OUTREACH: Findings from Interim Report
DOD's Persian Gulf Medical Registry Hotline and VA's Persian Gulf Helpline effectively educate callers about the availability of the CCEP and the Persian Gulf Health Registry, respectively. Both telephone systems adequately refer callers to points of contact at medical treatment facilities.
DOD's GulfLINK offers a user friendly, accessible resource that deposits information pertinent to Gulf War veteran's illness in a central location.
Since GulfLINK contains contradictory intelligence reports, the net effect of posting these declassified documents on GulfLINK could be to confuse rather than enlighten the interested public. Without a better system for organizing and presenting information, persons using the resource could gain false impressions or misunderstand documents.
Although mailings such as the memorandum from Secretary Perry and Chairman Shalikashvili can be expensive, they are a reasonable method of getting information to the concerned population.
VA's On-line service and World Wide Web home page provide computer users with a widely accessible Gulf War veteran's illness education and referral resource.
VA's print PSA gives readers useful information on Gulf War veteran's illnesses. VA's broadcast PSAs, which publicize the Helpline number but do not mention illness or potential illness as a reason to call, need improvement.
VA's use of the term "priority care" in reference to Gulf War veteran's eligibility for health care creates false expectations among a significant portion of its clientele.
Public and congressional concern for the health of Gulf War veterans has been evident since the world witnessed the 1991 oil well fires on television. DOD did not set up hotlines or sites at medical treatment facilities to provide information and medical referral services to Gulf War veterans until 1994, a significant delay in response time.
VA's Helpline started late in comparison with its other efforts to address the issue of Gulf War veteran's illnesses. It was established two years after the initiation of the Persian Gulf Health Registry and one year following the passing of Public Law 103-210, which initiated "priority care" services. VA had conducted some outreach in tandem with the establishment of the Health Registry, but its Persian Gulf Review newsletter was sent only to those already participating in the Health Registry.OUTREACH: Recommendations from Interim Report
Operators at the DOD Medical Registry Hotline, DOD Incident Reporting Line, and VA Helpline should be instructed to ask "How did you find out about this number?" as a method of qualitatively measuring the success of the different methods for publicizing the numbers.
In the next Comprehensive Clinical Evaluation Program end-of-evaluation questionnaire, which participants answer when the initial evaluation is completed, DOD should include a question about satisfaction with the referral provided by the Persian Gulf Medical Registry Hotline.
DOD and VA should utilize more refined performance measures to determine how well outreach services are reaching concerned parties. Caller volume data are not adequate.
To assist the general public in interpreting the declassified intelligence documents on GulfLINK (a DOD site on the World Wide Web), DOD should prepare a user's guide. This guide should explain in general terms the various sources of intelligence information, how they may differ in quality and reliability, and how intelligence analysts compile and evaluate reports from a variety of sources in the field to obtain corroboration before preparing a final assessment. This guide should be featured prominently on the GulfLINK home page.
In its outreach campaign, VA should forego use of the term "priority care." VA should state clearly that Gulf War veterans are entitled to receive the Persian Gulf Health Registry examination free of charge, including any diagnostic testing found to be medically necessary and counseling regarding findings.
VA should make its broadcast public service announcements (PSAs) about the toll-free Helpline more explicit. The PSAs should include brief explanations of the purpose of the Helpline and the referral process for the Persian Gulf Health Registry.
Future conflicts are likely to generate controversial and unexplained health concerns, and DOD and VA should anticipate the need and plan for outreach services and implement them expeditiously.
OUTREACH: Findings from Final Report
In their geographic areas, Vet Center staffs have established working relationships with the veterans community, veterans service organizations, local municipal and state veterans liaison offices, in-region Guard and Reserve units, community social services organizations, local VA medical center personnel, and military establishments. These relationships enable Vet Centers to provide education and outreach to local communities about issues and clinical programs concerning Gulf War veterans, and a significant number of Gulf War veterans use their services.
