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25–103 2017

PERSIAN GULF WAR: AN ASSESSMENT OF HEALTH 

OUTCOMES ON THE 25TH ANNIVERSARY 

HEARING 

BEFORE THE

SUBCOMMITTEE ON OVERSIGHT AND 

INVESTIGATIONS 

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED FOURTEENTH CONGRESS 

SECOND SESSION 

TUESDAY, FEBRUARY 23, 2016 

Serial No. 114–57 

Printed for the use of the Committee on Veterans’ Affairs 

( 

Available via the World Wide Web: http://www.fdsys.gov 

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(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

JEFF MILLER, Florida, Chairman 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida, Vice-Chairman 

DAVID P. ROE, Tennessee 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

JACKIE WALORSKI, Indiana 

RALPH ABRAHAM, Louisiana 

LEE ZELDIN, New York 

RYAN COSTELLO, Pennsylvania 

AMATA COLEMAN RADEWAGEN, American 

Samoa 

MIKE BOST, Illinois 

CORRINE BROWN, Florida, Ranking 

Minority Member 

MARK TAKANO, California 

JULIA BROWNLEY, California 

DINA TITUS, Nevada 

RAUL RUIZ, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

KATHLEEN RICE, New York 

TIMOTHY J. WALZ, Minnesota 

JERRY MCNERNEY, California 

JON TOWERS, Staff Director 

DON PHILLIPS, Democratic Staff Director 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATION 

MIKE COFFMAN, Colorado, Chairman 

DOUG LAMBORN, Colorado 

DAVID P. ROE, Tennessee 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

JACKIE WALORSKI, Indiana 

ANN M. KUSTER, New Hampshire, Ranking 

Member 

BETO O’ROURKE, Texas 

KATHLEEN RICE, New York 

TIMOTHY J. WALZ, Minnesota 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Veterans’ Affairs are also published in electronic form. The printed 

hearing record remains the official version. Because electronic submissions are used to 

prepare both printed and electronic versions of the hearing record, the process of converting 

between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process 

is further refined. 

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C O N T E N T S 

Tuesday, February 23, 2016 

Page 

Persian Gulf War: An Assessment of Health Outcomes on the 25th Anniversary ........................................................................................................................ 1 

OPENING STATEMENTS 

Honorable Mike Coffman, Chairman ..................................................................... 1 

Honorable Ann M. Kuster, Ranking Member ....................................................... 2 

WITNESSES 

Carolyn Clancy, M.D., Deputy Under Secretary for Health for Organizational 

Excellence, U.S. Department of Veterans Affairs .............................................. 4 

Accompanied by: 

Stephen Hunt, M.D., M.P.H., Director, Post-Deployment Integrated Care 

Initiative, U.S. Department of Veterans Affairs 

Victor Kalasinsky, Ph.D., Senior Program Manager, Gulf War Veterans’ 

Illnesses Research, U.S. Department of Veterans Affairs 

Deborah Cory-Slechta, Ph.D., Professor of Environmental Medicine, Pediatrics 

and Public Health Sciences, Acting Chair, Department of Environmental 

Medicine, University of Rochester School of Medicine ...................................... 6 

Prepared Statement ......................................................................................... 27 

Roberta F. White, Ph.D., Chair, Department of Environmental Health, Boston 

University School of Public Health ..................................................................... 9 

Prepared Statement ......................................................................................... 30 

Accompanied by: 

Mr. James H. Binns, Gulf War Researcher, Former Chairman, Research 

Advisory Committee on Gulf War Veterans’ Illnesses 

Mr. Anthony Hardie, Gulf War Veteran, Director, Veterans for Common 

Sense ..................................................................................................................... 10 

Prepared Statement ......................................................................................... 33 

Accompanied by: 

Mr. David K. Winnett, II, Gulf War Veteran 

STATEMENTS FOR THE RECORD 

Lung Cancer Alliance .............................................................................................. 38 

National Gulf War Resource Center ...................................................................... 39 

Mr. James H. Binns ................................................................................................. 41 

Ms. Montra Denise Nichols, MSN .......................................................................... 69 

Kimberly Sullivan, PhD .......................................................................................... 73 

Mr. David K. Winnett, II ........................................................................................ 75 

Lea Steele, Ph.D. ..................................................................................................... 81 

QUESTIONS FOR THE RECORD 

Questions from Chairman Mike Coffman for the Department of Veterans 

Affairs: ................................................................................................................... 83 

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PERSIAN GULF WAR: AN ASSESSMENT OF 

HEALTH OUTCOMES ON THE 25TH ANNIVERSARY 

Tuesday, February 23, 2016 

U.S. HOUSE OF REPRESENTATIVES, 

COMMITTEE ON VETERANS’ AFFAIRS, 

SUBCOMMITTEE ON OVERSIGHT

AND INVESTIGATIONS, 

Washington, D.C. 

The Subcommittee met, pursuant to notice, at 4:35 p.m., in Room 

334, Cannon House Office Building, Hon. Mike Coffman [Chairman 

of the Subcommittee] presiding. 

Present: Representatives Coffman, Roe, Huelskamp, Kuster, and 

Walz. 

Also Present: Representative Denham. 

