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Gulf Illnesses: Stepped-up Efforts, New Research Initiatives
Prepared statement of Dr. Stephen C. Joseph, assistant secretary of defense for health affairs, The Hospitals and Health Care Subcommittee, House Veterans Affairs Committee, Thursday, March 09, 1995

Mr. Chairman and distinguished members of the committee, it is an honor for me to come before you today as the assistant secretary of defense for health affairs to discuss the department's medical and research programs concerning illnesses related to the Persian Gulf war.

Mr. Chairman, let me first provide some assurances to you, the American public and our troops and their families. For the past two years the Clinton administration has been heavily engaged in caring for our Persian Gulf troops and in solving the difficult puzzle known as Persian Gulf illness. Just this Monday the president, in a speech before the Veterans of Foreign Wars, described the very aggressive program of research and care already under way. But we need to go further.

For the future the president announced that we will "step up our treatment efforts and launch new research initiatives." The departments of Defense, Veterans Affairs and Health and Human Services will be funding millions of dollars in new research initiatives. New specialized care centers are being opened for those troops whose illnesses are difficult to diagnose or treat.

But the president went even further. In stressing his personal commitment on the issue the president announced the creation of a presidential advisory committee, a committee that will report to president and the American public and focus on government efforts to find the causes of these illnesses and improve care available to gulf war veterans.

With a firm Clinton administration commitment to research and care firmly in place I believe it is important to frame our efforts by providing some background information. Approximately 697,000 service members were deployed to the Persian Gulf in 1990-1991 in support of Operation Desert Shield/Desert Storm.

Very importantly, the vast majority of soldiers, sailors and airmen returned from this large deployment healthy and remain fit for duty today. Since the war with Iraq, most gulf war veterans seeking medical care have had readily diagnosable illnesses, the same types of illnesses that would be expected in such a large population of adults. However, there are service members who have suffered illnesses that are not easily explained. It is this group on which we are focusing our medical research efforts.

To better understand why some veterans were reporting diverse symptoms that were not readily explained I established the Comprehensive Clinical Evaluation Program on June 7, 1994. The CCEP was launched to provide a systematic, in-depth medical evaluation for all military health care beneficiaries who are experiencing illnesses that may be related to the Persian Gulf deployment.

Since June 7, 1994, the Department of Defense has enrolled approximately 15,000 participants in the CCEP. Of the 4,674 people with completed evaluations, 2,074 patients' records have been reviewed and validated and have been entered into the CCEP data base.

The CCEP is a systematic program that allows us to accomplish several objectives. As I have said from the beginning, first and foremost the CCEP is really all about taking care of our people. It makes the medical care of Persian Gulf veterans and their family members a high priority. It allows us to identify patterns of health problems across this group of patients. Finally, the CCEP is the first and necessary step to understanding the illnesses related to the Persian Gulf deployment.

I should issue a word of caution here. The CCEP was designed to provide medical care and was not designed as a formal research project. Further, because the CCEP results are derived from a self-selected population of patients, the distribution of illnesses cannot, of course, be directly related to the overall population of 697,000 gulf war veterans nor can the specific distribution of diagnoses be compared directly to the VA registry because of differences in demographic characteristics between the two registries. Although qualified by these factors, the CCEP nevertheless provides very accurate and specific information about the types of symptoms and illnesses that are affecting gulf war veterans presenting for medical evaluation because it provides a systematic, comprehensive medical evaluation.

Preliminary findings, based on the review of 2,074 CCEP patients with validated evaluations, include the following:

 

  • Eighty-four percent of the first 2,074 CCEP patients have a clear diagnosis or diagnoses which explains their condition. These diagnoses represent a very broad range of known clinical entities for which these patients are receiving treatment and are responding favorably.
  • Infectious diseases account for relatively few diagnoses, about 4 percent, and do not represent a major cause of illness among CCEP patients. Based on information from the CCEP and other sources, we are aware of about 30 patients who were diagnosed with leishmaniasis as a result of the Persian Gulf deployment.
  • Twenty-one percent of these patients have psychologically related medical conditions.