The outreach initiative of VA's Persian Gulf Family Support Program was an effective method of communicating information about Gulf War veterans illnesses-in particular the established government clinical programs-to veterans, Reservists, National Guard members, and local communities. The program used trained, knowledgeable personnel in the field to establish a communication network with the community and deliver specific information directly to Gulf War veterans.
Ninety percent of separating active duty service members attend Transition Assistance Program (TAP) workshop briefings conducted jointly by DOD, VA, and DOL. VA benefits briefings during the TAP workshop could be an effective method of outreach about DOD and VA programs for evaluating Gulf War veterans illnesses, yet there is no evidence their clinical programs receive mention.
Through the initiatives of the Women Veterans Health Programs, VA has implemented a range of efforts to inform women veterans about available health services.
In regions with significant Latino populations, Vet Centers and VA medical centers deliver bilingual, cross cultural outreach and services.
While newspaper articles and television and radio broadcasts disseminated by DOD's American Forces Information Service provide adequate media coverage of Gulf War illnesses-related issues, few of the media products perform the outreach functions of publicizing government-sponsored Gulf War veterans clinical programs and methods of referral into them.
DOD's 1996 Internal Information Plan-Persian Gulf Illnesses describes its Comprehensive Clinical Evaluation Program, yet fails to provide the most basic information on how to register for it.
Effective risk communication is essential to the government's credibility on Gulf War veterans' illnesses, but DOD and VA have not seriously attempted to educate veterans about health effects of service in the Gulf War or to establish a dialogue concerning research programs relevant to veterans' concerns.
Several federal agencies have developed, tested, and validated techniques for health risk communication that could be adopted by DOD and VA.OUTREACH: Recommendations from Final Report
DOD and VA should follow the model of field-based outreach demonstrated in the Vet Centers and the Persian Gulf Family Support Program when developing health education and risk communication campaigns for active duty service members, Reserve and National Guard personnel, and other veterans. General, less specific outreach methods-e.g., hotlines and public service announcements-should be viewed as important supplements, but not as replacements.
VA should direct its Transition Assistance Program workshop benefits counselors to specifically mention DOD and VA programs related to Gulf War veterans' illnesses.
VA should ensure that its initiatives under the Women Veterans Health Programs specifically provide information about Gulf War-related programs.
VA should ensure that its outreach to Latino populations specifically provides information about Gulf War-related programs. As the Committee states in its Interim Report, DOD and VA should develop and utilize more refined performance measures to determine how well outreach services are reaching concerned parties. DOD and VA officials (specifically those in the American Forces Information Service and its broadcasting arm, the Armed Forces Radio and Television Service) using media products for outreach initiative should be aware of the difficulty in enumerating the actual readership and viewership figures and be concerned about how effectively their message saturates the targeted population.
DOD should reissue its Internal Information Plan on Gulf War-related illnesses. It should make a special effort to note the revision provides the toll-free number and that individuals are encouraged to register for its Comprehensive Clinical Evaluation Program. It also should take this opportunity to provide updated information.
In an attempt to increase veterans' and the public's awareness and understanding of the full range of the government's commitment to addressing the nature of Gulf War veterans' illnesses, DOD and VA should reevaluate the goals and objectives of their risk communication efforts. DOD and VA should develop effective methods that provide the affected community with comprehensive information concerning possible exposures to environmental hazards, potential health effects from risk factors, and explanations of ongoing and completed clinical and epidemiologic studies.
DOD and VA should immediately develop and implement a comprehensive risk communication plan. This effort should move forward in close cooperation with agencies that have a high degree of public trust and experience with risk communication, such as the Agency for Toxic Substance and Disease Registry and the National Institute for Occupational Safety and Health.
Because health risk information and education applies to service members who remain on active duty, members of the Reserves and National Guard, and veterans no longer in military service, DOD and VA should closely coordinate the federal government's risk communication effort for Gulf War veterans and others members of the affected community. Departmental commitments to any plan should be viewed as continuous and long-term; a sustained effort is particularly critical in light of veterans' and public skepticism arising from the recent revelations related to chemical weapons.
