THE WHITE HOUSE
Office of the Press Secretary
Gulf War Veterans' Illnesses: Presidential Initiatives
The President has been concerned about the health problems of Gulf War veterans from the outset of his Administration. Both the President and First Lady focused their attention on these health problems, meeting with veterans and bringing federal agencies together to address their concerns through improved programs and benefits. The President has reassured veterans and their families that the government will leave no stone unturned to ensure that those who served their country in the Persian Gulf receive the care they need.
As early as 1993, the President supported legislation that created a special eligibility for health care for Gulf veterans and authorized a multi-million-dollar contract for a review of research strategies. Later in 1993, an interagency research council was formed which soon gave rise to a formal federal board when the President directed a high-level response to the health concerns of Persian Gulf veterans.
President Clinton formed the Persian Gulf Veterans Coordinating Board composed of three of his Cabinet members in early 1994. The Secretaries of Defense, Health and Human Services, and Veterans Affairs in turn formed working groups with scientists and program experts from the agencies and assembled a Board staff to assure interdepartmental collaboration and communication.
In May 1995, President Clinton established the Presidential Advisory Committee on Gulf War Veterans' Illnesses to provide an independent and comprehensive assessment of the entire range of government activities relating to the health concerns of Gulf War veterans. The 12-member panel of veterans, scientists, health care professionals and policy experts traveled across the nation between August 1995 and November 1996, taking testimony as well as scrutinizing federal medical care programs and the focus of research priorities. The panel's findings and recommendations are detailed in its final report submitted in December 1996.
Who Served in the Gulf War
> Some 697,000 active duty service members and activated National Guard and Reserve unit members served in the Persian Gulf theater of operations during Operations Desert Storm and Desert Shield.
> The majority of troops were deployed to the Gulf theater of operations before the air war began on January 16, 1991, and more than half of the deployed troops were withdrawn from the area by the first week of May 1991. (Note: an additional 250,000 personnel have been deployed over the ensuing five years, with several thousand U.S. military members currently serving ashore and afloat in the Gulf region.)
> Many Gulf veterans have reported that they suffer from a diverse group of symptoms, including fatigue, skin rash, headache, muscle and joint pain, memory problems, shortness of breath, sleep disturbances, gastrointestinal symptoms, and chest pain.
Summary of Government Responses to Gulf Veterans' Concerns
> In 1992, VA created the Persian Gulf Registry Program for all veterans who served in the theater, inviting them to come in for a free medical examination; this registry continues to facilitate both the provision of care and research efforts.
> DoD established the Comprehensive Clinical Evaluation Program (CCEP) to provide care and systematically evaluate Persian Gulf veterans and their family members.
> DoD, HHS, and VA have also been investigating possible causes of the veterans' health problems, including various chemical exposure combinations, leishmaniasis, health effects of oil well fires, petrochemical exposure, chemical/biological warfare agents, effects of vaccines and medications, and exposure to depleted uranium.
> The three departments are engaged in more than 80 federally supported Persian Gulf-related research and evaluation projects, including studies of general health and environmental effects. This extensive portfolio includes grants to more than a dozen non-federal researchers, federal agencies and academic institutions examining a variety of health issues in Gulf veterans or conducting studies of specific risk factors or illnesses.
> In May 1995, President Clinton set up an independent advisory committee to review the research agenda as well as all other government activities related to the health concerns of Persian Gulf veterans. As noted earlier, its final report was delivered in December 1996.
VA HEALTH CARE - PERSIAN GULF REGISTRY
Centralized Registry. VA's Persian Gulf Registry Program offers a free, complete physical examination with basic laboratory studies to every Persian Gulf veteran. A centralized registry of participants who have had these examinations is maintained to enable VA to keep them informed through periodic newsletters. This clinical database of 62,000 Persian Gulf veterans who have taken advantage of the physical examination program also provides a mechanism to catalog prominent symptoms, reported exposures and diagnoses. VA has named a physician at every VA medical center to coordinate the special examination program. In June 1994, VA expanded the basic examination protocol, which elicits information about symptoms and exposures, and also directs baseline laboratory studies, including blood count, urinalysis, and a set of blood chemistries.
Additional Testing. In addition to this core laboratory work, for every veteran taking the Persian Gulf program examination, physicians may order additional tests and specialty consults as symptoms dictate. If a veteran's symptoms remain unexplained, VA provides an expanded assessment protocol, standardized in collaboration with DoD, for use in evaluation of unexplained illnesses.