OPENING STATEMENT OF MIKE COFFMAN, CHAIRMAN 

Mr. COFFMAN. Good afternoon. This hearing will come to order. 

I want to welcome everybody to today’s hearing entitled ‘‘Persian 

Gulf War: An Assessment of Health Outcomes on the 25th Anniversary.’’ 

First, as a preliminary matter, I would like to ask unanimous 

consent that—let’s see. Who do we have? Oh, I guess they’re not 

here. I don’t have to do that. 

Ms. KUSTER. The answer is yes. 

Mr. COFFMAN. As a fellow Gulf War veteran, I have invited them. 

Unfortunately, they’re not here. Let’s see. 

This hearing will examine VA’s treatment of and current health 

outcomes for veterans suffering from Gulf War illness. The hearing 

will focus largely on the issues that have arisen since our last hearing on Gulf War illness on March 13, 2013, and specifically review 

VA’s efforts to improve treatment and outcomes. This hearing 

marks the 25th anniversary of the Persian Gulf War, a conflict of 

swift intensity and short duration with what could be the lowest 

incident of post-traumatic stress disorder of any American war, according to some reports, including VA’s own National Center for 

Post-Traumatic Stress Disorder. 

Unfortunately, this anniversary also marks numerous problems, 

some of which haven’t improved since our hearing on Gulf War illness 3 years ago. I’m deeply concerned about how VA continues to 

characterize Gulf War illness as a mental disorder, as evident in 

its current clinical guidelines. I’m perplexed that these same clinical guidelines are based in part on research that the Institute of 

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Medicine has warned is potentially biased or influenced by pharmaceutical manufacturers. I’m also frustrated by the fact that VA 

is prescribing psychotropic drugs for not only Gulf War illness but 

apparently also for instances of traumatic brain injury and posttraumatic stress. And I wonder about a possible connection between drug manufacturers and their sponsored studies and the 

high rate of prescription drugs being dumped on veterans with Gulf 

War illness. My concerns regarding VA’s overuse of drugs are well 

founded, given this Committee’s hearing last June that revealed 

VA administrators acknowledging the practice of overprescribing 

medication and turning veterans into drug addicts. 

VA has previously testified that Gulf War illness is not a mental 

malady. And its own training course states that it, quote, ‘‘cannot 

be ascribed to any known psychiatric disorder, somatoform disorder, PTSD, or depression,’’ unquote. Even so, VA continues to 

treat veterans as if Gulf War illness was a psychiatric problem. 

And that is an affront to those who have real physical ailments due 

to their service. 

I find it hard to believe cardiovascular disease, the physical scarring of lungs, central sleep apnea, head trauma, cataracts, and a 

variety of cancers are the manifestation of psychosomatic or psychiatric issues. If it could be as simple as a veteran thinking such 

things exist and then they disappear, I would think—simply 

think—VA is an organization truly capable of caring for veterans, 

and all of the Department’s continued failures would simply be resolved. 

What is even more frustrating is that the Institute of Medicine 

is apparently recommending no more Gulf War illness research be 

conducted. And that makes no sense whatsoever. But, then again, 

VA has published so few recent studies that this seems part and 

parcel of business as usual. 

Gulf War veterans, myself among them, are tired of hearing the 

same rhetoric from the VA. Quite frankly, I have had enough of VA 

telling me one thing and doing the exact opposite. The fact that 

very little, if anything, has changed in the 3 years since we last 

held a hearing on VA’s treatment of Gulf War illness is not only 

completely unacceptable; it is infuriating. I look forward to a spirited discussion on this important issue. 

With that, I yield to Ranking Member Kuster for any opening remarks that she may have. 

OPENING STATEMENT OF ANN M. KUSTER, RANKING MEMBER 

Ms. KUSTER. Thank you, Chairman Coffman. 

And thank you for your service in the Gulf War. We’re all grateful for that. 

Sunday marks the 25th anniversary of the end of Operation 

Desert Storm. And over the course of this quarter century, many 

veterans who served in that conflict have suffered from symptoms 

that are not readily identifiable or well understood. In fact, nearly 

30 percent of Gulf War veterans suffer from Gulf War illness. 

These veterans still struggle to receive accurate diagnoses for their 

symptoms and access to needed health care. These veterans struggle to get effective treatment for their conditions. And for too many 

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years, veterans suffering from Gulf War illness have been told: It’s 

all in your head. 

I think we can all agree today that Gulf War illness is not psychosomatic. Gulf War illness is a chronic, often painful, and sometimes debilitating disease. And our veterans deserve access to VA 

care and the most effective treatments for their illnesses and injuries. 

I’m concerned that recent findings from the Institute of Medicine 

may have been interpreted by some to mean that veterans should 

only receive mental health treatment for Gulf War illness. I’m also 

concerned that recent research findings may be interpreted to deny 

Gulf War veterans and all veterans suffering from ill-defined conditions access to VA health care and effective treatments. 

I wish to hear from all of our witnesses today so that we may 

begin to better understand the conclusions and recommendations of 

the researchers and experts in this field. It’s so very important that 

we develop clear goals to ensure that our veterans receive access 

to health care, both for mental health and physical health symptoms, and the most effective treatment for their service-connected 

injuries and illnesses. 