In its coordinated risk communication plan, DOD and VA should engage veterans service organizations as intermediaries-and include personnel in leadership positions, such as senior enlisted personnel (for active duty military) and state veterans' service officials-in the effort to establish an efficient information exchange process where veterans receive accurate information and the departments receive valuable feedback on clinical programs, health concerns, and communication efforts.MEDICAL AND CLINICAL ISSUES: Findings from Interim Report
No uniformity existed among the services in their predeployment or demobilization policies and procedures at the time of Operation Desert Shield/Desert Storm.
There is little evidence that quality control procedures were employed to ensure that existing policies were actually carried out during deployment or demobilization.
DOD's policies and procedures were not adequate in all cases to prevent members with preexisting conditions from deployment or to identify health problems extant at the time of demobilization, and these conditions could have contributed to some current health concerns.
FDA and DOD undertook an urgent and orderly course of action under the circumstances to devise a means to address the real threat of chemical and biological warfare in the Gulf War.
FDA has not been proactive in addressing public comments on the interim final rule or in devising better long-term methods for governing military use of drugs, vaccines, devices, and antibiotics intended for chemical and biological warfare defense.
When a waiver of informed consent is granted, the government has a strong obligation to conduct long-term followup of military personnel who receive investigational products.
DOD did not keep adequate records on who received anthrax and BT vaccines and PB in the Gulf War theater. There is little possibility now of developing reliable data about which or how many persons received those products.
DOD and VA admit to problems with missing or lost medical records, but neither system appears to place a priority on correcting these problems.
DOD's rationale for the requirement that records of vaccinations be kept secret was not well understood. This requirement confused and complicated recordkeeping procedures and hindered systematic followup of health issues.
The issue of accurate medical and vaccination records is central to the concerns of many ill veterans, and the absence of records has been suggested by some as evidence that the government is engaging in a cover-up of its own predeployment practices.MEDICAL AND CLINICAL ISSUES: Recommendations from lnterim Report
DOD should regularly review and update the policies and procedures that govern the pre-, during, and postdeployment medical assessment of the Ready Reserve to ensure they are current and adequate.
DOD should establish a quality assurance program to ensure compliance with pre-, during, and postdeployment medical assessment policies.
Prior to any deployment, DOD should undertake a thorough health assessment of a large sample of troops to enable better postdeployment medical epidemiology. Medical surveillance should be standardized for a core set of tests across all services, including timely postdeployment followup.
Given that FDA's Interim Final Rule permitting waiver of informed consent for use of unapproved products in a military exigency is still in effect, DOD should develop enhanced orientation and training procedures to alert service personnel they may be required to take drugs or vaccines not fully approved by FDA if a conflict presents a serious threat of chemical and biological warfare.
If FDA decides to reissue the Interim Final Rule as final, it should first issue a Notice of Proposed Rule Making. Among the areas that specifically should be revisited are: adequacy of disclosure to service personnel; adequacy of recordkeeping; long-term followup of individuals who receive investigational products; review by an institutional review board outside of DOD; and additional procedures to enhance understanding, oversight, and accountability.
DOD should assign a high priority to dealing with the problem of lost or missing medical records. A computerized central database is important. Specialized databases must be compatible with the central database. Attention should be directed toward developing a mechanism for computerizing medical data (including classified information, if and when it is needed) in the field. DOD and VA should adopt standardized recordkeeping to ensure continuity.MEDICAL AND CLINICAL ISSUES: Findings from Final Report
DOD has not been responsive to the Committee's recommendation that prior to any deployment, DOD should undertake a thorough health evaluation, including a core set of diagnostics, of a large sample of troops to enable better postdeployment medical epidemiology along with timely postdeployment followup.
FDA is moving toward soliciting public comment on alternatives to the Interim Final Rule related to permitting a waiver of informed consent for use of investigational products during military exigencies. The Committee remains seriously concerned about the amount of time-currently approaching six years-FDA is taking to open the process to public comment.