Most of these conditions are relatively common in the general population and include such diagnoses as depression, anxiety, tension headache and stress-related disorders. These patients have been provided appropriate treatment and many have responded well. I think it is important to understand that these people are hurting as much from their symptoms as if they had diabetes or arthritic knees. The good news is, as with most of all the CCEP patients, we are able to provide treatment and offer these patients relief.

 

  • About 16 percent of patients with completed CCEP evaluations have ill-defined symptoms, also commonly seen in civilian medical practice, such as fatigue, headache and sleep disturbances. These patients will receive further evaluation by DoD.
  • Based on the CCEP experience to date there is no clinical evidence for a new or unique agent causing illnesses among Persian Gulf veterans.

Although the specific distribution of illnesses in this nonrandomly selected sample cannot be generalized to the entire gulf war veteran population, the preliminary results of the CCEP are consistent with conclusions of a National Institutes of Health technology assessment workshop that "no single disease or syndrome is apparent, but rather multiple illnesses with overlapping symptoms and causes." Likewise, the Defense Science Board determined that there was insufficient evidence that supported a coherent "syndrome."

To better understand the nature of these difficult diagnoses DoD has established two national specialized care centers for those individuals who require further evaluation and, especially, care for conditions possibly related to environmental, psychosocial, biological or medical factors associated with deployments. The specialized care centers are located in Washington, D.C., and San Antonio, Texas. The centers offer the full array of specialty evaluations and coordinated, patient-centered care for referred Persian Gulf veterans and their family members.

For as long as is needed the CCEP will continue to provide gulf war veterans and their families with the diagnostic tools and medical care they deserve. In addition to medical care the CCEP will undoubtedly identify scientific hypotheses for future medical research. I want to emphasize that the cornerstone of our medical approach is to keep an open mind, to foreclose no possibilities prematurely and to "let the chips fall where they may."

In conjunction with the CCEP the department continues to work closely with the departments of Veterans Affairs and Health and Human Services in a coordinated and intensive scientific research effort to assess the health consequences of military service members deployed to the Persian Gulf. In FY [fiscal year] 94 DoD alone dedicated more than $4 million to medical research focused on Persian Gulf health issues.

Along with providing high quality medical care the departments of Defense, Veterans Affairs, and Health and Human Services have initiated numerous scientific research studies to evaluate the health consequences of serving in the Persian Gulf. Further, DoD is engaged in a number of collaborative research projects with the VA and HHS. Each project assesses the health consequences of military service as a result of the Persian Gulf war. Although the research activities span a broad range of areas, I'd like to mention some of the critical studies:

 

  • The Navy is conducting several large epidemiologic studies which will compare morbidity and mortality among Persian Gulf veterans with military personnel who were not deployed to the Persian Gulf. Results are expected late this year. The goal is to determine whether the incidence of diagnosable illnesses and nonspecific complaints, like fatigue, are different from what would be expected.
  • Studies will assess reproductive health and birth outcomes using hospitalization records of gulf war veterans compared to a nondeployed control group. The analyses should be complete by this fall.
  • Additionally, DoD is collaborating with the VA to conduct a large, randomized epidemiologic study of 30,000 veterans. Again, gulf war veterans will be compared to a nondeployed military population. Data collection is expected to begin late this summer.
  • Studies in progress include infectious disease projects (especially tropical disease research).
  • Research is also under way to identify the health effects of exposure to depleted uranium. Early results are encouraging, although long-term follow-up is necessary to fully evaluate such as exposure.
  • Research is currently progressing to identify possible interactive effects of certain chemical compounds used during the gulf war with pyridostigmine. For those who may not be familiar with pyridostigmine bromide, it is a pill that, when used as a pretreatment, provides meaningful, therapeutic enhancement to injectable treatment of nerve agent-exposed patients.

These studies will evaluate the health consequences of the Persian Gulf war and will contribute to the development of programs to protect the health of military personnel during future deployments.