We know that veterans of the Iraq and Afghanistan wars are 

also coming to VA hospitals in need of treatment for their symptoms, sometimes symptoms that are similar to those suffered by 

Gulf War veterans. That’s why it’s vital that the research continues 

so that we will best understand the very best treatments and continue to explore issues relating to causation in order to protect the 

health of our servicemembers going forward. I believe it’s incumbent upon us to learn as much as we can about what are our Nation is asking from our servicemembers and their families when 

they volunteer and raise their right hand. We must recognize and 

be prepared to address the cost of that service and use our best efforts to ensure that our veterans are made whole again after returning home. 

And here I might just add that the Chairman and I spent time 

together over Thanksgiving in Afghanistan. And one of the concerns is, if we don’t understand the causation behind the Gulf War 

syndrome and exposure to toxins or other trauma, psychological injury, PTSD, TBI, and how this is all coming together, we’re not 

going to have an understanding of what it means to put our current troops in harm’s way in Iraq and Afghanistan. So I feel very 

strongly that we need to continue to investigate causation while we 

move forward with treatment for veterans that have already been 

exposed. 

So thank you, and I yield back. 

Mr. COFFMAN. Thank you, Ranking Member Kuster. 

We are now joined by United States Representative Jeff Denham 

from the State of California, a Gulf War veteran. 

I ask unanimous approval for Mr. Denham to be able to participate in this hearing. 

Ms. KUSTER. Absolutely. 

Welcome, Mr. Denham. 

Mr. COFFMAN. So ordered. 

Mr. DENHAM. I get my own card. 

Mr. COFFMAN. Thank you, Ranking Member Kuster. 

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I ask that all Members waive their openings remarks as per this 

Committee’s custom. 

With that, I invite the first and only panel to the witness table. 

You are currently seated. On that panel, for the Department of 

Veterans Affairs, we have Dr. Carolyn Clancy, Deputy Under Secretary for Health for Organizational Excellence. She is accompanied by Dr. Stephen Hunt, Director of VA’s Post-Deployment Integrated Care Initiative, U.S. Department of Veterans Affairs, and 

Dr. Victor Kalasinsky—I believe, got that wrong—senior program 

manager for VA’s Gulf War Veterans’ Illnesses Research, VA. 

Also on the panel, we have Dr. Deborah Cory-Slechta, Professor 

of Environmental Medicine, Pediatrics and Public Health Sciences, 

and Acting Chair of the Department of Environmental Medicine at 

the University of Rochester School of Medicine, who will be testifying in her capacity as chair on the Committee on Gulf War and 

Health of the Institute of Medicine. 

Dr. Roberta F. White, chair of the Department of Environmental 

Health at Boston University School of Public Health, who is accompanied by Mr. James H. Binns, Gulf War Researcher and former 

chairman of the Research Advisory Committee on Gulf War Veterans’ Illnesses. 

And Mr. Anthony Hardie, a Gulf War veteran and Director of 

Veterans for Common Sense, who is accompanied by Mr. David K. 

Winnett, II, a Gulf War veteran. 

I ask the witnesses to please stand and raise your right hand. 

[Witnesses sworn.] 

Mr. COFFMAN. Very well. Sit down. Please be seated. And let the 

record reflect that all witnesses have answered in the affirmative. 

Dr. Clancy, you are now recognized for 5 minutes. 

STATEMENT OF CAROLYN CLANCY, M.D. 

Dr. CLANCY. Thank you. Good afternoon, Chairman Coffman, 

Ranking Member Kuster, Members of the Subcommittee, Representative Denham. I’m accompanied today by Dr. Stephen Hunt, 

director of our Post-Deployment Integrated Care Initiative. As Deputy Under Secretary for Organizational Excellence and an internist, my background has been conducting and supporting research 

to improve patient care and inform public policy for much of my career. So I know how important it is to get the science right and assure you that VA is taking every step possible to advance research, 

clinical care, and education on Gulf War illness. 

Since our last hearing in 2013, VA has funded or conducted over 

60 studies. Funding for Gulf War research has increased steadily 

from $5.6 million in 2011 to over $14 million this year. And that’s 

a very conservative estimate. For example, a study funded this past 

June is a randomized trial of something called CoQ10 thought to 

change subcellular function in a way that could help treat the effects of Gulf War illness. Other studies evaluate the effectiveness 

of a broad range of treatments for musculoskeletal pain, fatigue, 

and cognitive issues using exercise programs, magnetic stimulation, and other innovative approaches. So, as we look for promising 

interventions through research, VA is also working diligently to 

treat these veterans that are now suffering from Gulf War illness. 

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From 2000 to 2015 the percentage of Gulf War veterans enrolled 

in our system has increased from 13 percent to about 33 percent. 

We offer continuing evaluation and treatment to the over 700,000 

men and women who served in Operations Desert Shield and 

Desert Storm. We have centers of excellence, three of them, called 

War Related Injury and Illness Study Centers, or WRIISCs—and 

we want to express our appreciation to the Congress for these— 

which are charged with conducting cutting-edge research, clinical 

education, and providing specialized care for Gulf War veterans 

with complex chronic unexplained or very difficult-to-diagnosis conditions. And demand for their services is no surprise; as the number of Gulf War veterans has increased, demand for these services 

has also increased. 