DOD has not been responsive to the Committee's recommendation that it should routinely inform recruits and troops, through orientation and training procedures, about the possible use of investigational drugs or vaccines for chemical and biological warfare agent purposes. DOD's lack of response in this highly sensitive area contributes to the perception of many that U.S. troops were inappropriately subjected to investigational drugs or vaccines during the Gulf War.
DOD has made progress in improving medical recordkeeping in-theater and stateside, but increased and sustained commitment from DOD's Joint Chiefs of Staff and Commanders in Chief will be necessary for current prototypes and plans to be fully and successfully integrated and implemented.
Clinical staff not directly involved in VA's Registry and DOD's CCEP are not well informed about the programs.
Follow-up treatment, particularly when mental health visits are involved, is problematic within both VA and DOD. Staffing constraints occasion long delays in scheduling appointments. Commanders are sometimes resistant to making sufficient time off available for active duty veterans to maintain an adequate treatment program.
Reproductive health care benefits available to active duty service members and their families through the Military Health Services System are comprehensive and the standard of care.
Reproductive health concerns are addressed on a case-by-case basis within DOD, and VA has extremely limited authority to treat such concerns at all. Neither DOD nor VA have widespread or systematic policies in place to address the concerns and questions of Gulf War veterans concerning reproductive health.
DOD and VA have implemented innovative programs to help veterans cope with combat-related stress.MEDICAL AND CLINICAL ISSUES: Recommendations from Final Report
Given that the Food and Drug Administration's (FDA) Interim Final Rule permitting a waiver of informed consent for use of unapproved products in a military exigency is still in effect, DOD should develop enhanced orientation and training procedures to alert service personnel they may be required to take drugs or vaccines not fully approved by FDA if a conflict presents a serious threat of chemical and biological warfare.
FDA should solicit timely public and expert comment on any rule that permits waiver of informed consent for use of investigational products in military exigencies. Among the areas that specifically should be revisited are: adequacy of disclosure to service personnel; adequacy of recordkeeping; long-term followup of individuals who receive investigational products; review by an institutional review board outside of DOD; and additional procedures to enhance understanding, oversight, and accountability.
DOD officials at the highest echelons, including the Joint Chiefs of Staff and the Commanders in Chief, should assign a high priority to dealing with the problem of lost or missing medical records. A computerized central database is important. Specialized databases must be compatible with the central database. Attention should be directed toward developing a mechanism for computerizing medical data (including classified information, if and when it is needed) in the field. DOD and VA should adopt standardized recordkeeping to ensure continuity.
The Persian Gulf Veterans Coordinating Board and other appropriate Departments and Agencies should be charged to develop a protocol to implement the following recommendation, which was made in the Committee's Interim Report: Prior to any deployment, DOD should undertake a thorough health evaluation of a large sample of troops to enable better postdeployment medical epidemiology. Medical surveillance should be standardized for a core set of tests across all services, including timely postdeployment followup.
VA and DOD should, in their educational outreach programs, specifically target staff members not directly involved in the care of Gulf War veterans.
DOD and VA should include timely updates on the Comprehensive Clinical Evaluation Program or Persian Gulf Health Registry, respectively, in their Continuing Medical Education programs.
VA and DOD should regularly brief their staffs on the Gulf War research portfolio and on the results of research studies as they become available.
VA and DOD should regularly review staffing needs, particularly in mental health, and increase recruitment and retention of adequate numbers of medical professionals to satisfy patient needs. Staffing reviews should consider that, despite increased medical surveillance and better preventive measures, future deployments also will generate a significant number of veterans who will need care for illnesses that are difficult to diagnose.
Since 1986, U.S. service members with certain chronic illnesses, e.g., asthma and diabetes, have been allowed to remain on active duty when regular medical monitoring is necessary. Veterans of the Gulf War with chronic illnesses are no different. Troop commanders should be reminded that adequate time off for follow-up medical appointments is a necessity and a priority.
