Since the end of the Persian Gulf conflict and the first reports of health problems in Persian Gulf veterans, the federal government has acted to ensure that veterans have access to medical care, can pursue appropriate avenues for compensation, and are informed of the various programs and activities made available to them by the VA and DoD. Research is now moving forward to address vitally important questions, the answers to which will help guide health care professionals in their treatment of Persian Gulf veterans, and will enhance the ability to minimize reoccurrences of such phenomena in future deployments. This working plan was developed to bring coherence to the research efforts being conducted or sponsored by the federal government, and to assist federal decision makers in the pursuit of various research directions.

In the introduction, three goals were articulated for research on Persian Gulf veterans' illnesses:

  1. Establishment of symptom and illness prevalence;

  2. Identification of risk factors; and

  3. Identification of diagnostic, treatment, and prevention methodologies.

The federal government is currently invested in achieving all three goals. However, it is evident that the greatest focus on research at the present must be in the area of epidemiology to ascertain symptom/illness/disease prevalence. Without this information it cannot be quantitatively determined whether Persian Gulf veterans are actually experiencing unusual or unexpected health problems; and if they are, the extent of the problem. The VA Persian Gulf Registry and the DoD Comprehensive Clinical Evaluation Program are valuable for revealing the nature of veterans symptoms and illnesses. However, they cannot, by their self-reporting nature, reveal the true population prevalence of the reported symptoms and illnesses. Population-based studies are needed to obtain this information.

VA, DoD, and HHS are each embarking on several population-based studies to determine symptom and illness prevalence. In addition, there are some small, highly focused, epidemiological efforts that are concentrating on ascertaining the prevalence of discernible symptom complexes such as chronic fatigue syndrome. These ongoing epidemiological investigations are clearly the most important. However, recent concerns about adverse reproductive outcomes and sexual dysfunction among veterans and their spouses adds a new dimension to the problem. Although all of the major population-based studies have components associated with reproduction and sexual function, there is a need for studies that are focused on these particular problems. As a vital adjunct to population-based studies, quantitative exposure information is badly needed. If there are findings of excess symptoms and illnesses in Persian Gulf veterans, geographical and temporal exposure data that can be assigned to veterans when they were in the Persian Gulf will greatly improve the prospects for determining an association.

Research aimed at the second and third goals theoretically should wait until findings from the population studies are complete. However, though research studies aimed at these goals are not currently as important as the population studies, they cannot wait for epidemiology findings. Appropriately targeted, parallel studies investigating specific etiological factors will anticipate epidemiology findings. Based on reviews by expert scientific panels it has become evident that the etiological factors of greatest concern are: exposures to psychophysiological stress; infection by Leishmania tropica, possibly leading to a mild viscerotropic form of the disease; and the potential interactive effects of concurrent exposures to pyridostigmine bromide, the insect repellents DEET and permethrin, and organophosphate pesticides. Consequently, carrying out appropriate research in these three areas now, while the epidemiology studies are in progress, should reduce the time required to interpret any positive epidemiological findings. Furthermore, the research questions that need to be posed addressing etiological factors should have generalizablility beyond the current concerns of Persian Gulf veterans, and thus address the needs of the third goal, i.e. the identification of diagnostic, treatment, and disease prevention methodologies.

Important specific areas of inquiry for which significant gaps in knowledge currently exist include:

As was stated in the introduction, this working plan is a living document. As research findings become available, the Research Working Group will periodically revisit the plan with the aim of defining additional needed research as well as refining and revising priorities.