In addition, a total of 145,000 Gulf War veterans have undergone 

a Gulf War registry exam allowing their health concerns to be evaluated by VA physicians and enabling them to be referred for additional care. We first learned from Gulf War veterans just how important it is to integrate all the care and services that veterans 

need, and to integrate and organize that around the veteran and 

the veteran’s needs. And, in fact, that became an organizing principle for much of our system and team-based primary care. And, in 

fact, that has helped us to organize our referrals to community providers when necessary as well. 

We know that many Gulf War veterans are affected by a debilitating cluster of medically unexplained chronic symptoms that can 

include fatigue, headaches, joint pain, indigestion, insomnia, dizziness, respiratory disease, memory problems. And the chronic multisymptom illness we see so often in Gulf War veterans is clearly not 

a psychological condition. So I want to be very clear on that. We’re 

committed to ensuring our research, clinical care, and education 

takes into account all of the factors that are relevant to returning 

that veteran to the highest level of function. We have aggressively 

pursued and fast-tracked studies in ways we can meet the research 

and treatment needs for all veterans that have been affected by environmental exposures. So that research serves two purposes. One 

is to improve clinical care that we’re providing now for those enrolled in our system. And the other is as the basis for presumptions 

or other benefits. Our philosophy has been to come down on the 

side of the veteran when the science supports it. And, as you’ve 

seen, we have made our policies more liberal for C123 crews and 

are now adding new presumptives for veterans who served at 

Camp Lejeune. In addition, we’ve been working with Ron Brown at 

the National Gulf War Resource Center to address a number of 

concerns and possible presumptions for Gulf War veterans. 

Going forward, we recognize that while we’ve learned a lot, we 

need and value the ongoing feedback and input from our stakeholders, this committee of course, the Research Advisory Committee, the Veterans Service Organizations, and, very importantly, 

Gulf War veterans themselves. 

As we conduct an in-depth review of the most recent Institute of 

Medicine report, we’re going to include 2 full days to receive public 

comments and feedback from our stakeholders and partners to assure that VA’s priorities are informed by veterans and stakeholders. 

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You know, vigorous disagreements in science are part of the 

landscape, and we welcome that at all times. That’s what moves 

science forward. And we’re committed to hearing from all sides. 

That concludes my testimony. My colleague and I look forward 

to answering your questions that you or the Committee may have. 

[THE PREPARED STATEMENT OF CAROLYN CLANCY, M.D. APPEARS

IN THE APPENDIX]

Mr. COFFMAN. Thank you, Dr. Clancy. 

Dr. Cory-Slechta, you are now recognized for 5 minutes. 

STATEMENT OF DEBORAH CORY–SLECHTA, PH.D. 

Ms. CORY-SLECHTA. Good afternoon. Is this on? 

I am Deborah Cory-Slechta, professor of environmental medicine, 

pediatrics, and public health sciences, and acting chair of the Department of Environmental Medicine at the University of Rochester 

School of Medicine. I served as chair of the ‘‘Committee on Gulf 

War and Health, Volume 10,’’ which was released February 11 of 

this year. The committee that I was chaired was asked to review 

and evaluate the scientific and medical literature regarding associations between illness and exposure to toxic agents, environmental or wartime hazards, or preventative medicines or vaccines 

associated with Gulf War service, paying particular attention to 

neurological disorders, including Parkinson’s, MS, ALS, and migraines, to cancer, particularly brain cancer and lung cancer, and 

chronic multisymptom illness, also known as Gulf War illness. Volume 10 updates two earlier Gulf War and Health reports: volume 

4, in 2006, and volume 8, that was published in 2010. 

The committee made recommendations for future research on 

Gulf War veterans. And I would note that this committee was composed of experts in neurology, epidemiology, pain, psychiatry, 

neurocognitive disorders, environmental health, and toxicology. 

And they were clinicians and researchers, none of whom received 

funding from Gulf War illness research programs. 

Volume 10 basically followed the approach used by earlier committees. We held two public sessions at which we heard from representatives of the VA, from Gulf War veterans, and Veterans 

Service Organizations, Gulf War researchers, and representatives 

of the VA Research Advisory Committee. We did not address policy 

issues such as service-connection, compensation or the cause of or 

treatment for Gulf War illness. We conducted an extensive literature search, reviewed the volumes 4 and 8 conclusions, as well 

as their primary and secondary studies. We also looked at animal 

toxicology, neuroimaging, and genetics. We tried to be totally inclusive. We divided our studies into primary studies. They had to be 

published in peer-reviewed journals demanding—or demonstrating 

reporting rigorous methods, including information on a persistent, 

not acute, health outcomes, used appropriate laboratory testing as 

applicable, and had a study population that was generalizable to 

and representative of the Gulf War population. 

Secondary studies were those studies that didn’t meet all of these 

criteria. Many of the secondary studies relied on self-reports of diagnoses rather than examination by a health professional or a 

medical record review. We used the same categories of association 

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that were used in the previous volumes. I won’t go through all 

those. Suffice it to say, we have a sufficient evidence of a causal 

relationship, sufficient evidence of an association, limited suggestive evidence of an association, inadequate insufficient evidence or 

limited suggestive evidence of no association. 