The government should conduct a thorough review of its policies concerning reproductive health and seek statutory authority to treat veterans and their families for service-connected problems. When indicated, genetic counseling should be provided-either via VA treatment facilities or referral-to assist veterans and their families who have reproductive concerns stemming from military service.
The government should continue and intensify its efforts to develop stress reduction programs for all troops, with special emphasis on deployed troops.
Since leadership and unit cohesion are so important in managing stress, DOD should specifically involve senior commanders and senior noncommissioned officers in stress management programs.RESEARCH: Findings from Interim Report
Despite the unique features of the Gulf War, it should be possible using epidemiologic approaches to determine whether Gulf War veterans have more or less mortality, symptoms, or diseases than an appropriately chosen comparison population.
Most of the studies examined by the Committee appear to be well-designed and appropriate to answer questions about mortality, symptoms, or diseases.
Some studies currently underway or planned at best will add little information to other better designed studies and could provide misleading information, leading to false conclusions.
External scientific review of the major epidemiologic studies has ranged from nonexistent, to one-time review of protocols, to standing scientific advisory panels which have an ongoing role in the design and execution of the studies. Ongoing external review has proved beneficial to several of the studies.
Public advisory committees might improve communications with the veterans asked to participate in epidemiologic studies.
A single coordinating body with an overarching perspective is needed to monitor whether outstanding research questions are being adequately addressed, whether individual studies will contribute to the overall effort, and the extent to which the studies are responsive to recommendations from external reviewers.
Sharing a subset of basic questions on demographics, symptoms, and exposures across large surveys of Gulf War veterans and controls could provide information useful for comparisons across the studies and better understanding of differences in the study populations.
There is little exposure data available for Gulf War veterans about many key risk factors. As a consequence, it will be more difficult to link adverse health outcomes detected by epidemiologic studies to some specific exposures or risk factors.
The Persian Gulf Registry of Unit Locations data from DOD will be important for investigating questions about Gulf War veterans' health issues, but it will not be a substitute for missing exposure data for many risk factors.RESEARCH: Recommendations from Interim Report
All epidemiologic studies aimed at Gulf War veterans' health issues should incorporate external scientific review and ongoing interaction with appropriate outside experts throughout the study process, from study design through analysis of results.
The Persian Gulf Veterans Coordinating Board should play an active role in allocating the limited resources available for research on Gulf War veterans' illnesses. The Research Working Group of the Coordinating Board should monitor the findings and recommendations of scientific peer review committees. If scientific reviews draw into question the usefulness of particular studies to the overall research strategy, the Research Working Group should, via the Coordinating Board, recommend appropriate actions to the Secretaries of the three departments involved.
DOD, DHHS, and VA should recommend their principal investigators use public advisory committees in designing and executing epidemiologic studies of Gulf War veterans' illnesses.
For those questions that are common to different epidemiologic surveys, coordination between principal investigators and survey design experts should take place to arrive at common wording. The Persian Gulf Veterans Coordinating Board's Research Working Group should take responsibility for this coordination.
The Persian Gulf Registry of Unit Locations should be made available to qualified government and private researchers as quickly as possible, within the constraints of confidentiality.
DOD should make reasonable and practical efforts to collect and record better troop exposure data during future conflicts and to make those data available as quickly as possible to health care researchers.RESEARCH: Findings from Final Report
DOD and VA have not taken serious steps to encourage their principal investigators to convene and use public advisory committees for its Gulf War veterans' epidemiologic health research.
DOD's Persian Gulf Registry of Unit Locations lacks the precision and detail necessary to be an effective tool for the investigation of exposure incidents. The effort has been no more successful than the effort to compile similar information following the Vietnam War to examine possible exposures to Agent Orange.
Overall, the government's current research portfolio on Gulf War veterans' illnesses is appropriately weighted toward epidemiologic studies and studies on stress-related disorders that are more likely to improve our understanding of Gulf War veterans' illnesses. For the most part, the government's prioritization process has worked.
