![](media/image1.wmf){width="6.459027777777778in"
height="1.7208333333333334in"}

April 2000

**ILLNESSES OF GULF WAR VETERANS**

**Highlights of VA Programs**

• ***Patient Care.*** VA operates a toll-free hotline at
***1-800-749-8387*** to answer Gulf War veterans\' questions and to
assist them with referrals to VA facilities for medical care if needed.
VA offers a full spectrum of health-care services for Gulf War veterans,
from free physical examinations for healthy-but-concerned Gulf War
veterans to those needing ongoing care for an illness, whether related
to military service or due to post-service civilian life. Under current
appropriations, access to VA medical care is available to all honorably
discharged veterans. A further provision specifically for Gulf veterans
allows VA to waive inpatient and outpatient copayments normally assessed
certain higher-income veterans who lack an adjudicated finding that an
illness is service-connected. This copay waiver applies where the Gulf
veteran\'s illness or disability is not of obvious recent origin nor
related to a birth defect.

• ***Statistics.*** VA tracks the utilization of its health care and
compensation benefit programs by Gulf veterans. For the latest
statistics, see http://www.va.gov/pubaff/gulfvets.htm.

• ***Research.*** To improve understanding of Gulf veterans\' health
issues, the federal government has funded 145 scientifically rigorous
research projects valued at \$133.5 million. The 145 include 40
completed and 105 ongoing projects. Research findings show that
Gulf-deployed veterans who were contacted in mail or telephone surveys
are reporting illnesses more frequently than other veterans. Research is
continuing to look for differences in objective medical tests and other
clinical findings while at the same time testing possible treatments,
such as a large antibiotic therapy trial now in progress. Other projects
are testing various case definitions for a possible \"Gulf War
syndrome.\" This term currently is of limited value in American medicine
because it does not identify a characteristic organ abnormality nor
reflect consensus on any set of inclusionary or exclusionary symptoms,
laboratory test results or medical signs.

• ***Compensation.*** VA has a special compensation authority available
only to Gulf War veterans which provides criteria for monthly monetary
benefits to Gulf veterans who have significant symptoms that defy
conventional medical diagnoses. VA compensation also is available to
veterans of any time period, including Gulf War veterans, based on
findings that a serious chronic disease or disability was incurred
during or aggravated by military service. This often is shown through
military service medical records. For VA, an ongoing challenge is
assessing the likelihood that any environmental exposures may have
contributed to latent diseases, meaning diseases that would first appear
after a veteran\'s discharge and thus would not have been evident in
service records under conventional \"incurred or aggravated in service\"
criteria. VA has contracted with an independent scientific body, the
Institute of Medicine, to report on whether a higher risk of illnesses
can be associated with potential Gulf exposures.

**VA Response to Gulf Veterans\' Concerns**

Within several months of the ground war and while nearly half of the
deployed troops were still in the combat theater, VA in May 1991 began
work on a health-tracking program aimed at environmental issues,
focusing initially on the effects of oil well fires.

\- more -

Gulf Veterans - Page 2

As veterans\' concerns broadened, in 1992 the program became the Gulf
War Registry physical examination program in place today, where every VA
medical center has a specific registry physician familiar with Gulf
environmental issues performing the protocol exam. Over the past eight
years, Gulf registry physical examinations have been provided to more
than 75,000 Gulf veterans, many of whom have no illnesses but desire the
free physical examination and an opportunity to speak with a physician
familiar with environmental issues. As the examination program evolved,
the testing protocol was expanded, improved and adopted as a model for a
similar Defense Department examination program.

VA has undertaken outreach efforts to publicize these and other medical
services for Gulf veterans and VA keeps in touch with those Gulf
veterans who have used VA services through newsletters featuring policy
and scientific developments (see http://www.va.gov/gulf.htm).

Although the health examination program has been an important access
point to steer ill veterans into continuing VA treatment, it is limited
in providing broad answers about the health of Gulf veterans. It lacks
such scientifically rigorous elements as a non-Gulf comparison group
that would define a \"norm\" for comparison. Further, because the
veterans are self-referred and are not a representative sampling,
findings cannot be extrapolated to Gulf veterans in general.

