have not found evidence today yet of a Persian Gulf illness, the spins go off in a lot of different directions there, and that's partly the read there, and that's partly where you get different kinds of headlines.

236 Clearly the message we're trying to get
out and that we wouldn't do toll-free hotlines, we wouldn't do the stories that we are doing, if we
didn't want people still to come in. We're trying to figure out what it is if they have theories. We wouldn't have gone through the whole investigation team operation.
An again, remember that this was launched relatively recently. If we'd already made up our minds, we wouldn't be going out saying: If you've got an idea, all you have to do is pick up this 800 line, call in, tell us what it is, we'll try and chase it down as best we can figure how to chase that down and to get that door open very much.
It's the same thing when I go out and do
tours of military bases. Part of my routine to go out there is to sit down with troops and talk through what their thoughts are, and you get very interesting stories when you go out there on the front lines and start to talk to people about what to do or when you're sitting around waiting for a plane to take off, and you have a couple of Marine

237 Reserve pilots who have very different views about
what it is, both of which are very important to us trying to sort of work through the picture.
We still have more to do. I mean, we're not--we would never say and clearly do not want to say that we are at the end of the education; it really is very honestly at the beginning, because before if we would have gone out, we very honestly would have been telling a story we didn't have the facts on. We now begin to get more and more the facts. We still have to proceed with great caution.
DR. MURPHY: If I could add, one of the approaches that VA has used in educating veterans about what we know so far about the illnesses of Persian Gulf veterans and also what programs are available to them is what we've called a Persian Gulf Health Day, which is essentially a townhall meeting that we hold at a local medical center.
We send out letters and flyers to
everybody who's on the registry and ask them to tell their friends to come on in, bring their

238 family members, and we send out a representative
from our headquarters and have some local health care providers available to give presentations on what we know, on what we have to offer them, and encourage them to access the VA programs.
We've done three of those so far. And they've had, you know, reasonable success.
You know, we've also used some other mechanisms to educate veterans and including The Persian Gulf Review, the newsletter that we send out to every registry participant. We also send those to the veterans service organizations, the regional offices. They're put out on tables in the medical centers.
We also encourage every Persian Gulf veteran, not just those who are symptomatic, to access the registry health examination program. And that is for the express purpose of allowing that individual to have one-on-one contact, to talk with a physician about their concerns and to get the answers that they deserve about their health and how it relates to their service in the Persian

239 Gulf.
So that's been, you know, one of the ways
the VA has approached that problem.
DR. LANDRIGAN: Yes. I'd like to ask a couple of followup questions about the matter of the claims that have been filed.
It strikes me first of all that those claims, if they're examined in some detail, constitute an extraordinarily valuable resource to our committee.
One of the things that we're always taught in occupational and environmental medicine is to focus on what are termed sentinel health events, occurrences that may signal the occurrence of more cases not yet reported in a population at risk.
And one of the beauties of starting with--of using
these claims, the medical claims or
exposure claims, as points of departure is that
examination of patterns among those claims might enable us to focus on certain disease entities or certain symptom complexes as opposed to trying to

240 sort through 16 million pages of intelligence data
that weren't collected with health outcomes in mind.
So I wonder if maybe we could somehow direct the staff to work with your staff to get some information on what's in there?
I don't know enough myself to say
specifically what it is that we would want, but we can talk with staff about that.
That is the first point, and I'll come back to that.
The second thing is, I know that
compensation is not really within the purview of our committee. But I must say that this situation where only about 15 or 20 percent of claims are accepted sounds a lot like the workers compensation arena where I and my colleagues do some work.
The classic story in workers comp is that if you have a traumatic injury like lose a finger, compensation is pretty automatic. The system works mostly well. And for diseases, it works poorly, because the burden of proof that must be sustained

241 by the claimant is really very high indeed.
And it would be interesting to learn now
or in the future what are your judgment criteria
and how high are the hurdles that the claimant has to leap?
MR. QUINTON: Okay. We would be glad to provide that response back to the committee. Mr. Gary Hickman, Director of the Compensation and Pension Service, certainly has that information. We are very carefully trying with each and every one of the Persian Gulf claims. So I will certainly make a point of getting that information and asking Gary to provide it to the committee.
MS. NISHIMI: I think the issue of looking
at individual claims, as with the medical records, is something that we could definitely evaluate.
MR. RIOS: It seems that the denial rate for the environmental claims is pretty high. I'd like for you to respond as to whether or not this is unusually high, or is this in line with other similar situations?

242 And the other thing is--and maybe you can
answer that, or maybe you can't, Dr. Murphy--is,
you've got 859 that were granted claims. What is the most common diagnosis that was reached on those 859?
DR. MURPHY: I honestly don't know what the most common diagnosis was in the environmental claims. I think the most common diagnosis overall is musculoskeletal conditions, and we can go back and get the information specific to the environmental claims.
The claims have been looked at very carefully and actually have undergone a re-review process. And I would suggest rather than us speaking from memory about, you know, some of these very specific pieces of information, that we do go back and ask the Compensation and Pension Service to provide that information for you.
CHAIRPERSON LASHOF: I think, you know, this is an important issue. It is an important issue, and staff will follow through. But it was not on the agenda for today and for the people who

243 are here to present. And I think it would be a
little unfair for us to pursue it much further. Elaine?
DR. LARSON: Yes. Back to the issue of access, two questions, the first one to Mr. Christopherson.
After our first meeting, I called the 800 numbers, the hotlines, and I got through after a couple of rings, a very nice response.
But I spoke with some individuals who were in the Gulf and who are still on active duty, who reported that early in the hotline times, they tried numerous times; they said five, ten times to ge through and weren't able to do so.
Mr. Quinton provided us with some specific data; 300 times veterans called and couldn't get through, for example; the numbers of calls that you're getting; the fact that 80 percent, 82 percent, talked to the voice mail message service, and the other 17 or 18 percent talked to a live person.
For DoD, what are the number of calls?

244 What's the percent of time that they get a recorded message versus a live person? What are the percent
that hang up, give up, you know, that kind of information? And I'm trying to get at how accessible it is.
MR. CHRISTOPHERSON: Somehow let me get back to you. I need to talk to our data people and go back. I'm not quite sure.
What we did is, when we set it up, by the way--and again, there will be periods of time, especially in the early days when the line was set up and especially in the clinical database, the incident reporting line has never really had as heavy a use unfortunately in some ways in that regard there.
The clinical line had some pretty heavy usage in the early days when it was first being put together, and my guess is that may reflect some of that experience.
We've kept that open and kept up very extensive hours, not just eight hours a day of live coverage, but much more hours, generally running

245 like 5:00 to 5:00 at a minimum and often beyond
that in hours to try and get the coverage.
But let me get back to the committee and
submit to you for the record sort of our layout of
what the calls are and when and give you a better picture of the pattern of calls, and to the extent we have non-response or difficulty getting response, let me get you that as well.
I'm not sure we have that. But I know we have at least the volume of calls, and I can get you a clear sense of whether there seem to be difficulties or overloading.
DR. LARSON: That's great. Now just one final question.
It's pretty clear that one can anticipate the need for such a hotline after a war. Would you not say that it's a reasonable recommendation that the next time this happens we don't wait four years before starting a hotline after the war? I mean it's a long time between the end of the war and the beginning of the hotlines?
MR. CHRISTOPHERSON: Yes. Let me pick up

246 on that, because it's a question you had asked
earlier as well, of the earlier panel, and I think it's an important thing to go through.
What we are doing now, and partly as one looks across--and the hotlines is clearly a part of that--we are trying to figure out now by trying a lot of different mechanisms to see what seems to produce the best results in a number of different ways, whether it's communicating out and educating our people; outreach in terms of trying to get people into clinical programs; getting incidents; classifying, declassifying information and getting it out.
I'm not sure that we know what the answer is, what's the best use of the taxpayer's dollar to get the result that we're looking for.
I think the clear sense is there are a number of things we clearly can do sooner, and I think we now know more about them and what things they are.
I mean, clearly I think our sense is that the clinical program would prove to be extremely

247 useful and important to do, and we would want to
put that in the field and, I think, obviously very early as an available kind of thing.
But one of the things that we are going to do is a whole debriefing on every piece of the puzzle we've talked about here--in addition, I'm sure you will do that as well--is try to figure out what makes the most sense, and therefore should we, for example, set up a toll-free hotline within weeks, within months?
What's the appropriate amount of time to do that, in the same way of looking at what is the appropriate time to go back and look at records?
When are the records, for example,
assembled enough, such that you can actually really get access, and what's going to happen with digitalization of records?
There's a bunch of those things, and we have to walk through each of those. I think your point is well-taken.