The committee found that in spite of many millions of dollars 

that have been spent on researching the health of Gulf War veterans, there has been little substantial progress in our understanding of their health, particularly of Gulf War illness. The volume 10 committee found little evidence to actually warrant 

changes to the volume 8 conclusions. We fundamentally agree with 

the volume 8 conclusions regarding the strength of the associations 

between deployment to the Gulf War and adverse health outcomes. 

Veterans who were deployed to the Gulf War have an increased 

risk for many long-term health conditions with—including PTSD, 

Gulf War illness, chronic fatigue syndrome, functional GI conditions, generalized anxiety disorder, depression, and substance 

abuse. And in the testimony that I’ve provided you, you can see our 

categories of association with different health effects summarized 

in box 1. 

As requested in its statement of tasks, the committee had additional discussions pertaining to Gulf War illness, specifically 

neurologic conditions, and lung and brain cancer, as well as Gulf 

War illness itself. So Gulf War illness, of course, is the signature 

adverse health outcome of having served in the Persian Gulf. Multiple studies have found that some Gulf War veterans, regardless 

of their country of origin and their different deployment-related exposures, have persistent debilitating and varying symptoms of Gulf 

War illness. In spite of over two decades of research to define, diagnose, and treat Gulf War illness, little progress has actually been 

made in elucidating the pathophysiological mechanisms that underlie it, the exposures that may have caused it, or the treatments 

that are generally effective for it. 

Gulf War illness is not an easily diagnosed condition. The committee concluded it is not a psychosomatic illness, but it does, like 

almost every disease and disorder that we know of, prevent— 

present with diverse systems, many of which overlap with other 

health conditions such as chronic fatigue, neurodegenerative disorders, and musculoskeletal. 

The committee concluded that, although the existence of an animal model would be advantageous for identifying and evaluating 

treatment strategies, we caution that developing an animal model 

is really precluded by the absence of any objective measures of 

chemical and nonchemical exposures during Gulf War service, let 

alone the frequency, duration, or dose of those exposures, or the 

highly likely interactive effects of multiple exposures, about which 

we know almost nothing. We found it unlikely that a single definitive causal agent will be identified in the many years—this many 

years after the war. Furthermore, many of the Gulf War studies 

have excluded the psychological aspects of the condition with regard to both diagnosis and treatment, although veterans report 

symptoms, such as chronic pain and sleep disturbances, that may 

be amenable to psychological therapies alone or in conjunction with 

other treatments. 

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We found new—little new information pertaining to MS, Parkinson’s, or Alzheimer’s disease, or migraines. We did recommend that 

ALS is the only neurologic disease for which we did find limited 

suggestive evidence for an association. But because the timeframe 

has been too short to really look at this, we recommended additional followup for prevalence of ALS in this population. 

Similarly, we found evidence for brain cancer to be inadequate, 

insufficient, and it found—we found no statistically significant increase in the current risk of brain concern in deployed Gulf War 

veterans compared to nondeployed counterparts. A finding that’s 

actually mirrored in another recent IOM study. 

With regard to lung cancer, there—in the 10 to 15 years followup that have been reported may not, again, like ALS, have been 

adequate—an adequate timeframe to really see whether in fact— 

Mr. COFFMAN. Dr. Slechta, I’m going to have to ask you to move 

along, simply because you’re at 7 minutes right now. 

Ms. CORY-SLECHTA [continued]. Sorry. Okay. 

In conclusion, what is striking about this and prior Gulf War and 

Health Committee’s finding is that—well, I’ll just skip to the end. 

Let me just quickly go through these. 

Recognize the connections and complex relations between brain 

and physical functioning and do not exclude any aspect of Gulf War 

illness. With respect to improving its diagnosis and treatment, the 

Department of Veterans Affairs and Department of Defense should 

develop a joint and cohesive strategy on incorporating emerging diagnostic technologies, personalized approaches to medical care into 

sufficiently powered future research to inform the studies. I would 

also say, in regards to what I heard before, the importance of biomonitoring of exposures before, during, and after military—the involvement in the military is going to be critical to ultimately providing any associations to chemical exposures. There need to be follow-up for neurodegenerative diseases that have long latencies and 

are associated with aging, as I mentioned before. And let’s see. 

Without definitive and verifiable individual veteran exposure information, further studies to determine cause and effect relationship 

between Gulf War chemical exposures and health conditions in 

Gulf War veterans should not be undertaken. We did come up with 

a list of outcomes where we believe that there are sufficient data 

already to suggest an association, that we don’t need to do more 

studies to redemonstrate those, somewhere, 25 years after the war, 

we’re not likely to see anything, and so some of those kinds of 

health conditions didn’t warrant follow-up, as well as some that we 

said had a longer latency and still needed to be considered. 

And, finally, one other thing was to begin to break out sex-specific and race/ethnicity-specific health information, which may be 

important not only to understanding different vulnerabilities by sex 

and race but also in terms of understanding mechanisms and treatment for disease. 

Thank you. And I’m sorry for going over time. 