By 1994, federal agencies had initiated a variety of controlled studies
on Gulf War veterans\' general health to provide rigorous scientific
answers in such issues as death rates and causes and birth defects in
the veterans\' offspring. VA launched a program of new hospital-based
environmental hazard research centers in January 1994.

**Research Accomplishments: 1991 - 2000**

Completed studies suggest that birth defects are not elevated in the
families of Gulf War veterans. A VA study of death certificates shows
that Gulf War veterans are dying from chronic diseases *less frequently*
than a comparison group (veterans who served elsewhere). Studies
analyzing inpatient records of Gulf War veterans and controls who were
sick enough to be hospitalized have not demonstrated any unusual
differences between Gulf veterans and the non-Gulf comparison groups.
The lack of positive findings in these areas should be weighed against
the natural latency of diseases such as certain cancers that may not
develop for decades.

Several scientific studies surveying Gulf veterans by telephone or mail
questionnaire have shown that as a group, Gulf War veterans are
reporting symptoms or diseases more frequently than non-Gulf comparison
groups. In sum, dozens of published studies have focused on issues
ranging from toxicology of various chemicals in animals to narrow
clinical hypotheses comparing groups of veterans. There is no doubt that
many Gulf veterans are suffering, sometimes with undiagnosed symptoms
affecting a variety of organ systems, but most health problems are
treatable with conventional medical approaches while research continues.

No single, easily identified unifying diagnosis or exposure has emerged
to explain the health problems experienced by some Gulf War veterans.
However, early data reported at a June 1999 scientific meeting based on
a large VA study\'s questionnaire phase found a cluster of reported
symptoms that are being further explored by George Washington University
(GWU) scientists in conjunction with VA researchers. This symptom
cluster of interest from the National Health Survey of Gulf Veterans and
their Families involves blurred vision, loss of balance or dizziness,
tremors or shaking and speech difficulty. The GWU-VA study will follow
up with objective physical examinations of those reporting the symptom
cluster as well as multiple groups of representative controls.

The studies indicating that deployed Gulf War veterans are reporting
more health symptoms than their non-deployed counterparts were
undertaken by researchers at VA, DoD, the Centers for Disease Control
and Prevention (CDC), as well as university researchers and scientists
in Canada and Britain.

\- more -

Gulf Veterans - Page 3

For example, a CDC epidemiological study found multiple symptoms more
prevalent in Air Force Gulf veterans compared with controls who served
in areas of the world away from the Gulf War. Although 39 percent of Air
Force Gulf War veterans who were still on duty and were studied by CDC
suffered from chronic problems with fatigue, mood, thinking and muscle
aches and pains, this was also reported by 15 percent of the non-Gulf
group.

Another large CDC study of Gulf veterans compared veterans who had lived
in Iowa at the time of their military enlistment to controls. The Gulf
veterans reported a higher prevalence of symptoms of depression,
post-traumatic stress disorder, chronic fatigue, cognitive dysfunction,
bronchitis, asthma, fibromyalgia, alcohol abuse and sexual discomfort.

A University of Texas questionnaire-based study administered to 249
members of a reserve Naval mobile construction battalion suggested six
possible syndromes in Gulf veterans.

**New Research Frontiers**

A major question for research is whether the self-reported higher rate
of illness shown in questionnaire surveys can be substantiated
objectively in medical examinations using conventional techniques. The
major VA National Health Survey of Gulf Veterans and their Families
designed to survey up to 30,000 veterans (half Gulf combat theater
veterans and half controls from service in other areas) has a clinical
examination component for a portion of each group. This study now is
examining veterans and their family members under a uniform,
comprehensive clinical examination protocol at selected sites around the
country. Pediatricians examining the children of veterans are gathering
data enabling a comparison of child health not only among the Gulf War
theater veterans and control cohorts, but also between children in the
same family born before the Gulf deployment compared to those born after
the conflict.

Primary hypotheses in the National Health Survey are focusing attention
on general health status as well as chronic fatigue syndrome,
fibromyalgia, post-traumatic stress disorder, and neurological
abnormalities. The study is expected to complete patient recruitment in
May 2001. Additional work by George Washington University in evaluating
the symptom cluster from the National Health Survey\'s early phases is a
spin-off project providing an additional series of examinations
specifically for those who reported a specific symptom combination.

