1. INTRODUCTION

1.1 BACKGROUND

A wide variety of symptoms and illnesses were first reported by veterans returning from the Persian Gulf conflict in late 1991. The initial response to this problem appropriately involved descriptive studies including:

Clinical evaluations;
Disease outbreak and cluster investigations;
Population surveillance;
Initial exposure inventory and assessment;
Troop location.

The response included establishing the Department of Veterans Affairs (VA) Persian Gulf Registry Health Examination Program ("Persian Gulf Registry") and Persian Gulf Referral Centers, and the Department of Defense (DoD) Comprehensive Clinical Evaluation Program (CCEP). These major clinical undertakings resulted from the need for a systematic collection of clinical, and other descriptive data regarding the health of Persian Gulf veterans that would aid in medical care of veterans and active duty service members.

As of April 1995, a total of 36,604 Persian Gulf veterans had completed the VA registry examination and had their examination data entered into a computerized database, the VA Persian Gulf Registry. Of the 31,705 veterans in the registry with one or more symptoms, 76% received medical diagnosis from VA clinicians, leaving 7,606 (24%) veterans with no conventional diagnoses for the symptoms. The DoD CCEP revealed a similar pattern of findings among the 2,607 participants who had completed the examination as of the same time: 84% with diagnosis and 16% with less well defined illnesses.

Overall, the VA Persian Gulf Registry and the CCEP have identified a wide spectrum of overlapping symptoms involving multiple organ systems. As of April 1995, the most commonly reported symptoms from the VA Persian Gulf Registry include:

            


SYMPTOM                   FREQUENCY          

Fatigue                         20%             
Skin rash                       18%
Headache                        17%
Muscle/Joint pain               16%
Memory loss                     13%
Shortness of breath             8%
Sleep disturbances              5%
Diarrhea and other GI symptoms  4%
Chest Pain                      4%

In the initial stages of the search for a cause of these symptomatic conditions, attention was brought to the multitude of environmental, occupational, and biological exposures that may have been experienced by many of the troops. When combined with the unique conditions of a rapid, large-scale deployment, it was evident that a quantitative understanding of the nature of these exposures would be needed along with better understanding of the illnesses.

1.2 THE ROLE OF RESEARCH

The inability to diagnose all of the illnesses of Persian Gulf veterans, as well as the need to establish whether there is a link between diagnosable conditions and service in the Persian Gulf, has resulted in the initiation of a broad-based research program. The research plan presented here is intended to help coordinate and focus the research efforts sponsored by the federal government in a coherent and cost-effective manner. This document presents an approach to answering questions about the nature of illnesses experienced by Persian Gulf veterans. This research is intended to pursue the following goals:

Establishment of the nature and prevalence of symptoms, diagnosable diseases, and other conditions in Persian Gulf veterans in comparison to appropriate control populations;
Identification of possible risk factors for any excess morbidity or mortality among Persian Gulf veterans;
Identification of appropriate diagnostic tools, treatment methods, and prevention strategies for any excess conditions that are found among Persian Gulf veterans.

Where appropriate and feasible, these goals will address the family members of veterans as well as the veterans per se.

1.3 RESEARCH COORDINATION

Government sponsored research is coordinated by the VA and executed by various departments and agencies of the federal government. The Research Working Group, through the Persian Gulf Veterans Coordinating Board (composed of representatives from VA, DoD, HHS, and the Environmental Protection Agency (EPA)), is charged with assessing the state and direction of research; identifying gaps in factual knowledge and conceptual understanding; identifying testable hypotheses; recommending research directions for participating agencies; reviewing research concepts as they are developed; and collecting and disseminating scientifically peer-reviewed research information.

1.4 PURPOSE OF THE WORKING PLAN

This plan:

Identifies the knowledge needed to achieve the above-stated goals;
Identifies the knowledge that is currently available or will be obtained from ongoing research at some time in the foreseeable future;
Identifies the research areas that need to be covered to close the gap between what is known and what is needed.

This plan is a dynamic working document that will undergo periodic modifications as new knowledge emerges and as research findings improve the understanding of Persian Gulf veterans' illnesses.