[THE PREPARED STATEMENT OF DEBORAH CORY-SLECHTA APPEARS

IN THE APPENDIX]

Mr. COFFMAN. Thank you, Dr. Slechta. 

Dr. White, you are now recognized for 5 minutes. 

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STATEMENT OF ROBERTA F. WHITE, PH.D. 

Ms. WHITE. Chairman Coffman, Ranking Member Kuster, and 

Members of the House Veterans Affairs Subcommittee on Oversight and Investigations, it’s the 25th anniversary of the Gulf War. 

Our veterans won this conflict in less than a week. However, concern remains high that the troops who produced this victory are 

and will remain ill without legitimate acknowledgement of their 

health problems and associated disabilities and without effective 

treatment options now or in the future. 

Despite decades of scientific evidence to the contrary, the VA and 

the Institute of Medicine have recently produced documents that 

minimize the poor health of these veterans by terming their illnesses to be functional, a medical term for psychiatric illness. This 

injustice is then compounded by a VA treatment guideline that 

suggests ineffective, unproven, palliative, and potentially harmful 

treatments for Gulf War illness that focus on psychiatric symptomatology. I speak as a clinician scientist who has worked with 

ill Gulf War veterans clinically and in research for over 20 years. 

My work on Gulf War illness is part of a 35-year career in which 

I have studied the effects of exposures to neurotoxic chemicals in 

adults and children. For 8 years, until last fall, I served as scientific director of the Research Advisory Committee on Gulf War 

Veterans’ Illnesses. It has been known since a year or two after 

their return from the Gulf that a subset of Gulf War veterans was 

experiencing debilitating physical illness. Research beginning at 

that time and continuing to the present has produced a consensus 

of scientific knowledge about this illness that I will summarize 

briefly. 

First, dozens of studies in multiple countries reveal that approximately 30 percent of the 1991 Gulf War veteran population suffers 

from a characteristic pattern of physical health symptoms that we 

call Gulf War illness. This pattern of health symptoms is not seen 

in veterans of other conflicts. 

Second, this illness is not the result of stress or other psychiatric 

factors. Rates of post-traumatic stress disorder are typically less 

than 10 percent. Furthermore, rates of Gulf War illness are not significantly higher in Gulf War veterans with psychiatric diagnoses. 

Third, Gulf War illness is associated with exposures to chemicals 

present in theatre, especially pesticides and pyridostigmine bromide, and possibly nerve gas sarin and particulates from the oil 

well fires. 

Fourth, effective treatments for Gulf War illness and other disorders that are induced by chemical exposures that damage the 

brain do not exist at present. However, recent research has identified treatment options that target specific nervous system and 

immunological mechanisms of Gulf War illness. These treatments 

are now being piloted. Despite these treatment advances, new recommendations for treatment of Gulf War illness from VA emphasize immediate referral for mental health evaluation. In addition, 

cognitive behavioral therapy is suggested. This is a palliative treatment at best and has been shown to be minimally effective in VA 

research on Gulf War veterans. 

Even worse, the treatment guidelines recommend 11 drugs to 

treat Gulf War illness, 10 of them psychiatric. All 11 drugs are 

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noted in the guidelines to have significant adverse side effects, including suicidal ideation. And these medications have not been 

studied with regard to their effectiveness in the treatment of Gulf 

War illness. The recent volume 10 Institute of Medicine report further contributes to this situation by minimizing the health problems of Gulf War veterans and again placing a psychiatric cast on 

them. Although the volume 10 IOM report states that the science 

has not changed since the volume 8 report, its conclusions fly in 

the face of the scientific consensus on Gulf War illness that I have 

described. The volume 8 report concluded that Gulf War illness 

cannot be reliably ascribed to any known psychiatric disorder. The 

volume 10 report distorts and disavows this conclusion by saying 

that the illness cannot be fully explained by any psychiatric disorder. Unlike prior reports that support mechanistic scientific research on Gulf War illness, volume 10 suggests that it is time research efforts focus on mind/body connectedness, and that further 

research to determine the relationships between Gulf War exposures and health conditions in Gulf War veterans should not be undertaken. To recommend stopping research into the mechanisms 

underlying the disease just as research into these mechanisms has 

begun to make real progress is shockingly shortsighted. And to suggest that psychiatric research has been neglected could not be further from the truth. 

During the first 15 years after the war, Federal Gulf War research focused mainly on psychiatric issues with negative results. 

It is unthinkable that the scientific progress now being made 

should be halted by a return to the psychogenic era. 

Thank you. 

[THE PREPARED STATEMENT OF ROBERTA F. WHITE APPEARS IN

THE APPENDIX]

Mr. COFFMAN. Thank you, Dr. White. 

Mr. Hardie, you’re now recognized for 5 minutes. 

STATEMENT OF ANTHONY HARDIE 

Mr. HARDIE. Thank you, Mr. Chairman, and Ranking Member 

and Members of this Committee for your service, for this hearing, 

and for the opportunity to speak with you today. 

This is just a brief overview. There are more details in my written submission. I really hope that you’ll take the time to read the 

few pages of it. 