248 MR. QUINTON: A regular part of our
outreach effort in the VA is a toll-free telephone
service for general benefit and medical
information, so immediately a veteran has access to that at any time. So immediately upon the--during and after the Gulf War, people did get access to information.
The focus on the Persian Gulf syndrome or other issues related to the Persian Gulf allowed the VA, as well as DoD, to pay special attention to the Persian Gulf veterans. So when we set up a separate toll-free number for the Persian Gulf War, which certainly was required by law, we were able to go back and look at some of the concerns that veterans raised, particularly under the health care, and establish mechanisms to respond to those types of questions that had been collected at the medical facilities.
So not only did we have a general information hotline that we maintain all the time, the 827-1000, but this toll-free system for Persian Gulf veterans was tailored specifically to their

249 needs, to explain to them where to go to submit a
claim for environmental hazards or general
disability, as well as how to get on the Persian Gulf registry and to go to the particular medical center for an illness, whatever condition they were experiencing.
So you still have these two conditions, situations, existing.
CAPTAIN KNOX: This is to Mr.
I am still concerned about active duty soldiers who either on behalf of themselves or have other people testify for them that they are very nervous and anxious about coming and asking for care.
And remembering that the commander is supreme in being on active duty, what are you doing to help soldiers who may have an identifiable condition and cannot take leave because of their commander?
MR. CHRISTOPHERSON: Well, a couple

250 things.
I don't think it's an issue of the commander--it's generally not an issue of the
commander not granting them leave; it's an issue of whether or not they choose to ask for the leave or sort of enter the process. It's a cultural issue which we know we have difficulty with.
That's why we went out very early again, like I say, with a letter from the Secretary and from the Chairman of the Joint Chiefs of Staff, to clearly give the imprint this is what we expect people to do, we want people to do; let there be no mistake about it from all levels of--the command level to the individual troop member in that regard there.
Do we think it all worked, and therefore has everybody come forward? The answer is no.
I mean, again, as I've told you, I've gone out and talked to troops on bases, and I know there are people who have yet to come forward, and we don't really have a complete and clear picture. I'm not sure we'll ever have a 100 percent picture

251 of what the real number is out there.
I think what we do is, we keep trying to
pound home the message; we keep trying to make sure
that people don't get into difficulty, if we see any reports of problems out there where somebody feels they were inhibited from coming forward.
It so far has not proven to be, we think,
a major issue. We do look a little bit more at certain cultures--the Marine culture, for example, where you run into issues--nothing to do even with the commander; there still can be concern about that, the commander issue--but the culture is not to complain, not to step forward, not to do that.
It's very hard to sort of--many times we
send a message to really say: No, no, come on in, come forward, and let's try and figure out what's going on there. We've also been very careful to make sure it doesn't hurt anybody by doing that.
I think the other part which is coming
into play more and more as the program matures is that it is becoming a part of regular medical treatment, so it's not like somebody has to say:

252 Excuse me, I want to go over and check out my
Persian Gulf illness. It's really becoming a part of the regular medical care, and therefore there isn't sort of the same problem of: Aha, I see they just went out of the room, and I saw them go into the Persian Gulf illness room!
And that means that "aha"--well, that sort of means--we don't have, I think, that occurring now as much; it will occur even less now that we're really using all the military treatment facilities to help identify people and get them into care.
And we've been using that to some extent, but we're going to use it even more in the future.
So again, it's not--it's not a perfect system. We're not sure how we get around it, because a lot of it is as much culture. But we've tried to at least deal with the command issue from the top down all the way through the system.
CHAIRPERSON LASHOF: Gary, could you share
with us whether you're doing anything to evaluate your different efforts?
I mean, what surveys, if any, have been

253 done to find out whether people do or don't know,
and which ones?
And you say you want to know which are the
most effective. Well, what are you doing to help
you come up with that answer?
MR. CHRISTOPHERSON: We have not to date
tried to do the surveys along this line. I think
very honestly we've been trying to go with best
judgment, and we've been trying to go with other--about what are some things to try out there.
We have to find some mechanisms to look
back at this and figure out what is there and what
did happen and what didn't happen.
Part of the problem--and it goes back to
your point--is, for the same reason there's so much difficulty getting people in or reporting on
illness, it's going to be very difficult to get a good, accurate response out of people even if we asked them on a survey question about that. It's still somewhat difficult.
I think we are still trying to figure out what are some mechanisms that allow us to

254 accurately evaluate how good our clinical programs
do, how well do we do in terms of getting to people; is there any way to begin to figure out who we might have missed and how important that is?
So we are still trying to figure out--we don't have those kinds of evaluation mechanisms on the table. We haven't even looked at that, very honestly.
MS. NISHIMI: Do you have any timeframe for doing that?
MR. CHRISTOPHERSON: This is--what I think--we don't have a special timetable. But let me go back.
This is all happening very quickly. This started off--the clinical program was the first start and the toll-free hotline to go along with it, and that's been in existence for essentially about a year or so.
The other programs, the investigation team, others, are very--relatively very new in terms of getting them up and going.
I don't want to give you a date I can't--that we

255 don't have yet. I think your point is
well-taken, and I think we need to look at it. And
I will do that.
about the VA? How are you assessing all of your outreach?
MR. QUINTON: We are very concerned about the type of information that veterans would request. Since we opened the toll-free system in St. Louis, we maintained by category the type of information that veterans were calling for, and we have categories to show whether they asked for medical information, whether they asked to be added to the Persian Gulf registry, whether they asked for a newsletter, whether they simply asked about how to go about receiving medical care, asking for the latest information on Persian Gulf research.
So we maintain it by category from the
people who called in and for the people who asked for information to be returned by mail.
The system allows the veteran to call and leave his or her name and indicate what information

256 they wish us to return. And of that, we have approximately 10,000 requests for information that
we provide and, in that system, we provide it within 24 hours. If they want the newsletter or if they want direction to a medical facility or the research information, that's done within a 24-hour timeframe.
The same type of information is captured on the bulletin board, on the personal computer board; whether we're providing the VA factsheets for a particular issue or public affairs notices that are generated from the health community or simply medical factsheets on the Persian Gulf to bring them the latest information on the medical research.
So we've captured that by category. It allows a veteran to call in, and they can ask for all information that's available, in which case we have a kit prepared that we will mail to them within a 24-hour period.
But to answer your question, we have tracked that by category based on the requests that

257 we receive.
CHAIRPERSON LASHOF: But my question goes
beyond that, and that is: How do you assess which of your information campaigns are working?
I mean, you both have public service announcements; you have newsletters; you have this hotline. Obviously you know the number of calls that come in.
But you really don't know how many people still don't know about it or aren't using it because they don't know about it versus aren't using it because they have no need to use it, whether you've done any surveys to assess how much of the information is out there and which they find as a veteran or as a military member is most effective and helpful.
MR. QUINTON: You're correct. I do not know how many people do not know. Our outreach effort assumes that we must continue to provide the information, that we continue to keep ongoing and current through our transition assistance program to active duty components, people who are ready to

258 separate, and to remind them through newsletters,
through public announcements, through magazines, through the veterans service organizations, or any other means to remind people of the information that is available.
But to answer your question, of the group of people that were in the Persian Gulf, I do not know how many people did not access the information. I can do the reverse. I can say who did and assure you that we are still aggressively trying to make sure that the information is out there in many different modes for people to access.
ADMIRAL CUSTIS: A question for Dr. Murphy.
It just occurred to me that in all the input we've had from the Veterans Administration, there's been no reference to the vet centers. Do you have any information about, does the workload in the vet centers consist of any of the Persian Gulf veterans?
DR. MURPHY: Again, I'm trying to remember

259 back to the statistics.
The vet center program is a readjustment
counseling program, for those members on the
committee that are not familiar with that program. It is a valuable resource to our veterans. They have locations in the downtown areas of many of the cities. They're not only located at medical centers.
They do have a large outreach program in addition to the other outreach programs that we've talked about today.
I believe--and again, I can check on the specific numbers, but my memory is that there were over 70,000 Persian Gulf veterans who had accessed the services of the VA's vet centers.
ADMIRAL CUSTIS: Well, for the committee's information, the readjustment counseling responsibility of the vet centers has to do with the problem of post-traumatic stress disorder.
CHAIRPERSON LASHOF: Let me ask Tom--where's Tom. MR. CHRISTOPHERSON: Thank you very much. CHAIRPERSON LASHOF: Thank you.

260 Tom McDaniels of our committee staff has
been in charge of looking at the outreach effort,
and he'll kind of tell the committee what he's managed to learn up until now, and we can tell Tom what else we'd like him to do.
MR. McDANIELS: Good afternoon. My name is Tom McDaniels, and I'm responsible for the memo on outreach programs and the associated attachments in your briefing book.
These are outreach components that a concerned veteran, spouse, or relative would most likely encounter when seeking information about Gulf War veterans' illnesses.
I hope the memo has provided sufficient background information for the briefings today for the Department of Defense and the Department of Veterans Affairs.
The purpose of outreach is to disseminate information and fortify the perception that issues are being adequately addressed.
The attachments include materials received

261 by veterans, media announcements they may have seen
or read, and tools used by agency personnel to
implement the Department's outreach efforts.
I will answer questions you might have concerning the memo and any of the attachments following my statement.
You will notice from the timeline--that's Attachment A in Tab Section D, page D-1--that most of the outreach efforts have come to life within the last two years, most likely in response to Gulf War veterans reporting illnesses and increased public and media attention. The assortment of attachments suggests that the word is getting out in various formats.
The charter directs the committee to
provide advice and recommendations on Government-sponsored outreach efforts. My initial
recommendations to the committee focus on the
I want to speak briefly on my recent site visit to the DoD and VA hotline centers. The memo describes the different functions of each center.