Meanwhile, controlled treatment trials are examining the potential value
of therapy for subgroups of Gulf veterans with specific combinations of
symptoms. The exercise and behavioral therapy (EBT) trial is testing
whether two therapeutic interventions \-- exercise training and
cognitive behavioral therapy \-- alone or in combination improve
physical function. The antibiotic treatment trial (ABT) focuses on a
hypothesized infectious cause of certain symptoms experienced by Gulf
veterans by evaluating outcomes from doxycycline therapy. Both the EBT
and ABT trials involve random assignment of both Gulf veterans and
controls to treatment or to a placebo group.

The safety of patients in clinical studies is a paramount concern to VA,
as is VA\'s commitment to evidence-based medical treatment. The two
treatment trials received extensive peer review from outside experts
during their design.

**Disability Compensation**

Since early 1995, VA has been providing compensation payments to
chronically disabled Gulf War veterans with undiagnosed illnesses. This
benefit was expanded under an April 29, 1997, regulation that
essentially eliminated the date of initial manifestation of latent
symptoms as a consideration in adjudication through the end of the year
2001. A disability is considered chronic if it has existed for at least
six months.

Outside of the new regulation, VA has long based monthly compensation
for veterans on finding evidence a condition arose during or was
aggravated by service. VA has approved more than 183,037 claims of Gulf
veterans for service injuries or illnesses of all kinds, including 3,117
approved under the undiagnosed illnesses regulation (latest statistics
at http://www.va.gov/pubaff/gulfvets.htm).

\- more -

Gulf Veterans - Page 4

**Independent Review of Risks and Disease Associations**

VA contracted with the independent Institute of Medicine (IOM) in 1998
to provide a comprehensive evaluation and summary of available
scientific information regarding the association between various
exposures or combinations of exposures and the health of Gulf War
veterans. The first report is due August 2000.

Based on the IOM report, VA will make a determination whether any
statistical associations warrant special disability benefits to link
various illnesses with specific exposures, or a \"presumptive
service-connection\" for adjudication of claims. Such policies would be
proposed through regulations. The model for this use of the IOM report
is that organization\'s review of studies related to the defoliant Agent
Orange. IOM reports have led to VA expanding compensation for Vietnam
War theater veterans by providing a solid basis for presumptive
service-connection policies.

Outside experts also have fostered improvements to Gulf War veteran
programs over the years. Both clinical care and direction for the
research agenda has been guided by both internal advisory committees as
well as numerous reviews of the federal response to Gulf War veterans\'
illnesses by teams of scientists, veterans, physicians, public health
specialists and members of Congress. Notable among the work of panels of
experts were the 1994 \"NIH Technology Assessment Workshop,\" a 1996
Institute of Medicine \"Report of the Committee to Review the Health
Consequences of Service During the Persian Gulf War,\" and the 1996
report of the Presidential Advisory Committee on Gulf War Veterans'
Illnesses.

**Risk Factors of Concern To Veterans**

Veterans have reported a wide range of factors observed in the Gulf
environment or speculative risks about which they have voiced concerns.
Many are the subject of research investigations and none have been ruled
out as a cause of illness. There appears to be no unifying exposure that
would account for all unexplained illnesses. Individual veterans\'
exposures and experiences range from ships to desert encampments, and
differences in military occupational specialty frequently dictate the
kinds of elements to which servicemembers are exposed.

Veteran concerns include exposure to the rubble and dust from exploded
shells made from depleted uranium; the possibility of exposure to the
nerve agent sarin or some yet-unconfirmed Iraqi chemical-biological
agent; and use of a nerve agent pre-treatment drug, pyridostigmine
bromide. Many other risk factors also have been raised.

In its study of possible associations of disease and Gulf environment
risk factors, the Institute of Medicine\'s first report is examining
pyridostigmine bromide, vaccines and their components, uranium and
depleted uranium, and the nerve agents sarin and cyclosarin.

\# \# \#