I’m Anthony Hardie, a 1991 Gulf War and Somalia veteran. I’m 

director of the Veterans for Common Sense, and while I’ve provided 

testimony on several occasions, today is especially notable. Exactly 

25 years ago tonight, we launched the ground war of Operation 

Desert Storm and successfully liberated Kuwait. Tonight, I would 

like to—for us to remember and honor the nearly 300 warriors who 

made the ultimate sacrifice. I would also like us to remember and 

honor our Gulf War veterans, including those in this room and 

watching, and our leaders who led us to decisive military victory. 

Our war was relatively short, but you’ve heard our stories before. 

And with one-fourth and one-third of us coming home with serious 

and debilitating health issues now known as Gulf War illness, we 

faced a new battle: a long war to obtain health care, effective 

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11 

health care, and VA assistance from entrenched government officials who seemed intent on minimization and denial at every turn. 

Even through to today, the VA describes our toxic wounds as medically unexplained. And, finally, in 1998, we won enactment of two 

landmark bills for Gulf War veterans to guarantee health care and 

benefits based on research. Yet from the beginning, VA officials circumvented their implementation that leads us to today. 

The Institute of Medicine recently released its final report on the 

Gulf War and Health series under VA contract as directed by the 

1998 legislation. It’s highly problematic. As I walked through the 

airport on my way home from the report’s release, the weight of the 

bag with nearly two decades of these IOM reports was heavy on my 

shoulder. And I want to show that weight. 

My heart was even heavier because their collective weight has 

added little to nothing for Gulf War veterans. It has not associated 

any of our exposures with our health issues, and has added little 

towards the development of effective evidence-based treatments for 

Gulf War illness. The real weight is being borne by Gulf War illness—Gulf War veterans who are suffering from Gulf War illness. 

This new report recommends no further research using animal 

models of Gulf War toxic exposures, which amounts to rolling up 

the sidewalk on this promising avenue of Gulf War illness research 

just when it’s beginning to unravel the underlying mechanisms of 

Gulf War illness and point to treatment targets. And these new— 

and this now affects not just non-VA CDMRP research, but VA research as well. In one section, it points out that the VA hasn’t reported critical data, but in other, recommends ending research on 

a long list of health conditions, despite long histories of them in 

Gulf War veterans not reported by VA. While acknowledging Gulf 

War illness is a 1991 Gulf War signature condition, there were no 

Gulf War illness researchers on this panel. It recommends a shift 

to brain/body interconnectedness that departs from the scientific 

opinion that effective treatments, cures, and—it is hoped—preventions can likely be found. Instead, this is more like the 1990s, when 

VA and DoD officials, some of whom are involved in writing this 

report, denied Gulf War veterans toxic exposures, denied benefits, 

and failed to develop treatments or preventions. And now VA and 

DoD have developed a clinical practice guideline that goes back to 

the very darkest days of the 1990s, authored by some of these same 

old names and ideas. 

Despite VA public statements to the contrary, including to this 

Committee, this guide for VA and DoD doctors is filled with references to psychosomatic and somatoform disorders; 52 times, to be 

exact. Its primary recommendations for Gulf War illness are cognitive behavioral therapy or talk therapy, exercise, and psychotropic drugs. Suicidal ideation is listed in the guide as a notable 

adverse effect for every single one of those medications at a time 

when we have a suicide crisis amongst veterans. VA has active 

Gulf War veteran studies on CBT and exercise, but somehow still 

recommends them as evidence-based in this definitive guide. Twenty-five years after our war, VA has circumvented most of the aims 

of the 1998 laws intended to help us. In addition to the above, VA 

lost its registry—lost its registry—for Gulf War spouses and children; ignored and then gutted the Gulf War Research Advisory 

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12 

committee; misleads Congress in its reports to Congress; found no 

link between Gulf War exposures in Congress, including in these 

manuals; identified almost no new presumptives. If we measure 

VA’s success by how it’s improved Gulf War veterans health 25 

years after the war, VA still has not a single evidence-based treatment for Gulf War illness. Others among us have died of ALS, 

brain cancer, and suicide. And only since the Congressionally Directed Medical Research Program was enacted through the support 

of many on this committee has VA even begun to look at developing treatments. And while there is real research progress, most 

of it is being made outside of and in spite of VA in the CDMRP, 

thanks to many of your support. Twenty-five years later, one-fourth 

to one-third of us Gulf War veterans continue to struggle with the 

health and life effects of Gulf War illness. We must not allow—we 

must not continue to allow VA and DoD to substitute risk communication for evidence-based health care, psychosomatic drugs for 

treatment-focused research, spin for substance, or don’t look/don’t 

find for the objective collection analysis and reporting of deployment health outcomes. The letter, the spirit, and the intent of the 

1998 Persian Gulf War laws that we fought so hard to win have 

yet to be achieved. 

And, again, this is just a brief overview. On this 25th anniversary of the Gulf War, our Gulf War veterans deserve the very best 

that modern science and the U.S. Government can offer to improve 

their health and lives. 

Mr. Chairman, as one of our Gulf War veterans and Members of 

this powerful Committee, please join together and with your colleagues on both sides of the aisle and in both Houses and help fix 

these serious issues once and for all. My fellow Gulf War veteran 

David Winnett and I look forward to your questions. Thank you, 

again, for this opportunity. 