262 Three of my suggestions for possible committee recommendations are aimed at improving veterans'
access to information through VA's Helpline. VA's Helpline is already a well-managed,
efficient hotline center, and it fulfills the mission assigned to it in Public Law 103-446. These suggestions, however, would increase its efficiency.
The committee may want to recommend that operators answer all calls. When I visited the center during peak usage hours, call volume was
quite low. I interviewed operators who stated that some callers become agitated by the auto-attendant voice mail system and its tedious script. The operators are fully qualified to answer all calls, and they have the time and manpower to do it.
The committee may want to recommend VA establish a strong link between the Helpline center and a central information source such as VA's Public Affairs Office here in Washington.
At this stage, the Helpline experiences the heaviest usage immediately following

263 significant public affairs developments such as the release of a letter from the Secretary of Veterans Affairs, the formation of the Presidential Advisory Committee on Gulf War Veterans' Illnesses, or the
release of a CCEP report. The operators were not informed of the first two events prior to them occurring when called.
Finally, the committee may want to
recommend that the VA adopt a medical referral system through its Helpline.
The memo describes DoD's database and information transfer system where the Hotline center contacts the medical treatment facility which, in turn, contacts the individual to set up the examination. This would shift the appointment- scheduling burden from the ill, possibly chronically-fatigued veteran to the medical treatment facility which already has personnel specifically assigned to treating Gulf War veterans.
I mention public service announcements in the memo, and I would like to take this opportunity

264 to play some for you. These are from VA's Office
of Public Affairs, Internal Communications and
Special Projects Services Office. The audio spots were developed in January of 1995, and the video spot was developed early in April of 1995.
Public service announcements have the
potential to reach millions of people and can therefore be a very effective outreach tool.
[Videotape played as follows:]
"Male Voice: The President has announced the deployment of American combat forces in Operation Desert Shield."
"Female Voice: Operation Desert Shield has resulted in one of the largest call-ups of Reserve and Guard forces."
"Male Voice: We are in the Nation's Capital as America celebrates our returning veterans in the National Victory Parade."
"Female Voice: If it's not over for you or your family, and you're a Persian Gulf veteran, call the toll-free Helpline at 1-800-PGW-VETS. That's 1-800-PGW-VETS."

265 MR. McDANIELS: And these are the audio
spots into different radio stations throughout the country.
[Audiotape played as follows:]
"I'm Jesse Brown, Secretary of Veterans
Affairs, with a special message for Persian Gulf
veterans. Information and help is only a phone call away. Just dial toll-free 1-800-PGW-VETS."
MR. McDANIELS: It continues. [Audiotape played as follows:]
"This is Dr. Ken Kaiser, Under Secretary for Health at the VA, with a special message for Persian Gulf veterans. Information and help are
only a phone call away. Just dial toll-free 1-800-PGW-VETS. That's 1-800-PGW-VETS."
[Audiotape played as follows:]
"This is Jesse Brown, Secretary for Veterans Affairs. There is a new VA Helpline for Persian Gulf veterans and their families. Dial toll-free 1-800-PGW-VETS for information about claims, health care, and research. Select from the information menu or talk to a Benefits Specialist

266 about your concerns. Just dial 1-800-PGW-VETS."
[Audiotape played as follows:]
"This is Dr. Ken Kaiser, Under Secretary for Health at the VA. There's a new Helpline for Persian Gulf veterans and their families. Dial toll-free 1-800-PGW-VETS for around-the-clock information about claims, health care, and research. Select from the information menu or talk to a Benefits Specialist about your concerns.
That's Persian Gulf Veterans Helpline at 1-800-PGW-VETS." MR. McDANIELS: From the examples in your
briefing books and also from what we've heard
today, we can see that DoD and VA have developed multifaceted outreach campaigns. Further assessment will disclose how effective these campaigns have been at getting information about the health consequences of serving in the Gulf to veterans.
Do sailors deployed at sea ever see outreach about a hotline number? Who actually received that memo from Chairman Shalikashvili and

267 Secretary Perry? That memo is on--that's
Attachment H, page D-77 in your briefing book.
I did not receive that, and I was a participant in Operation Desert Storm.
Further assessment will also enable the committee to provide a recommendation about the duration of these programs.
Outreach is relatively inexpensive, has significant marginal returns, and both Departments have the resources to maintain these outreach campaigns for as long as necessary.
Also for Dr. Larson, I have not seen that data that you wanted on the breakdown of the DoD hotline calls. I suspect that the veterans you talked to might have called initially at its inception. After my site visit, I am convinced that that would not happen again. They've got a voice mail system that accepts calls when all of the operators are busy, and the operators then return those calls. So that shouldn't be a concern for the future.
CHAIRPERSON LASHOF: Thank you very much,

268 Tom. I appreciate your memo and the work you've
done on this. I think it's very helpful for the committee.
Does the committee have any questions for Tom?
Mr. Johnson?
MR. JOHNSON: Just one quick question and that is: What's the frequency of exposure on the television public service announcement?
MR. McDANIELS: That we do not know. That's the difficulty of assessing public service announcements. In your attachments, if you look at page D-85, 86, and 87, these are reports that the TV station or the radio station will send back to whoever is sending out this public service announcement. Sometimes you get these reports, and sometimes you don't.
On 85, you'll also see the estimated cost it would have cost the Government, had they paid for this time.
On page D-88, that is an estimate of one of the services that distributed this public

269 service announcement. That is an estimate, based
on readership, about how many people might have seen the public service announcement. But it's difficult to gauge.
MR. JOHNSON: Are there any other techniques available through the media survey world? Obviously there are lots and lots of services that monitor all broadcasts from all stations in all markets.
I mean, are there ways of getting any better sense of whether or not this is of any importance, as we think about this?
MR. McDANIELS: I am not aware of that, but that is something we will definitely investigate for the future.
Besides this example of a clipping service that clipped these particular articles, I do not know if there is the same type of thing for a television market.
MR. JOHNSON: There is. It's somewhat costly.

270 MR. JOHNSON: But, you know, you might
just look into whether or not--there may be
somebody who does it for public service announcements in some form, because there are so many of them that are out there, and there must be other people who need to know whether or not they are getting exposure and whether or not they're likely to be having any kind of market penetration.
DR. CAPLAN: Tom, I was curious. Do you
have any impression--I know you haven't done yet content analysis--of how many of these public service ads or brochures actually utter the sin that dare not speak its name: Persian Gulf War syndrome, health-related problems to service in the Gulf?
If I looked at those PSAs, I know they're about something. But I'm not sure what they're about.
MR. McDANIELS: I think the print public service announcements are more specific. But that video one was one that they never mentioned anything except for "if you're having problems with

271 something" or if you--it just wasn't specific.
DR. CAPLAN: And the radio spots, too.
MR. McDANIELS: Right, yes. And that I don't know. I know what the print--they do get the message across that there may be illnesses related to serving in the Gulf.
DR. CAPLAN: Because that would be something I'd like to see if you could get some read on as to explicitness or specificity.
MR. McDANIELS: I'd also like to say, I only have the VA public service announcements. I don't--I haven't seen a DoD one. I did try to contact Public Affairs there twice and did not get any return phone calls by the time of this meeting. So I will definitely continue trying to find those.
CHAIRPERSON LASHOF: Tom, clearly on the
public service announcements we've heard and seen, they're obviously very general.
Are any of the media ones or print ones at all specific to urging people to come in for the Comprehensive Clinical Evaluation Program?
MR. McDANIELS: All the public service

272 announcements I've seen and heard are really
publicity for the hotlines. So you must call this number to get further information, if you're concerned about illness, in the case of the print media, or just call this number. It's very vague for the visual and audio media.
CHAIRPERSON LASHOF: But the outreach we've heard about the importance of the Comprehensive Clinical Evaluation Program as being
a form of outreach, how is that word getting out to the veterans, that there is such a thing and they should come in for it?
In your work, I mean, we've heard some about that importance. But in your looking at it, have you come up with any firm data about that?
MR. McDANIELS: How to know for sure that
the information is actually getting out about the health registries?
CHAIRPERSON LASHOF: Yes. Other than through the hotline.
MR. McDANIELS: Besides brochures and pamphlets that VA provides at the medical centers

273 and also if you call the hotline to get mailed to
you or at a meeting such as this or at a VA Health Day, I haven't seen any specifically--any public service announcement specifically target for the actual health registry. They've all been targeted to publicize the hotline numbers, and from there you'll call for further information.
CHAIRPERSON LASHOF: Any other questions for Tom?
[No response.]
CHAIRPERSON LASHOF: Thank you very much. We'll take a brief break. Let's limit it to ten minutes and be back at 3:00, as we'll hope to finish up by 4:30.
CHAIRPERSON LASHOF: Our final panel of today, following through on outreach, are from the veterans groups, and we have Mr. Tracy Underwood from the American Legion; Mr. Charles Sheehan-Miles from the National Gulf War Resource Center; and Mr. David Addlestone from the National Veterans Legal Services Program.