VA HEALTH CARE - MEDICAL EXAMINATIONS
Examinations and Eligibility. VA provides medical care to Persian Gulf veterans for illnesses possibly related to exposure to toxic substances or environmental hazards. Any Persian Gulf veteran who VA determines might possibly have an illness resulting from exposure to a toxic substance or environmental hazard in the Persian Gulf theater of operations has special eligibility for hospital and outpatient care. They have a higher eligibility for treatment than other non-service-connected veterans. For Gulf veterans with unexplained symptoms, the local VA physicians also may refer veterans to a local tertiary care facility, or to one of VA's four Persian Gulf Referral Centers for additional specialty consultations. They are located at VA medical centers in Washington, D.C.; Birmingham, Alabama; Houston, Texas; and Los Angeles, California.
Examinations for Families. Also, VA is inviting spouses and children of Persian Gulf War veterans to take advantage of special health examinations being scheduled through VA's national Persian Gulf Helpline. The free exams, administered by contractors of 33 VA medical centers, are available only to spouses and children of veterans who served in the Persian Gulf War and who have received a Persian Gulf Registry examination. VA estimates that the $2 million authorized by Congress for this program will provide physical examinations for approximately 4,500 individuals. The program does not provide follow-up, treatment or compensation for the veterans' spouses or children.
VA HEALTH CARE - TOLL FREE INFORMATION LINES
VA offers a toll-free information line at 800-PGW-VETS (800-749-8387) with operators trained to help veterans with questions about care and benefits and schedule the spouse and child examinations described above. Information also is being disseminated 24-hours-a-day through a national electronic bulletin board at 800-US1-VETS (800-871-8387) or (FTP/Telnet to VAONLINE.VA.GOV by Internet) as well as through a Persian Gulf Veterans' Illnesses page on VA's World Wide Web site at http://www.va.gov./health/environ/persgulf.htm.
VA HEALTH CARE - COMPENSATION
Compensation Benefits. Realizing that research will take time to find answers to Persian Gulf veterans' health questions, the Clinton Administration supported legislation, enacted in 1994, to give VA authority to award compensation benefits to chronically disabled Gulf War veterans with undiagnosed illnesses.
Under a final regulation published February 3, 1995, VA has begun paying compensation to Gulf veterans suffering from chronic disabilities resulting from undiagnosed illnesses that became manifest during service in the theater or within two years thereafter. Some 26,738 veterans with Gulf service currently are receiving VA compensation or pension benefits for chronic disabilities, injuries or diagnosed illnesses.
DOD'S COMPREHENSIVE CLINICAL EVALUATION PROGRAM
In-depth Medical Evaluation. DoD, in collaboration with VA, developed the Comprehensive Clinical Evaluation Program in June 1994 to provide an in-depth medical evaluation to all eligible beneficiaries who have health concerns following service in the Gulf. All service members eligible for health care at DoD medical facilities -- active, ready reserves or retired -- who participated in Operations Desert Shield and Desert Storm, as well as their family members, are eligible for the program. To register, individuals should call the DoD Hotline (800-796-9699).
Findings. In April 1996, DoD issued its fourth report on 18,598 participants. DoD physicians find the majority of CCEP participants have clear diagnoses which include a variety of common conditions for which they are receiving treatment. The report concluded that based upon the CCEP experience to date, there is no clinical evidence for a single or unique syndrome among Gulf War veterans. However, a mild illness or a syndrome affecting proportions of veterans at risk might not be detectable in such a case series. The results of the CCEP are consistent with the conclusions of a National Institutes of Health Technology Assessment Workshop Panel that no single disease or syndrome is apparent, but rather multiple illnesses with overlapping symptoms and causes.
Specialized Care. A specialized care center established at Walter Reed Army Medical Center in Washington, D.C., provides therapeutic care for some CCEP participants. The center uses multi-disciplinary teams to provide intensive programs to improve the health of patients experiencing disabling symptoms. An additional specialized care center is located at Wilford Hall Medical Center in San Antonio, Texas. This center provides treatment for Gulf War returnees with chronic pain and other health concerns.
In late 1996, DoD requested the National Academy of Sciences Institute of Medicine to reevaluate the relevancy of the CCEP examination process in light of the March 1991 demolitions at Khamisiyah, Iraq. This report is expected in early 1997. As of January 1997, 38,000 personnel have requested participation in the CCEP. This number includes 9,300 individuals who have requested registration without examination.
EXPANDED DEPARTMENT OF DEFENSE INVESTIGATIVE EFFORTS
Expanded Team. In November 1996, DoD initiated an expansion of its Gulf Illnesses Investigative Team from 12 to 110 personnel. This expanded organization, under the direction of a newly-designated Special Assistant to the Secretary of Defense for Gulf War Illnesses, focuses additional resources on the question of what may be causing Gulf War illnesses. The team is composed of representative elements of critical DoD components to ensure that research and analytical efforts and outreach programs are effective, coordinated and meaningful.