Research on Gulf War veterans' illnesses is treated, appropriately, as a subset of the government's broader research portfolio on the health consequences of military service. Any new research funds should be directed toward the principal uncertainties, which are: long-term health effects from stress; long-term health effects from low-level exposure to chemical weapons; long-term health effects from exposure to known carcinogenic and mutagenic compounds, such as mustard agent; and long-term health effects of interactions between pyridostigmine bromide and other agents.
Stress is not well understood in terms of diagnoses, physiological sequelae, and effective prevention and treatment strategies; yet it is likely to be an important contributing factor to illnesses currently reported by Gulf War veterans. Additional attention to basic and applied research on stress-related disorders across the entire federally funded biomedical research portfolio would benefit DOD's and VA's capabilities to manage combat stress and its effects.
The efforts of the Coordinating Board's Research Working Group would benefit from the active participation of additional representatives from other federal agencies with relevant expertise, such as the National Institutes of Health and the Agency for Toxic Substances and Disease Registry.
VA's November 1996 establishment of a new Environmental Hazards Center focused on reproductive health and developmental outcomes from environmental exposures is an important step forward in developing policies for the treatment of veterans and addressing their concerns.RESEARCH: Recommendations from Final Report
The Research Working Group of the Persian Gulf Veterans Coordinating Board should require that any proposals for new, large-scale Gulf War veterans' epidemiologic health research describe a plan to incorporate a public advisory committee into the study design, dissemination of results, or both. The Research Working Group should consider justifying a waiver of such a committee only under rare circumstances.
The government should develop more accurate and reliable methods of recording troop locations to facilitate post-conflict health research in the future. DOD should make full use of global positioning technologies.
The government should plan for further research on possible long-term health effects of low-level exposure to organophosphorus nerve agents such as sarin, soman, or various pesticides, based on studies of groups with well-characterized exposures, including: a) cases of U.S. workers exposed to organophosphorus pesticides; and b) civilians exposed to the chemical warfare agent sarin during the 1994 and 1995 terrorist attacks in Japan. Additional work should include followup and evaluation of an appropriate subset of any U.S. service personnel who are presumed to be exposed during the Gulf War. The government should begin by consulting with appropriate experts, both governmental and nongovernmental, on organophosphorus nerve agent effects. Studies of human populations with well-characterized exposures will be much more revealing than studies based on animal models, which should be given lower priority.
Since a number of Gulf War risk factors are potential human carcinogens that could result in increased rates of cancer beginning decades after exposure, VA should continue to monitor Gulf War veterans through its ongoing mortality study for increased rates of lung, liver, and other cancers.
Depleted uranium munitions are likely to be used in future conflicts involving U.S. service personnel. To fully elucidate the health effects of depleted uranium munitions, VA should conduct research that compares the health status of individuals with embedded fragments of DU shrapnel with appropriate control groups.
The government should continue to collect and archive serum samples from U.S. service personnel when feasible.
The Research Working Group should more thoroughly consult with other federal agencies with relevant expertise-such as the National Institutes of Health (particularly the National Institute of Environmental Heath Sciences) and the Agency for Toxic Substances and Disease Registry-on basic, clinical, and epidemiologic research and on risk communication.CHEMICAL AND BIOLOGICAL WEAPONS: Findings from Interim Report
Although much was known at the time of the Gulf War, UNSCOM's work provides a more definitive picture of Iraq's CBW capability and doctrine, revealing advanced capabilities and underscoring the considerable uncertainty regarding Iraq's intentions to use CBW agents against American and Coalition troops.
The U.S. government's decision to reexamine the records of the Gulf War for evidence of exposure to CBW agents is prudent in light of the health concerns of veterans and the findings from UNSCOM's investigations. The Committee intends to monitor the investigations of PGIT and CIA.
DOD is taking reasonable steps to improve battlefield CW agent detection capability by developing equipment that will detect mustard agent and that will not sound false alarms in response to common battlefield interferents.
The inability to provide real-time detection of BW agents constitutes a serious deficiency in the U.S. chemical and biological defense posture.