274 I will ask each of them to speak in that
order, and then we will open it up for questions
from the panel and by the committee.
Mr. Tracy Underwood?
MR. UNDERWOOD: Good afternoon, Madam Chairwoman and members of the advisory committee.
My name is Tracy Underwood. I'm an
Appeals Representative with the American Legion. I am located at the Board of Veterans Appeals.
The American Legion appreciates this opportunity to offer its evaluation on the Department of Defense and Department of Veterans Affairs outreach initiative for Gulf War veterans and to discuss its own outreach efforts.
The American Legion, Gulf War veterans, their families, and their advocates appreciate President Clinton's continued leadership on this sensitive and complex and critical issue.
The Federal Government's outreach initiative towards Gulf War veterans are, in a word, improved. This description reflects how these efforts have evolved since 1991 when the

275 outreach then could be described as poor or non-existent.
In May of 1991, then Deputy Secretary of
Veterans Affairs, Anthony Priscenti, directed VA to
begin tracking the health of returning Gulf War veterans because of the oil fires in Kuwait. He did so because he felt this was a proactive policy which best fulfilled VA's mission of caring for those who have borne through the battle.
He was not alone in recognizing that unless the Federal Government took the initiative in determining and documenting the health efforts of the environmental hazards Gulf War veterans were exposed to, then it would be failing to take responsibility for those it sent to war.
The American Legion fully supported Deputy Secretary Priscenti's decision. Unfortunately restrictions in Federal regulations prohibited VA from providing most Gulf War veterans with health care. These regulations and laws, as they were based, failed Gulf War veterans and doomed Deputy Secretary Priscenti's initiative.
This failure forced the United States

276 Congress to mandate an action. The Persian Gulf
War registry was finally created in the fall of 1992 by the Act of Congress.
Only under continuous and intense pressure from the American Legion, outspoken Gulf War veterans, and the Congress has VA and DoD reacted to the needs of Gulf War veterans.
The outreach initiatives of DoD and VA have followed a similar pattern. They have improved only because of criticism directed at their initial quality and effectiveness. These improvements, however, have been consistently undermined by the Federal Government and particularly the Department of Defense's initial attitude towards sick Gulf War veterans.
When growing numbers of Gulf War veterans initially reported persistent and often debilitating medical symptoms, both VA and DoD passively addressed their symptoms as primarily stress-related. DoD strongly insisted that the illnesses were only a problem among Reservists and

277 members of the National Guard.
The over 28,000 active duty Gulf War
veterans who have enrolled in the DoD's
Comprehensive Clinical Evaluation Program, CCEP, debunks that initial position. But the damage has been done.
VA and DoD initially insisted that these illnesses were all in the heads of the Gulf War veterans, and they subsequently made halfhearted attempts to outreach after intense public and Congressional pressure.
Is it any wonder why the Gulf War veterans hesitated to avoid DoD and VA programs?
To date, four and a half years after the end of the conflict, there are a number of successful outreach initiatives being implemented by the Federal Government. The success of these initiatives is displayed by the number of Gulf War veterans who have signed up for the VA's Persian Gulf registry and DoD's CCEP. To date, over 50,000 veterans are enrolled on VA's registry, while over 28,000 are enrolled in DoD's CCEP.

278 Unlike the Federal Government, the
American Legion has led from the front in a global effort to inform Gulf War veterans about available services and care.
The American Legion's family support network was established in the fall of 1990 during Operation Desert Shield. This network was created after a team of Legionnaires, with the blessing of President Bush, visited troops in Saudi Arabia. Their visit made it clear to them that there was a need for this program.
It is a permanent nationwide network that gives aid and comfort to families of those men and women on active duty, who have been deployed overseas or away from their homes as a result of national crisis.
Family members left behind are put in contact with their local American Legion post. Volunteers from the post mow lawns, help repair cars, or just visit and listen to family members' concerns and fears.
Most importantly, the post answers

279 questions about problems and benefits available to military families.
The American Legion, through this program,
attempts to fill a gap left by the Federal
Government's lack of assistance to families of deployed service members.
The family support network also utilizes the American Legion's temporary financial assistance program for families and financial emergencies. To date, this program has given grants totaling over a half million dollars to families in need, filling another gap in the Federal Government's service to its military families.
The American Legion, through its monthly magazine and biweekly dispatch newspaper, has spread the word of the programs available for Persian Gulf veterans.
In 1992, the American Legion sent over four million VA claims forms to its magazine and encouraged Gulf War veterans with disabilities to file a claim with the VA.

280 The American Legion has worked closely
with Congress on legislation that led to the
creation of VA's Persian Gulf registry, for the VA to grant Gulf War veterans access to medical centers, created new rules governing compensation for Gulf War veterans, and recommended studies that will attempt to determine what ails Gulf War veterans and what treatments are available to make them whole once again.
The American Legion has appeared on or worked in consultation with 60 Minutes, CNN, and other television news programs and talk shows, in order to participate in the public debate concerning service in the Persian Gulf. The Legion has also participated in radio talk shows and is continuously interviewed by the print media.
As part of its international outreach efforts, the American Legion hosted a delegation of Royal British Legionnaires and British members of Parliament this past July in Washington. The delegation information about British Gulf War veterans who are ill and met with officials from VA

281 and DoD, members and former members of Congress and
sick Gulf War veterans.
The American Legion has also been in
contact with veterans' groups in Canada, Australia,
and France concerning their sick Gulf War veterans. The American Legion worked closely with
the National Veterans Legal Services Program in providing training for American Legion PSO service officers schools. PSOs are professional service officers who work at VA regional offices across the world. The goal of this training is to ensure that Gulf War veterans are provided with the best and most accurate advice as they file claims and appeals with VA.
The Legion commends the NVLSP on its publication, The Self-Help Guide for Veterans of the Gulf War. This superb resource provides answers to the many questions about Gulf War veterans concerning claims and benefits.
The American Legion has also participated in numerous conferences and workshops across the nation on the health consequences of the Gulf War

282 and has answered thousands of letters and phone
calls from Gulf War veterans seeking information. The American Legion has not rested on its
laurels. It recently formed a task force to coordinate its efforts on behalf of the Gulf War veterans, their families, and their advocates. The task force mission will be accomplished through an interdisciplinary approach to the problems confronting these veterans.
A special emphasis will be placed on outreach, not only in the traditional media--print, radio, or television--but also through the Internet with the introduction of the American Legion's home page later this fall.
The task force will work with the
Association of Occupational and Environmental Clinics, AOEC, with whom the American Legion is negotiating an agreement. The AOEC will assist the American Legion in evaluating the ongoing scientific studies and literature relating to the health concerns of Gulf War veterans.
The American Legion is also commissioning

283 a study that will quantify the economic impact on Reservists and members of the National Guard
activated during the Persian Gulf War.
After several years of criticism from the American Legion, outspoken Persian Gulf veterans, and the Congress, the Federal Government's initially poor outreach initiatives have improved. This improvement, however, begs the question.
Why did the Federal Government fail to
properly address the health concerns of Gulf War veterans as soon as they were reported?
Why were the Federal Government's initial outreach efforts so poor?
A private physician treating a Gulf War veteran commented that the veterans' illnesses were similar to being shot by a bullet made of ice. The damage is done, but the evidence has melted.
Had the VA and DoD not immediately dismissed Gulf War veterans' initial complaints and had DoD conducted thorough separation physicals, perhaps common symptoms would have been identified earlier than they were.

284 The Federal Government's outreach would
have seemed more genuine to Gulf War veterans if
its initial reaction had been more compassionate. This concludes my testimony.
CHAIRPERSON LASHOF: Thank you very much,
Mr. Underwood. We will come back with questions later.
Now we will move to Charles Sheehan-Miles. MR. SHEEHAN-MILES: Madam Chairman and
members of the committee, I would like to thank you for this opportunity to present information on behalf on behalf of the National Gulf War Resource Center.
The resource center was established in June of 1995 to provide information and resources to the grassroots organizations which have formed up around the country. Those organizations are working to deal with this issue. They are working one-on-one with veterans; most of them are run by veterans; and most of them are veterans who are sick.
We are a new organization. We've got very

285 limited resources. Our current membership includes
17 domestic Gulf War veterans organizations and two British veterans organizations. Each of these groups was founded to help veterans and have an estimated combined membership of 5000 members, plus an unknown number of family members who are affected by the illnesses.
In an effort to provide the committee with information which may help you in understanding the concerns of veterans, the resource center recently conducted a preliminary survey of Gulf War veterans on issues related to health care delivery by the Department of Defense and the Department of Veterans Affairs. The results we're going to show you today include the responses of 50 veterans.
This is obviously a very small sample. We
can't sit here and say that we've got a huge scientific study and these are conclusions. I will say that they reflect the experience of myself working with veterans and of the other people I work with.
One other issue that I also want to

286 address before I start going into the data we came
up with is, we are planning on targeting this information and putting together a new survey and coming back to you in February with the results. We are going to survey several hundred veterans, hopefully as many as a thousand over the next few months and try and get some responses for you on exactly how they are being affected.
The survey population profile: Over about two weeks, we interviewed 50 veterans. They are from across the United States, from a wide geographical area, and all were veterans who were ill or who have sought assistance or information from one of our member organizations.
They were distributed in three ways. First, they were sent to our member organizations across the country via fax and E-mail. We did leave out the British organizations on this.
Second, they were sent to approximately
200 subscribers to an Internet mailing list which carries information of interest to Persian Gulf veterans.

287 And finally the bulk of the surveys were
conducted by telephone. The respondents were
assured that their identity would remain anonymous. The data is limited in certain ways, and
these should be considered when we're reviewing this data.
All of the respondents were members of Gulf War veterans' organizations. These are individuals who have come to us to request assistance; they are subscribers to the E-mail list; they are people who have had problems with the VA and the Department of Defense and they've sought help elsewhere. So to an extent, that's part of--that's going to be built into these answers.
By the same token, these are the very individuals who should be targeted by these outreach programs. These are the people who are sick, and these are the people who need help.
86 percent of our respondents were male and 14 percent female. And this is fairly close to the number we had in the Gulf.