Declassification Effort. In March 1995, DoD established a declassification effort encompassing research, medical, operational and intelligence records that could increase understanding of the causes of Gulf War illnesses. By October 1996, the DoD declassification project had reviewed over 5.4 million pages of operational and intelligence information. Seven hundred thousand pages were provided to the Analysis and Investigation Team for further review. About 23,000 pages of information were posted on the GulfLINK World Wide Web home page.
IG Investigation. In June 1996, DoD learned U.S. troops destroyed large quantities of ammunition at Khamisiyah, a sprawling ammunition storage site in southern Iraq shortly after the Gulf War ended. Evidence that chemical weapons may have been among the munitions destroyed there on March 4 and 10, 1991 has triggered an intensified effort on the part of DoD to reconstruct the events at that time. The Army Inspector General is also conducting an in-depth inquiry into all the events and activities surrounding Khamisiyah. Additionally, the Assistant Secretary of Defense for Intelligence Oversight is looking into the handling of intelligence information about Khamisiyah.
Expanded Outreach. In October 1996, the DoD announced a series of actions to seek the help of 20,000 Gulf War veterans who may have been near Khamisiyah, Iraq during the period March 4-15, 1991. The expanded outreach actually commenced in August 1996 when DoD began contacting 1,168 U.S. service members assigned to units involved in the March 4, 1991 demolition at Khamisiyah. Veterans are being asked to call the DoD Gulf Veterans hotline numbers to provide any information they believe is pertinent and to report any medical problems they may be experiencing. The incident reporting hotline number is 1-800-472-6719.
The National Academy of Sciences has recently agreed to advise DoD on its overall approach to Gulf War illnesses and to recommend any needed changes to that approach.
The federal government has steadily expanded research into the illnesses reported by Gulf War veterans, including the latest portfolio of 15 studies that include non-federal researchers, federal agencies and academic institutions. The compendium of new projects is in addition to some 70 federal research projects and other studies detailed in the November 1996 update to The Working Plan for Research on Persian Gulf Veterans' Illnesses. The new initiative results from a nationwide request for protocols that triggered 111 responses. The scientific proposals received were reviewed by independent panels of experts and graded for scientific merit and for program relevance to key questions surrounding health issues of Gulf veterans.
The Persian Gulf Veterans Coordinating Board, through its Research Working Group, has intensified efforts related to possible effects of low-level exposures to chemical warfare agents. Based on the Coordinating Board's recommendation, three new peer-reviewed, basic science research projects in this area have been funded, and an additional $2 million has been identified for future studies.
During 1996, DoD allotted $12 million for general research. In 1997, DoD has committed $12 million for general research and $5 million for studying the effects of low-level chemical exposure, oil well fires, depleted uranium, cancer incidence, birth outcomes and health risk assessments.
The Working Plan for Research on Persian Gulf Veterans' Illnesses identifies major research questions and gaps in current knowledge, and required research that will close the gaps between what is known and what is needed. Among the 21 key research questions listed in the plan, the one identified as most important is the determination of whether Persian Gulf veterans are experiencing a greater prevalence of illnesses in comparison with an appropriate control population. Thirteen controlled scientific studies are being funded to address that question.
Additional research goals include identifying possible risk factors for any excess illness or death, as well as finding appropriate diagnostic tools, treatment methods, and prevention strategies for any conditions found. The research plan helps coordinate federally-sponsored research to ensure all the relevant research issues are targeted and unnecessary duplication is avoided.
Persian Gulf veterans have expressed concern about birth defects in their children. While there are no current data supporting an increased rate of birth defects in the children of Persian Gulf War veterans, this is an important research question and deserves extremely careful review. A study conducted by the Mississippi State Department of Health in conjunction with the Centers for Disease Control and Prevention (CDC) showed no increase in birth defects or illnesses among children born to Persian Gulf veterans in two National Guard units. In addition, preliminary results of DoD epidemiological research demonstrate no increase in the overall rate of birth defects among children born after active duty service members returned from the Gulf compared to children of a control group of active duty service members who did not serve in the Gulf. Ongoing DoD, VA and CDC studies are examining the issue of birth defects, reproductive health, and family health status. Because of the broader importance of reproductive health to veterans, VA established a fourth environmental hazards research center at the Louisville, Kentucky VA Medical Center in collaboration with the University of Louisville focusing on reproductive and developmental outcomes.
RESEARCH STUDIES AND EVALUATIONS
National Institutes of Health. A panel of non-government experts brought together at a National Institutes of Health-sponsored workshop in April 1994 examined data and heard from both veterans and scientists. The panel concluded that no single cause or biological explanation for the reported symptoms could be identified and indicated that it was impossible at that time to establish a single case definition for the health problems of Gulf veterans.