The ability to monitor low-levels of CW agents would improve the health care surveillance of U.S. troops.CHEMICAL AND BIOLOGICAL WEAPONS: Recommendations from Interim Report
CIA and DOD should coordinate their analyses to ensure a comprehensive review of the complete record of the Gulf War. Each agency should make full and prompt disclosure of all findings.
DOD should devote more attention to monitoring low-level (subacute) exposures to chemical warfare agents. One possible basis for such a system is the automated air-sampling system developed by the U.S. Army Edgewood Research, Development and Engineering Center for the United National Special Commission on Iraq, which is using it to monitor emissions from Iraqi chemical plants. Another approach might be to modify the detection system the U.S. Army uses to monitor for leaks at chemical weapons storage depots.
DOD should continue to invest in the development of a biological point detector/alarm system that can detect and identify biological warfare agent aerosols rapidly enough to enable troops to take protective measures before being exposed.CHEMICAL AND BIOLOGICAL WEAPONS: Findings from Final Report
In the face of credible evidence of the presence or release of chemical warfare agents, low-level exposure of U.S. personnel at the affected site must be presumed while efforts to develop more precise measures of exposure continue.
The evidence of chemical warfare agent release at Khamisiyah is overwhelming, and low-level exposure to troops within a 50 kilometer radius should be presumed while efforts to develop more precise measures of exposure and more detailed knowledge of the demolition activities continue.
Other site-specific exposure of U.S. troops to low levels of chemical warfare agents cannot be ruled out. A theater-wide time/distance analysis is insufficient to address positive detections by Fox reconnaissance vehicles and M256 kits.
DOD has conducted a superficial investigation of possible chemical warfare agent exposures that is unlikely to provide credible answers to veterans' and the public's questions.CHEMICAL AND BIOLOGICAL WEAPONS: Recommendations from Final Report
All U.S. service personnel assigned to units near the Khamisiyah demolition activity should be notified and encouraged to enroll in VA's Persian Gulf Health Registry or DOD's Comprehensive Clinical Evaluation Program. In determining the extent of possible chemical warfare agent exposure at Khamisiyah and any other sites that future investigations uncover, the government should use the best theoretical and practical assessment tools available. The Committee recognizes the large number of variables that can affect the outcome of any determination, but identifies the following as essential principles:
à Where objective, unrebutted evidence suggests the release of chemical warfare agents in the vicinity of U.S. troops, every effort should be made to identify the source of the agent and to model the downwind footprint of the potential distribution of agent at the general population exposure level (or lower threshold, if appropriate);
à When a downwind footprint is established, a conservative, presumptive-exposure area should be defined that reflects the uncertainties of the modeling effort. The presumptive-exposure area should, at a minimum, include all sites within a circle that has a radius equal to the length of the downwind footprint; and
à Troops within the presumptive-exposure area should be notified and encouraged to enroll in the CCEP or Registry.
All reports of positive M256 kits and Fox detections must be thoroughly investigated. Where unit logs record positive detections by either type of equipment, members of that unit should be notified and encouraged to enroll in VA's Persian Gulf Health Registry or DOD's Comprehensive Clinical Evaluation Program.
To ensure credibility and thoroughness, further investigation of possible chemical or biological warfare agent exposures during the Gulf War should be conducted by a group independent of DOD. Openness in oversight activities-including public access to information and veteran participation-public notice of meetings, opportunity for public comment, and regular reporting are essential. Full public accountability is critical.COORDINATION: Finding from Final Report
Many issues related to post-conflict health concerns of Gulf War veterans are common to the aftermath of other military engagements. Governmental responsibility to address such concerns spans the missions of several federal departments and agencies, but is a priority for no agency. Resolving these issues in a timely and effective manner requires interagency coordination at the highest levels of government.COORDINATION: Recommendation from Final Report
A Presidential Review Directive (PRD) should be issued to instruct the National Science and Technology Council to develop an interagency plan to address health preparedness for and readjustment of veterans and families after future conflicts and peacekeeping missions. The President's Committee of Advisors on Science and Technology and other nongovernmental experts, as appropriate, should be asked to review the plan 12 months after the PRD is issued and again at 18 months to ensure national expertise is brought to bear on these issues.NATURE OF GULF WAR VETERANS' ILLNESSES: Findings from Final Report
Gulf War veterans have experienced no excess mortality from natural causes during or after the war. Gulf War veterans have experienced excess mortality from external causes, such as injuries, which is consistent with the experience of veteran populations from previous conflicts.