288 One of the things that kind of surprised
as we went through this was the quality of outreach
and the quality of medical care was different for men and women.
The geographic distribution of the
respondents is wide-ranging. The majority of answers came from the Eastern States, 38 percent from the Southeast including Texas, 30 percent from the Northeastern States. 14 percent of responses came from individuals from the Midwestern States and only 8 percent in the West, and we included Alaska and Hawaii with those.
The average age was 36 years old, and the vast majority of responses coming from individuals between 27 and 38. We received only a few responses from individuals over the age of 46.
I think this puts our--I don't have the
exact date on this; we're going to be finding out--this puts our average age to probably about three
or four years older than the average age of the
people who served.
The responses came from individuals who

289 had served in all four services with an
overwhelming majority from the Army. 14 percent served in the Navy; 6 in the Air force; and 2 percent in the Marine Corps. And again, this is fairly close to the percentage of the services who served in the Gulf, although I think our number of Marines was fairly low.
Half of our respondents were active service members during the Gulf War, and National Guardsmen and Reservists were spread fairly evenly.
One of the things that should be addressed
here is that we've heard fairly frequently that one of the potential causes for these problems and complaints is that: Well, the Reservists just weren't ready to go; they weren't prepared; they weren't trained well enough. And yet when you go out and you look at the membership of these organizations that are actively trying to get medical care, the majority of them were on active duty.
We asked 13 questions of the veterans in the survey. I'm only going to go over some of

290 these. Only some of them directly apply to
outreach; a few indirectly apply; and a couple we're just going to leave out. They are in your briefing books.
The first question was: Are you on the Persian Gulf registry?
Next page. It's upside down.
We wanted to identify how many people have participated in the registry program, and the vast majority had. It was kind of disturbing in that a number of people reported that they didn't know whether they were on the registry or not. They had been to the VA; they had apparently gone through some kinds of exams; but whether or not they were actually on the registry, they couldn't answer the question. And as you can see, more women didn't know than men.
The next one.
And we also asked how many of the veterans had received The Persian Gulf Review in the mail. This is something that is supposed to be sent out to every veteran on the registry, and it's supposed

291 to keep them informed on the current research
issues and other things that may help them. Quite a bit of money has gone into
producing The Persian Gulf Review. Unfortunately 52 percent of our respondents indicated they never received it, and worse, 80 percent of the female veterans had never received it.
The only real hypothesis we could come up with for this trend was that first of all, when a veteran changes address, the registry data apparently doesn't follow them. So if you move a block or to a new city, then the review will continue going to the old address.
However, a number of respondents did state that they stayed at the same address for the last several years, and yet they still never received this information in the mail, and we don't know what the answer is on that.
Okay, next.
This is a question that was raised at the last subcommittee meeting, and it was something that we included in the survey because we felt it

292 should be addressed.
A number of veterans have reported to us
that they were told that if they went into the
registry exam, that they were automatically initiating a VA claim. This is a real important issue for a lot of these vets, because they're too sick to work, and the compensation issue also is tied into whether or not they are entitled to medical care. If they are service-connected or non-service-connected, it affects their availability.
And luckily, I--we thought it was going to be worse than it was. Only one in five of the people we talked to stated that they had been told that. All of them came out of the Southeast Region.
I'm not sure if that's a trend. Again, the numbers here are so small that I can't tell you if that's just happening out of a particular VA hospital. But it was something we noticed and we are going to follow up on.
We asked our respondents if they were

293 satisfied with the quality of VA health care.
Obviously this is going to be a very subjective judgment. Some of them may feel that they've gotten an incorrect diagnosis or they've been callously treated. Some people may feel quite the opposite.
We were very disturbed by the low number of veterans who said they were satisfied with the care they're getting, and we were extremely disturbed by the fact that none of the women said that they were satisfied.
The question of whether or not veterans were billed for their Persian Gulf-related problems again leads back to the priority care issue and the registry exams.
When a veteran is going and seeking care for something and they have filed a claim for service-connected, then they are presumed to be service-connected until they get denied, and they should not be billed for those visits.
However, as you can see, a fairly large number are getting bills. Their insurance

294 companies are being billed. And sometimes they
just come to their house where the VA demands large amounts of money.
And we found that a lot of our members feel this is very discouraging in going back to the VA. You know, many of them are not working. They have very little funds.
Next, please.
38 percent of our respondents stated that at least once they had been denied service by the VA for Persian Gulf-related problems. Again, the number was much higher for women.
Again, this is a problem that seriously needs to be addressed at the level of the hospitals, and this is part of what I want to talk about with the outreach, and while there's a lot of great programs that are being discussed, that have been legislated, that we get the pamphlets on and the information on, they're not reaching the local hospitals around the country.
You know, it's not uncommon for a veteran to walk into a hospital, get the Persian Gulf

295 registry exam, say they were exposed to something--depleted uranium, for instance--and have the doctor
ask them what depleted uranium is. You know, this
is not unusual; it anything, it's the rule. And that lack of training translates, when you're visiting a hospital and you're sick, into lack of care.
Are VA procedures explained to you clearly? This is a pretty broad question, and it applies to the procedures for getting on the registry, for getting health care, eligibility rules, and the rules for compensation.
And again, the vast majority of our respondents said: No, they're not explained clearly. They don't understand. And that's quite simply, the rules are incredibly complex, and that's why there's organizations out there that spend a great deal of time and money training people just so they can counsel veterans on their eligibility.
One of the things that we're going to recommend has to do with that in the communication

296 of these things, not necessarily in the format that they're being explained now, because many of our
members pick up these pamphlets, and there are so many exceptions and changes in the rules that they don't understand whether they're eligible for a program or not.
We asked whether the VA telephone hotline was helpful. This is an issue. A number of them have called.
We did have one veterans' advocate from Michigan. He told us that he tells his veterans not to call the hotline because it will confuse them.
And again, this goes back to the issue of the VA procedures and the regulations. It's extremely difficult to understand, and something's got to ge done to make it clearer to people who are sick whether or not they can get medical care.
Summary. Almost all of our respondents
stated that they're on the VA registry. Their responses indicate the VA has failed to keep the veterans informed. This was noted in the questions

297 concerning The Persian Gulf Review, as well as an understanding of VA regulations and processes.
Our survey also indicates that veterans are not getting followup exams and final diagnosis. And you'll find the data on that in your packets. And they are still being billed for war-related treatment and being turned away for service.
Finally--and this is an issue that I
initially wasn't going to bring up today--the
percentage of veterans who are receiving service-connected compensation, and consequently treatment
as for undiagnosed illnesses--and this is the legislation that was passed last year--is a lot
lower than it should be.
We heard the numbers a little while ago
about the people who are getting regular service-connected compensation claims, and then we heard
the numbers for the people getting environmental
The last numbers we've got--and I will get this data to you--we got some numbers from the VA
in June that stated that 109 out of 19,000

298 undiagnosed claims had been approved. So a little
bit less than 5 percent. And I want to find out if that's still current, if we're still running the same percentage, because, if so, then the new law, as it was passed last year, is not being implemented the way it was supposed to.
We only asked six questions of the active duty, and part of that was, again, we're going to target this; we're going to expand the survey and come back in a few months with much more in-depth data for you.
The first question is: Are you in the CCEP? The vast majority indicated that they were.
We went on to ask if you've received a
diagnosis, and then have you been told that your problems are primarily psychiatric? And 60 percent said yes.
And these are people who been encouraged by this memo, although a lot of our members indicate they've never seen the memo that was sent out. But they're going in; they're going through the CCEP, and then they're being told "you're

299 crazy" essentially.
DR. BALDESCHWIELER: Can you tell us how
many people were involved in this?
MR. SHEEHAN-MILES: The active duty, we
had ten. Again, the data, it's hard to give you
real hard conclusions until we can go back and do a further survey.
I will say it does reflect the members that I've worked with. I just moved down from Boston. I was with Gulf War veterans in New England. And over the course of a year, we worked with several hundred veterans and active duty and Reserve people, and this does accurately reflect what we went through.
Are you satisfied with the quality of Department of Defense health care? That's a fairly straightforward question.
I think the individuals who answered these surveys, if they were satisfied, they probably wouldn't be coming to us for help. But I do want to make that clear, that we've got a pretty high percentage there, at least out of the folks we're

300 dealing with.
And the next question is one that we found
really disturbing. 50 percent of the active duty
stated that they'd been punished for poor
performance due to their illnesses, and these punishments ranged from everything from an Article 15 for missing a formation, not being able to go PT, to one who is being forcibly retired.
You can skip past that one. Next.
I want to restate again, these are preliminary conclusions. They do reflect what we've experienced, and we're going to go out there and see if we can confirm this with a much larger survey.
First of all, the Department of Veterans Affairs does not provide equal care, compensation, or outreach to women veterans.
Number two, the Department of Veterans Affairs is failing to fulfill the letter and spirit of the law when providing compensation for undiagnosed illnesses.
Number three, the Department of Veterans

301 Affairs does not explain eligibility rules and
other processes to veterans in a clear manner. Four, the Department of Veterans Affairs
is not providing sufficient followup on the registry exam.
Five, the Department of Veterans Affairs is continuing to deny treatment to ill Persian Gulf War veterans.
Six, the Department of Defense is rushing to diagnose sick veterans with psychiatric illnesses rather than doing further testing to find the causes of physical problems.
And seven, the Department of Defense is punishing individuals for disabilities they acquired while they were in service.
These conclusions are obviously real harsh. Again, they reflect what we've experienced both in working with our members, and to some extent they reflect data we've seen from the Department of Defense and VA.
One of my missions for the next few weeks is going to be collecting some of that information

302 to deliver to the committee staff that they can
bring to you.
Our recommendations are fairly simple:
Number one, that the VA increase its outreach efforts to women veterans and provide specialized training to its medical and administrative staff concerning the special needs of women veterans.
Most VA hospitals, that we've been able to tell, don't have any specialized care for women. The vet centers have some programs, and there are some programs starting, and I think there's been incredible improvement. At the same time, though, I've had too many women veterans call us up and say they went to the VA, and they couldn't get help.
Next, we believe the Department of
Veterans Affairs needs to review its adjudication of undiagnosed illness claims and that the guiding regulation for that, one or both needs to revise, so the law is carried out as it was passed by Congress.
Number three, that the Department of

303 Veterans Affairs and Defense intensify their
research efforts in order to develop case definitions and eventually a treatment protocol for ill Persian Gulf veterans.
I also want to add to that the current protocol as it stands for the VA Persian Gulf registry needs to be sent out to the hospitals, because an awful lot of people we've had go to the hospitals around the country--and this is consistent everywhere--they get to the hospital, and the doctors are not aware of the specialized testing that should be done; they don't know about the Phase II parts of the process; and they don't know where to send them for these referral centers.
Number four, the Department of Defense
needs to immediately stop punishing veterans for their illnesses and stop discharging them without proper review.
Number five, the Department of Veterans Affairs needs to review its eligibility requirements and make these rules more clearly available to their customers.