National Academy of Sciences. DOD and VA have contracted with the National Academy of Sciences to review existing scientific and other information on the health consequences of Gulf operations. An interim report was issued January 4, 1995, and a final report is expected soon.
Naval Medical Research Center. The Naval Medical Research Center in San Diego, in collaboration with VA investigators, has begun epidemiological studies comparing Gulf veterans and control-group veterans (who served elsewhere) to detect differences in illnesses, hospitalizations and birth outcomes in large cohorts of active duty service members.
In its National Health Survey of Persian Gulf Veterans, the VA is conducting a mail survey of a random sample of 15,000 Persian Gulf veterans and active duty members with Gulf service to compare their health status with an equal-sized group not deployed to the Gulf. Results of initial responses now are being analyzed. Information on the health status of family members also is included, including birth outcomes and illnesses in the children born to veterans in the survey. A health examination will be offered to a representative sample to help evaluate participants' symptoms.
CDC, in collaboration with the Iowa Department of Public Health and the University of Iowa, has conducted a telephone survey of approximately 4,000 active and retired military personnel from Iowa to compare the health status of veterans who served in the Gulf with that of veterans who served during the Gulf War but were deployed elsewhere. Publication of results is expected soon.
CDC also is studying a group of Air National Guard Persian Gulf War veterans in Pennsylvania for any pattern of unusual illnesses. In the Morbidity and Mortality Weekly Report (6-15-95), the CDC said preliminary findings indicate that some chronic symptoms were reported more commonly by Persian Gulf War veterans than by non-deployed Persian Gulf War-era service personnel. However, standardized physical examinations and reviews of lab test results did not reveal consistent abnormalities. Final results of the study will be published within a few months.
VA has analyzed cause-of-death data gathered from death certificates for its Mortality Follow-up Study of Persian Gulf Veterans, comparing Gulf-deployed veteran non-combat deaths with a control group of troops never deployed to the Gulf. As has been observed after other wars, veterans of the Persian Gulf War have experienced a higher incidence of death due to accidents. When this contributing factor is excluded, Persian Gulf veterans have not experienced a higher mortality rate due to disease-related causes. Both the Persian Gulf and non-deployed control group veterans had a lower death rate than Americans their age in general. A report was published in the New England Journal of Medicine (11-14-96).
In October 1994, VA established three environmental hazards research centers with an initial focus on the possible health effects of environmental exposures of Persian Gulf veterans. The centers are located at VA hospitals in Boston, Massachusetts; East Orange, New Jersey; and Portland, Oregon. The centers are being funded for five years with a total annual budget of approximately $1.5 million and an additional $300,000 for equipment costs in the first year of operation. A total of 14 individual protocols are scheduled on a variety of interdisciplinary projects. A fourth environmental hazards research center focused on reproductive outcomes was announced in November 1996 to be located in Louisville, Kentucky.
The Baltimore VA Medical Center is following the health status of individuals who retained embedded fragments of depleted uranium from injuries sustained during the Persian Gulf War.
The Birmingham VA Medical Center is conducting a pilot clinical program that includes an extensive battery of neurological tests aimed at detecting the kind of dysfunction that would be expected after exposure to nerve agents.
DoD will study the effects of chemical/environmental exposures.
DoD is continuing its work as a world leader in developing a less invasive test for viscerotropic leishmaniasis that may provide for broader diagnostic screening in the future.
DoD has developed a geographic information system (GIS), or troop location registry, that contains location information on more than 4,000 units from all Services. The GIS allows military unit locations during Operation Desert Storm to be compared with air quality measurements, reported SCUD attacks, chemical and biological weapon detection reports, weather data and other factors. This system helped to identify units in the Khamisiyah area.
Both VA and DoD are continuing to examine the role of stress from deployment and post-traumatic stress disorder, with a goal of developing intervention strategies.
The Central Intelligence Agency has played a major role in the massive government effort to locate and review classified documents relating to the Gulf War. Together, CIA and DoD have reviewed over 5.4 million pages of operational and intelligence information, resulting in the declassification of thousands of pages. Moreover, CIA has carefully studied the events at Khamisiyah and has coordinated preliminary modeling work in an effort to ascertain the extent of possible chemical exposure of our forces there.
In response to allegations related to claims by two former agency employees that there is evidence of chemical weapon use during the Gulf War, CIA has initiated an investigation by its Inspector General. That investigation is still in progress (as are those being conducted by DoD). All of the documents on which the claims were based were provided to the Presidential Advisory Committee and made public.
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