Information from the clinical programs indicates musculoskeletal conditions and ill-defined conditions are common components of Gulf War veterans' illnesses.
Data from the clinical programs and epidemiologic studies indicate stress-related disorders are common components of Gulf War veterans' illnesses.
Among the subset of the Gulf War veteran population examined in the ongoing clinical and research programs, many veterans have illnesses likely to be connected to their service in the Gulf. Currently, the extent of service-connected illness in the population is unknown.
Stigmatization of psychosomatic illness seriously interferes with some veterans seeking care.
It is unlikely that exposures in the Gulf War theater are responsible for the birth defects of children born to veterans.
VA's examination program for spouses and children of Gulf War veterans has little or no value as a research program and offers no incentive for participation, thus raising expectations about the government's ability to respond to health care needs in veterans and their families that are impossible to meet.
The absence of baseline data regarding the reproductive history and health of military personnel makes determinations of the effects of exposures during deployment more complex and difficult.NATURE OF GULF WAR VETERANS' ILLNESSES: Recommendations from Final Report
Research on possible causes and methods of prevention of excess mortality from external causes among veterans should receive high priority.
Research on Gulf War veterans' illnesses should emphasize investigating the causes and methods of prevention and treatment of musculoskeletal conditions.
Research on Gulf War veterans' illnesses should emphasize investigating the causes and the methods of prevention and treatment of stress-related disorders.
Since the stigmatization of mental illness continues to be a problem for society at large, DHHS should place a priority on developing public education outreach programs that note the indissoluble association between the mind and the body. DOD and VA should make a special effort to address and target such needed educational outreach to their communities.
Since Congress has extended VA's examination program for spouses and children of Gulf War veterans, VA should formulate what it intends to do with the results and consider mechanisms to reimburse travel and other costs.
The government should consider methods for routinely sampling military populations regarding reproductive health so that an appropriate baseline exists for evaluating reproductive outcomes following deployment. In particular, DOD should consult with the National Center for Health Statistics and strongly consider implementing its National Survey of Family Growth and related methodologies for collecting data.GULF WAR RISK FACTORS: Findings from Final Report
Although some veterans clearly have service-connected illnesses, current scientific evidence does not support a causal link between the symptoms and illnesses reported today by Gulf War veterans and exposures while in the Gulf region to the following environmental risk factors assessed by the Committee: pesticides, chemical warfare agents, biological warfare agents, vaccines, pyridostigmine bromide, infectious diseases, depleted uranium, oil-well fires and smoke, and petroleum products. Some of these risk factors explain specific, diagnosed illness in a few Gulf War veterans, for example, leishmaniasis has been diagnosed in 32 individuals. Prudence requires further investigation of some areas of uncertainty, such as the long-term effects of low-level exposure to chemical warfare agents and the synergistic effects of exposure to pyridostigmine bromide and other risk factors.
A number of Gulf War risk factors-e.g., mustard agent, aflatoxin, and certain petroleum products-are potential human carcinogens that could cause increased rates of cancer beginning decades after exposure.
Stress is known to affect the brain, immune system, cardiovascular system, and various hormonal responses. Stress manifests in diverse ways, and is likely to be an important contributing factor to the broad range of physiological and psychological illnesses currently being reported by Gulf War veterans.GULF WAR RISK FACTORS: Recommendations from Final Report
DOD and VA should perform long-term mortality studies of Gulf War veterans appropriate for investigating cancer rates in the Gulf War veteran population in the coming decades.
The entire federal research portfolio should place greater emphasis on basic and applied research on the physiologic effects of stress and stress-related disorders.