304 Again, the biggest dilemma--and this is
not in my report, but it's a couple of things I
want to touch on--the medical and administrative personnel out in the hospitals don't have the training.
Here in Washington we hear about all these programs, and I go out and I call the hotline or if I look on the bulletin boards or if I look on the Internet, I can find all kinds of information about these programs. If I go to the hospital, it's real hard.
As an anecdotal example, when we first moved to Boston a year and half ago, we nearly had to threaten to sue just to find out who the Persian Gulf coordinator was. And I was on the registry already.
And again, it's the same kind of thing. The personnel are not trained. They don't know what the potential exposures are. They don't know what the common illnesses are.
The outreach is good, but, you know, you get the outreach, and then you go into the

305 hospital, and they treat you real badly, you're not
going to go back. And that's just as important as going in the first time.
I'd like to thank the committee for
hearing me today. Thank you.
CHAIRPERSON LASHOF: Thank you very much. We will move on to Mr. Addlestone, and
then we'll come back and open it up for questions. MR. ADDLESTONE: Dr. Lashof and members of
the committee, I am David Addlestone, the Joint Executive Director of the National Veterans Legal Services Program, and I'm an attorney with approximately 30 years of experience with military and veterans' law issues.
I'm accompanied by Ronald Abrams, who is also an attorney on our staff and our Director of Training and is the primary author of our self-help guide on Gulf War vets, which you may have seen.
Our project is primarily interested in
education of veterans' advocates and production of self-help materials for veterans, although we do engage in a substantial amount of advocacy

306 activities.
I am going to try just to amplify on my
written remarks and be as responsive to any
questions that we're capable of doing, and I'll defer to Ron, because he's much more of an expert on some issues than I am.
I am a lawyer, not an outreach specialist obviously, but I've had considerable experience in assisting military veteran clients and client groups with very real or perceived grievances with the Government, so I'm going to try to at least touch on that experience and give you some observations, some of it scientific; some of it has been bandied around the room already today.
And I don't come in a mode to be
adversarial to the Government. I certainly have in the past, but I don't intend to be. So I certainly don't mean to denigrate any employees of the agencies.
However, some of what I say may be taken that way. But I'm mainly going to be talking about what I think are perceptional problems out here. I

307 think there are some very general limitations to
what Government can do, and I think there are some very general observations that can be made about perceptions that veterans, particularly combat veterans, have about Government service and what the Government should do with them after they finish military service.
Now the good news is, we're historically very far along on this issue. We're clearly not faced with a Veterans Administration that took a very defensive posture on the Agent Orange issue. And that issue was a complicated issue. I think it had a lot of the Vietnam War wrapped all around it, and it played a--and economics played a very large role in that decision.
Well, that's basically behind us, although some aspects of that issue are still alive.
Secretary Brown is clearly a person who
wants to avoid that. His background suggests all that. And the public posture and the directives he has issued thus far are commendable, and he is certainly to be commended for that.

308 Outreach by both agencies has been rather
extensive and historically significant. But there
seems to be a lot of background noise behind this outreach, and the outreach may not be being heard or if it's being heard, it's not being heard clearly enough to give it credit for what it attempts to do.
Again, I'm trying to focus on some of the inherent problems with outreach, particularly to this group of veterans.
Some of the factors we're going to run into in any issue are going to be here, and I think we just have to live with them.
There are going to be provocateurs of the left and right who are out to make money or attain their own agendas around any issue like this. It's too loaded with all those interesting issues to avoid drawing people to it.
We're going to have our conspiracy
theorists who think that conspiracies make the world go around and all Government is evil, and they are always going to be with us.

309 And then we have the universal skeptics
who don't believe anybody. They'll think anybody
who's involved in this is out for their own agenda or something of that nature.
And we can't do much about these folks. However there is some historical baggage that comes along with this, and it really can't be overlooked.
I think there is a culture of distrust by
veterans of the VA and the Department of Defense, and I suppose--here's where I'll probably part company with my colleagues from those two agencies in the room. But let me expand on this.
We've got serious perceptual problems, and we've got serious bureaucratic problems. This feeling of distrust among veterans that I'm referring to is particularly acute when it comes to health issues relating to their military service.
Now I don't know whether the surveys may
show that a majority of veterans don't feel this way, but then a majority of Americans don't even vote.
So I think what I'm talking about is the

310 active minority perhaps of people who get out there
and debate issues and are involved, and they are the people that dominate the public debate, and what they say is generally tucked away in the back of people's minds.
Obviously not all veterans experience what I'm going to describe here, and I personally had a very pleasant time in my military service and got a lot out of it. But what I'm going to describe are the people that seem to have come away from it with a bad taste.
Even the people that are neutral, there are stories that sort of abound in our culture about military service and what the VA does to correct some of the problems.
I think we start with the whole notion of war. I mean, this is when rational political discourse has broken down and you resort to war, and the object is to win, of course.
Really, is anybody ready for it? And no one likes it. And unfortunately I think protecting the soldiers' health is really secondary to winning

311 a war. I'm not passing a moral judgment on that.
I mean, I think that's a fact of life.
Risks are calculated with a victory
objective, which again is a very broad
generalization, but that's the way things are thought out.
Yesterday I heard a Senator ask members of the State Department whether they were willing to sacrifice 200 American lives in Bosnia, and they were making him answer the question.
Well, it's a pretty good question, and it was a pretty good answer. And they said: Yeah, maybe, if we calculate what the long-term objectives are.
These soldiers nevertheless--and we're usually talking about young people who are the ones that experience the downside of war--they experience injury and death to sometimes take apparently useless territory or to achieve tactical and strategic objectives. And all through our popular culture we see this.
They get gassed; they're exposed to exotic

312 diseases; they've walked in the mushroom atomic
clouds; they've stripped asbestos from ships without adequate protection.
They were exposed to defoliants and other harmful substances in Vietnam. And there's been drug experimentation, we know.
And then in this case we have some sort of toxic mix involving uranium, oil, diseases, experimental medicine, and I think the veterans very strongly think chemical and/or biological weapons.
I mean, I think our cultural norm is that the average GI takes it on the chin, and the only way they survive is through assistance of their comrades or by their own guile. I mean, just movies, books--Galipoli, Hamburger Hill, Breaker Morant, Paths of Glory, All Quiet on the Western Front--I didn't even mention one Vietnam--I mean, you can use all of those.
I think it's a cultural norm to accept that the average GI gets screwed. And so that's all sort of in this background.

313 And in part now the VA is generous because
of this. I mean, you don't--they don't use a
strict cause-and-effect analysis to grant benefits. Usually if you come out worse than you came in, you get VA benefits. And that's in part society's recognition that people are asked to experience often horrendous experiences that can't be recorded in one's records.
We've always essentially had civilian soldiers in this country, and they're not terribly tolerant of bureaucracies. The average World War II veteran that comes in now for VA benefits, fifty years after the fact, is looked upon by bureaucrats saying: Well, there couldn't possibly be anything wrong with him; why didn't he come in 50 years ago?
Well, 50 years ago, most people went home.
If you look at the AWOL rates from World War II, you'll see a graphic example of that.
They have now been met with the bureaucracy that says: Why did you wait so long? There's nothing in your service records, or there's no conclusive proof of this. And the conclusive

314 proof issue is a lingering background sound in a
lot of this.
A lot of the current answers are really
not quite enough to satisfy this particular group
of soldiers. We're hearing a lot about
declassification of documents. We're hearing a lot about research, all of which I understand. It makes sense to me. But I don't think it offers very much to people who are very, very concerned.
Now I think in general, talking about
Government outreach, it's difficult. The documents I've read I think are bland, impersonal, and cold. It's a language problem in a lot of these documents, and I can understand why.
I mean, the Government--I mean, people don't--they don't want to alarm people, or they can't really take issue with something that appears to be a policy decision. But I think there certainly could be improvements. They are bureaucratically cold in some respects. Most VA form letters are very, very form, almost impenetrable, and they really turn off the people

315 that receive them.
VA doctors are very busy. I mean, I'm
not--I recognize the fact that they have an awful
lot of clients, and they're treating a lot of people for free, and they have a lot of people coming in who just like to come in and see doctors all the time because it's free. So there's some institutional impediments to being warm and friendly all the time.
What we've got here is a particularly difficult group of people who say: Well, you made these smart bombs that would go down smokestacks, and now you're telling us you've got to keep researching what may be wrong with us. I mean, they say: Well, why didn't you do it before? How could such a rich and intelligent Government like ours have not anticipated these problems?
I mean, it's not exactly like it was a secret that there was going to be a war in the Middle East. I mean, if I'm not mistaken, the Department of Defense has prepared for that for decades.