There are two sets of funds that we are using to fund Persian Gulf-related research. In both cases we are working with the Persian Gulf Veterans Coordinating Board. The board, headed by the secretaries of DoD, VA, Department of Health and Human Services, was established to coordinate clinical care, research and compensation issues.

With respect to the first set of funds, the department is working with the Persian Gulf Veterans Coordinating Board to help identify DoD-funded medical research proposals totaling approximately $5 million in FY 95. DoD will disperse this money to agencies and institutions external to the federal government. Research proposals will be selected after the projects have been independently peer reviewed for scientific merit; the proposals will also be competitively bid.

We will work closely with the departments of Veterans Affairs and Health and Human Services through the Coordinating Board to select the best scientific research studies in three specific areas: epidemiologic studies, studies involving pyridostigmine bromine and other clinically related research projects. ... With respect to the second set of funds totaling about $5 million in FY 95, DoD will supplement the research mentioned above. To help DoD determine what research to fund, the Persian Gulf Coordinating Board will identify research gaps with respect to the Persian Gulf and prioritize protocols based on scientific merit and value. Projects supported by these funds could potentially come from agencies both external to and within the federal government and will be directly funded by DoD based upon the recommendations of the coordinating board.

Now there is one area, chemical and biological exposure, which has been the subject of intense media coverage and public interest. Let me summarize what we know of the exposure of our troops to chemical and biological weapons. Hundreds of false chemical alarms that were activated due to dust, heat, smoke and low batteries have led many to believe that chemical agents were used.

[Desert Storm commander in chief Army] Gen. [H. Norman] Schwarzkopf's experience was that these alarms were taken seriously and immediately investigated and that never was there confirmation of actual chemical presence. Just last week he was quoted in USA Today in reference to Iraq's using of chemical or biological weapons. What Gen. Schwarzkopf said was, "There's absolutely no evidence that we ever ran into during the war, or anything that's come up since the war, that I know of, that says they used them."

Two independent agencies with distinguished scientists, environmental health experts and physicians from the leading universities in this country have addressed the chemical and biological weapons/warfare issue. These groups were the Defense Science Board and the Institute of Medicine (a body of the National Academy of Sciences). Both of these groups arrived at essentially similar conclusions about the lack of evidence on chemical and biological weapons as being causative factors in the symptoms seen in Persian Gulf veterans.

Now we all know how difficult it is to prove the negative, to prove that there was no exposure to chemical or biological weapons. On the other hand there is no persuasive evidence of such exposure, even after much scrutiny. But we are not done. It is our intention to find the answer, whatever it may be.

The department has declassified a substantial number of military documents which might offer some insights. The department is engaged in an ongoing effort of research, clinical work and investigation of anecdotes and theories. It is our sincere hope that all of this together can provide us the answers being sought by our troops and their families.

In closing, let me again turn to the president's personal commitment to our Persian Gulf veterans and quote his words to the Veterans of Foreign Wars, "We must listen to what the veterans are telling us, and respond to their concerns. ... We will leave no stone unturned. And we will not stop until we have done everything that we possibly can for the men and women who -- like so many veterans in our history -- have sacrificed so much for the United States and our freedom."

Mr. Chairman, the Department of Defense is fully committed to providing high quality, compassionate medical care to gulf war veterans and their families no matter what the cause. This remains our No. 1 priority, but that is not enough.

Parallel to providing outstanding medical care we will continue to seek answers for our troops and their families from the research community. The aim of our research program is to evaluate and understand the health consequences for our people serving in the Persian Gulf. But beyond that we are determined to enhance our current programs to protect the health of our troops and their families during future deployments.

Let me express my deep appreciation for your interest and concern for the health of the Veterans of the Persian Gulf war and your active support of military medicine as we continue to use science to provide the answers to a very complex set of health questions.

 

Published for internal information use by the American Forces Information Service, a field activity of the Office of the Assistant to the Secretary of Defense (Public Affairs), Washington, D.C. Parenthetical entries are speaker/author notes; bracketed entries are editorial notes. This material is in the public domain and may be reprinted without permission