316 We hear about the possibility that fine
sand may have caused some problems, and I've heard
there's a Rolls Royce study. Now I understand they're talking about airplane engines. But I think most people would start thinking about Arab
sheiks riding around in Rolls Royces. And just the way a lot of the language rolls out, it has the tendency perhaps to turn people off.
And the question is: Why couldn't a lot of this have been anticipated?
I mean, the people cover up their faces. I'm told maybe this is not just religious; it's cultural. I mean, I learned this in Sunday school about hygiene and the biblical restrictions on eating pork and other forms of food. I mean, this is not something new, and this is certainly something that the Government should have anticipated.
I mean, I'm thinking this is what people are thinking.
Particularly if you used depleted uranium, particularly if most people think that chemical and

317 biological weapons were used. I mean, that's the
sense I get just talking to veterans' advocates or meeting with veterans' groups.
And people are particularly appalled that their families may be affected. And all the law, of course--the agency can only say: Well, the law says all we can do is do some research to see about possible effects on families; we can't treat your families.
Now the agency's hands are tied. They really can't do anything there. But these are, I think, some of the responses that are turning off the audience out there, the recipients of the outreach.
Now some--perhaps some suggestions. As I said, I don't think Government is particularly good at outreach.
And just a good example, I picked up this report to veterans. The second word is "small", "a small number". Well, I mean, it's already shown a bias right there.
Now I can understand the problem someone

318 had writing this, because you don't want to alarm
people. It's literally true. But it's a complete turnoff, the way that it's structured. It's not designed to make someone think: This is going to
be something that's really going to try to touch me and tell me "I understand".
The American Legion can deal face-to-face with people. We can write self-help guides. And we can be--we have the advantage of being able to say: We understand. We can say: We don't know the answer to your problem, but we understand that you're hurting.
And Government outreach or Government publications or Government 800 numbers don't quite--can't quite do that. And maybe it's possible to do it, but I think it's extremely difficult.
I notice in The Persian Gulf Review some very complicated headlines in here about something enhancing something. I don't think--but at the end, it says--the last tag line at the end is: Note: You can find representatives of the veterans

319 service organizations to help.
Well, there are representatives of
veterans service organizations that will help every veteran, and they will sit down with them and provide them with some understanding and private counsel, not an 800 number. And then this is something that perhaps should be amplified a little bit more.
I know the VA works regularly with the veterans service organizations. But I think burying something like that in here for people who are actually looking to go somewhere to have someone sit down with them--and frankly you can't always help people that come to you -- one of the hardest things I learned as an attorney was to tell people: I can't really help you, but let me explain to you why. And at least people can
sometimes leave--and good physicians are the same--people at least leave with a feeling that they've
had their concerns listened to.
The focus on health care is critically
important. I think to the extent that people can

320 be told that they'll be funneled into some kind of
health care program, I think that would alleviate a lot of the anxiety. People are really concerned about getting well. I don't see a whole group of people out there that are clamoring around for compensation benefits. These are young people that want to get back on with their lives. I don't see that as being the driving force behind all this.
I think the press could be worked with a
little bit better. You can issue all the press releases that you want, but it's an adversarial situation. I mean, let's face it. It's a better
story if it's sensational. It's a better story if it's got deformed children. It's a better story if the veterans are angry and challenging the Government.
So the agencies have their work cut out for them when dealing with the press, but they've got to realize that. They can't just say: Oh, that's the press twisting everything. They've got to anticipate it.
I mean, the DoD press release--the press

321 release wasn't that bad, but it didn't anticipate
what the--how it would be picked up.
It's sort of interesting. We, with 32
cents and about two hours work, we got this
featured in "Dear Abby", this self-help guide, and we got 2000 letters this month from people.
It didn't take a lot of creativity. I mean, I know getting to "Dear Abby", so it takes a little bit of creativity, but you can do it.
And I did--this is not a scientific analysis, but I asked the people, and I've read some of the letters; everybody in the office has read some. These are the nine categories that seem to come up most often, what do people want. I mean, this is the functional equivalent of calling an 800 number. Whether they send a check for this or not, they--I get calls at home in the middle of the night, calls to the office, but people writing letters, too.
And the nine categories--
CHAIRPERSON LASHOF: I'm going to have to ask you to try to finish up.

322 MR. ADDLESTONE: This will be it.
Help with filing a claim.
Statistics, they were interested in statistics on sick veterans.
Information where they could get help for family members.
Appealing a denied a claim.
Help on problems with VA hospitals. Getting in touch with other Gulf War
Information on toxic substances. Information on private assistance.
And what would be the origin of the illness with an implication that there's been some Government coverup.
These are all very personal concerns that you don't really call an 800 number for. I mean, the people out there really want to be connected with somebody who can sit down with them.
So I think one thing that the outreach efforts could do is perhaps link up the calling veterans with service organizations or other

323 organizations that are willing to provide the one-on-one counseling.
Thank you.
CHAIRPERSON LASHOF: Thank you. The floor
is open for questions from the panel.
DR. TAYLOR: Just a clarification from Mr.
Sheehan-Miles regarding the survey population.
You had 50 persons that were surveyed, ten
of which were active duty?
MR. SHEEHAN-MILES: Ten of which had been
through the Comprehensive Clinical Evaluation
Program. Some of those had already retired and had also gone through the VA system. So there's a little bit of overlap there.
MR. SHEEHAN-MILES: Where there's--there were, I think, half a dozen individuals who had been through both systems.
DR. TAYLOR: Okay. So now your expansion of the survey, you're trying to get at least a thousand participants?

324 MR. SHEEHAN-MILES: Well, that's probably
a little too much to hope for. We have very little resources. Our budget for this was about $37 plus
the long-distance, you know.
But I think realistically we can probably come up with 500 veterans over the next four to five months.
The big thing right now is, we're
developing the questionnaire, and we want to make sure that we really target our responses. This, quite frankly, was put together very quickly.
DR. TAYLOR: And how do you get to target the audience, then, the persons that you survey? Are they volunteers, strictly volunteer phone calls?
MR. SHEEHAN-MILES: It's a little mixed. Within the resource center itself, we've contacted some of the people who have called us for help. We sent them out to our member organizations, and they in turn surveyed their members and people who had called them for help.
And then, again, we operate an Internet

325 mailing list that just carries various information
of interest to Gulf War veterans. Some of them are sick. And probably the majority on the mailing list are sick. But there are some healthy ones, too.
And we just mailed it out and waited for responses. So....
DR. TAYLOR: Thanks.
MR. RIOS: These 50 that responded, do they all have claims pending before the VA right now?
MR. SHEEHAN-MILES: No. If you can hold just a moment, I can tell you the exact percentage on that. Most of them did.
83 percent of the veterans had filed a claim with the VA, and out of that only 60 percent of the women had done so.
MR. RIOS: Of those that had claims pending, out of the 50, had any of them been granted, some kind of positive response, or been

326 granted their claims?
MR. SHEEHAN-MILES: For regular
MR. RIOS: Right.
MR. SHEEHAN-MILES: 40 percent overall
stated that they were receiving benefits, at least
10 percent, and 20 percent of the women did.
For the undiagnosed problems, we had one veteran say yes--or excuse me--two said yes, they are receiving compensation for undiagnosed illnesses.
DR. LARSON: Joyce?
DR. LARSON: I hope I speak for the
committee in just following up on this survey by saying that a survey like this, well done, would be very, very helpful to the committee.
And I know that you have limited
resources, but I would certainly urge you to seek some epidemiologic advice about the population that you survey, so that if you do spend the time and the resources for a survey like this of 500 people,

327 we have a good sense of who the denominator is and
who, then, the results apply to, because, you know, sort of one of the basic tenets is, of course, that we want to make sure that it's a sample that's representative of as much as possible of those that served.
MR. SHEEHAN-MILES: That's actually one of the things we want to address. We do have a very small number of medical professionals we're working with, and in the followup survey we want to make sure we're a little bit more targeted in terms of real accuracy on that.
The survey was put together by people in this case who are not scientists. We knew these were issues that needed to be asked about.
I think in our future answers we are going to be able to get a little more reliability on that issue.
DR. TAYLOR: You mentioned that you're working with AOEC the next time, right? Someone mentioned AOEC.
CHAIRPERSON LASHOF: Yes. Tracy Underwood

328 did.
MR. UNDERWOOD: Yes, I did, the American
We have conducted surveys and studies, the
American Legion has, and we have worked closely
with Ron Abrams right here on surveys and studies which you were just talking on, a large amount, a large quantity.
And, you know, I mean, I've heard what was said earlier, the figures that were quoted, okay, as far as Persian Gulf veterans and compensation, disability claims approved, and denials.
And, you know, I was recently in the regional office here in Washington, okay. I had hands-on with the veterans, those Persian Gulf veterans coming in that are very ill. And, you know, I can honestly say I haven't seen any approved--very, very few. Let me correct that: very, very few I've seen approved.
Now something we must understand or I would like to enlighten you on. He said 859 were approved.

329 You know, a veteran--there are other
issues that can be involved, okay. You have the undiagnosed--a veteran can file a claim for
undiagnosed illnesses, but also have other illnesses that do not fall into that category. They are approved, those other illnesses. They're not approving the undiagnosed illnesses, okay. So that's your statistics.
So, you know, Ron Abrams can elaborate on this more, because he' been working close with the American Legion, doing these studies. He can really tell you why the denials are happening.
said before, I think this is an issue or the subject of a further panel. I think we should
delve into it, get hard data, and we will get staff working on that and put it on the agenda for a future meeting of this committee.
I'd like to just follow through with Elaine Larson's comments, Mr. Sheehan-Miles, that a survey of unhappy veterans who are displeased with their service will tell us something about that

330 group; that is: What are the things that make the
unhappy ones unhappy? And it has some validity for that, if we recognize that it's that kind of a sample.
If you're looking for what percentage of veterans as a whole are unhappy, then you have to put forward quite a different net. And that may be beyond what your group is prepared to do.
So I think it's very important that you define the purpose of your survey and decide who you want to survey; that is: Do you want a sample of all veterans to see what percentage are unhappy, or are you looking at the unhappy veterans, trying to find out what it is that makes that group unhappy?
And both have validity. But you need to know what you're doing. And that would be helpful, I think, to the committee.
DR. BALDESCHWIELER: I would benefit from a brief tutorial on eligibility requirements.
What is it that--what is it that Congress

331 actually legislated? I mean, it was clearly not a priority in the sense that we understand it?
MR. ADDLESTONE: I'd defer this one to my colleague.
MR. ABRAMS: Are we talking about
compensation benefits or medical benefits?
DR. BALDESCHWIELER: Well, again, I would like to understand the difference.
Does eligibility for benefits mean
eligibility for medical service or guaranteed compensation?
MR. ABRAMS: First of all, Gulf War veterans have a special advantage. Vets who seek free care from the VA usually must apply for a service-connected condition or an injury caused by VA health care, or there are some other rules like being a former prisoner of war.
The VA may offer medical care to other people, but that's not always free. Only if they're very poor is it free. They have that rule, too.
DR. BALDESCHWIELER: And I understand that

332 "very poor" means--
MR. ABRAMS: Under a certain income limit.
DR. BALDESCHWIELER: Which is of the
MR. ABRAMS: And you don't want me to go
into that now.
DR. BALDESCHWIELER: But it's on the order
of $22,000 to $25,000.
MR. ABRAMS: Under that, under that. It's
around $21,000 as a rough--but then we go into the
side issues there. I just didn't want to confuse you with that.
DR. BALDESCHWIELER: But that's roughly the means test.
MR. ABRAMS: Now that's not the case for the vets of the Gulf War. They're entitled to free outpatient care, free VA inpatient care, and free VA nursing home care, unless the VA makes an affirmative finding that the veteran's condition was caused by something unconnected with the veteran's service during the Gulf War.
So the burden of proof is on the VA to

333 say: Listen, you have a problem, but it's nothing
that could possibly have been caused by the Gulf War. You fell out of a building after you were discharged from service and hurt your knee; that's not going to be something that we're going to give you free care for.
Now there's a lot of other issues. It's in the self-help guide. And what I wanted to also
tell you is, the rules for compensation, which--it's like entering the magic door. Once you're service-connected, you're entitled, they have to
treat you in the hospital for any condition. That service connection opens up the door to the VA hospital medical treatment.
The first thing is that the veteran has to have had a chronic, undiagnosed illness, a medical
problem that's existed for six months or more --that is the legal definition for that--and it can
be proven by statements from friends and family
members or documented by a doctor.
And that means that if somebody has had
memory loss and his family or her family can come

334 in and tell them: This person's having trouble;
they have trouble remembering things, and that's lasted for six months; that's a chronic condition. That rule is liberal.
The signs or symptoms of this illness either have had to reveal themselves during the veteran's service in the Gulf War, or they must have been shown not later than two years after the date when the veteran last served in the Gulf and were severe enough when they were shown to warrant at least a compensable evaluation, which means 10 percent under the VA waiting schedule which lists percentages of disability, and you plug certain things in.
Again, I don't think we need to spend time going over that. That's the rules in order to get compensation for undiagnosed illnesses.
If the veteran is diagnosed, then they fall into the category of any other veteran seeking compensation benefits, and there are different rules.
DR. BALDESCHWIELER: I guess this really

335 raises two questions.
One, is the system basically performing
according to those rules?
MR. ABRAMS: No. There is a serious
DR. BALDESCHWIELER: And second, of
course, do the rules make sense, but--
MR. ABRAMS: Well, I can't talk about the
rules making sense, because what has happened is,
the entire VA system has a problem.
Right now, when a veteran is denied
entitlement to compensation, they can appeal. The first step is to a hearing officer. And right now, 35 percent, about that, of the appeals at the hearing officer level are being overturned and granted.
If the veteran is not happy, still they can appeal to the Board of Veterans in Washington, D.C., and at that level about 19 percent are being overturned. And even more striking, 50 percent are being sent back because the VA didn't do its job at the regional offices. And then the vet can appeal

336 to the court, and at the court 50 percent of those
cases are coming back because the VA didn't do its job there.
So you have a system, outside of Gulf War veterans, which present complicated claims that isn't working very well. So they're not going to be real happy with their compensation claims.
caution the committee that compensation is beyond the scope of the committee, and we do need the Veterans Administration here to respond to some of those.
We will ask staff to get back into this issue in terms of the aspects of it that are within the realm of the committee and provide the information to the committee and put it on the agenda of a future meeting.
MR. SHEEHAN-MILES: If I could, I'd like to add one more point on that, though.
When a veteran actually gets turned down for that claim, then technically the VA has made an affirmative decision that that is not related to

337 Gulf War service, and unless he's living in
poverty, loses entitlement to medical care. And then they really get into poverty.
We've got I don't know how many families who have lost everything because of the way these rules are working.
CHAIRPERSON LASHOF: Well, we all recognize there's a problem with our medical care system at the moment.
Other questions?
Oh, all right. Dr. Murphy?
DR. MURPHY: I'd like to correct that, because that statement is false.
DR. MURPHY: When a veteran is denied--when a
veteran's claim is denied for service-connected disability, it does not necessarily mean
that that Persian Gulf veteran will then be denied medical care. The burden of proof is different
when deciding whether the veteran gets priority care than for service-connected disability.
There are many cases where a veteran may

338 be denied service-connected disability, because
there's a higher burden of proof for that than a presumption that it could possibly be related to an exposure that occurred in the Gulf.
So in many cases, medical care is
continued despite disability claims being denied. CHAIRPERSON LASHOF: Thank you very much. Do you have any comments on any of the
other issues at this point, Dr. Murphy? Do you want to make any other comments on the issues that have been raised?
I mean, we've gotten beyond where we started. But since they raised it and you're here, you don't have to feel under obligation--we'll take it up at another meeting--but I'm certainly willing to give you a chance.
DR. MURPHY: I think that the impression that's been left about care of women veterans is also not correct.
There are specific programs within VA for women veterans. The Persian Gulf Helpline has specific information about how to contact a women

339 veterans coordinator. Those numbers are available
through the Helpline.
There is a women veterans coordinator at
every single medical center, who will walk a woman
veteran through the system and is available to tell Persian Gulf veterans and any other woman veteran how to get the services that they are eligible for within VA.
You know, we also have looked at mechanisms to address the specific needs of some of the women in the Gulf. And in addition, our research programs have focused specific attention on women veterans.
As you know, we've just started a national Persian Gulf survey, and there was an effort made to over-sample women, so that we have an adequate representation and can make good statistical analyses of that data.
So I think to say that VA is not addressing the issues of women veterans is false, and we'd like the chance to talk about that in the future.

340 ADMIRAL CUSTIS: Joyce, before Dr. Murphy
gets away, may I ask one more?
ADMIRAL CUSTIS: Dr. Murphy, are you aware
of any situation in which a Persian Gulf veteran
comes to the VA for examination and care in which they are charged for that service?
DR. MURPHY: Unfortunately I can say that I do know of specific instances. And when we become aware of those, our office has personally intervened.
You know, there's one instance that I am aware of where someone was inappropriately charged for a Persian Gulf registry examination, and I can tell you that when they queried our office about it, we immediately straightened out that problem.
The other confusion, I think, is coming in
that veterans are not being personally billed, but their insurance companies may be.
As you know, there's legislation that allows VA to recoup medical care cost for all

341 veterans who are not service-connected for their illnesses. And my understanding of the way the regulations were written was that the only veteran
whose insurance company might not be billed for their general medical care are those who have service-connected disabilities.
So people who are eligible for priority care may still have a bill sent to their insurance company, if they have a private insurer, for care that is given on an outpatient or an inpatient basis in the VA.
CHAIRPERSON LASHOF: Thank you. Are there other questions that any members of the committee have?
[No response.]
CHAIRPERSON LASHOF: If not, thank you all very much. And there is just some minor committee business, and then we can adjourn for the day.
You all received folders in addition to your book, and in the folders is some of the testimony, but there is also a yellow sheet with the dates of the future meetings. I hope you all

342 take a look at those tonight, look at your
calendars, and let us know tomorrow if there are any problems.
Otherwise, we will see you all at 8:30 tomorrow morning.
Thank you.
[Whereupon, at 4:16 p.m., the meeting was recessed, to reconvene at 8:30, Thursday, October 19, 1995.]