[THE PREPARED STATEMENT OF ANTHONY HARDIE APPEARS IN THE

APPENDIX]

Mr. COFFMAN. Thank you for your testimony, Mr. Hardie. 

Mr. Hardie, do you recall—and so when we talk about, first of 

all, the duration of the war, that there were troops on the ground 

in August of 1990, and then the fact is that the air campaign, I 

think, started on January 27; ground war started on February 24. 

But there was certainly contact prior on the ground side with Iraqi 

forces. But there was—the term—was it ‘‘blow in place’’?—I think, 

is a combat engineering term—and that there were chemical munitions— 

Mr. HARDIE. Yes, sir. 

Mr. COFFMAN [continued].—that were blown in place that the 

Department of Defense denied. Do you remember what the name 

of the location was, primary location was, and the date— 

Mr. HARDIE. Yes. Mr. Chairman, it was in early March of 1991, 

after the end of the war. It was at a place called Khamisiyah, and 

candidly, it was the only one of the incidents that we Gulf War veterans were ever able to get DoD to admit to. There were many others. 

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Mr. COFFMAN. But it took how long—it took—was it 5 years? I 

can’t remember. What was the time length that it took? Because 

there was a coverup, quite frankly. 

Mr. HARDIE. Yes. 

Mr. COFFMAN. Because there were—the page out of General 

Schwarzkopf’s log was missing on that day. All other records were 

destroyed intentionally. They said they were—I can’t remember— 

accidentally destroyed. But they were destroyed nonetheless. So 

there were no fingerprints. And the statement by the Department 

of Defense was that no U.S. troops were exposed to chemical—to 

any chemical munitions, chemical weapons. We know that’s not 

true today. Nobody faced disciplinary consequences for lying. And 

then—and then so the research never took that into account because the Department of Defense denied that. How long did it take 

the Department of Defense to finally acknowledge that U.S. troops 

had been exposed? 

Mr. HARDIE. Well, Mr. Chairman, my understanding—my recollection that it was about 5 years. 

Mr. COFFMAN. About 5 years. 

Mr. HARDIE. About 1996. And, again, to emphasize, as you just 

said, that was one of—that was the only incident that we were successfully able to get DoD to acknowledge. And all that information, 

that evidence, came from Freedom of Information Act requests 

from a large number of veteran advocates out there who did an incredible job of digging up and finding out what DoD and VA and 

the CIA did not want to— 

Mr. COFFMAN. What was the name of those pills we had to take? 

Mr. HARDIE. Pyridostigmine bromide, sir. 

Mr. COFFMAN. And they were not FDA approved. Is that correct? 

Mr. HARDIE. That’s correct. My understanding, though, is that 

DoD has recently approved them now for use. And that’s extremely 

concerning, given the health effects that me and the men in my 

unit had. I can’t understand how that’s even possible. 

Mr. COFFMAN. And what was the purpose? Was that for biological or— 

Mr. HARDIE. So, sir, it was an anti-nerve-agent prophylactic— 

Mr. COFFMAN [continued]. Nerve agent. Okay. 

Mr. HARDIE. It was in order to help to improve the survivability 

if we were hit with one particular nerve agent. Although now research by Dr. White and others has shown that this drug in combination with other chemicals is extremely problematic and—for 

health, and causes Gulf War illness-like symptoms in laboratory 

animals. The kind of research that the IOM report recommends 

ending. 

Mr. COFFMAN. And then Saddam Hussein had blown a lot of the 

oil wellheads to obscure, I think, his own movement or positions of 

his troops. And then, of course, through our own bombing efforts 

probably destroyed the balance to where there were days, I remember a wall of black smoke would be coming at you. And you were 

literally engulfed in that oil well fire. Smoke emanating from those 

oil well fires for very long periods of time. Do you feel that that’s 

been adequately researched in terms of what the health effects of 

that were? 

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Mr. HARDIE. Mr. Chairman, I don’t feel that any of it has been 

adequately researched. I think the VA has done an atrocious job. 

I think that many of the—there’s a long list of conditions in the 

1998 laws that were supposed to be—VA was supposed to contract 

with IOM for. Many of those were never researched, including low 

levels of mustard, which we know was in the January 19 plumes 

drifting over the troops. The studies of sarin failed to connect illness in animals exposed to sarin with human health outcomes. 

That’s extremely problematic. And, of course, these days, we’re not 

putting human beings into a gas chamber exposing them to a deadly nerve agent like sarin. So there’s this impossible, impossible 

standard that has prevented the 1998 laws from ever being 

achieved. Again, I don’t believe any of the substances have been 

adequately researched or in the right ways. 

Mr. COFFMAN. Have you—this is my last question. Have you uncovered at all why the command senior leaders, they chose to destroy those chemical weapons there as opposed to properly dispose 

of them? 

Mr. HARDIE. That’s a more complicated question, sir. I don’t 

have—I have my own beliefs. But I don’t have a good explanation. 

I do say that it’s extraordinarily disappointing, particularly that 

those logs—General Schwarzkopf’s logs disappeared. I served in an 

intelligence role in the 1991 Gulf War and kept logs of my own, 

which have never been able to—have been found. My entire unit’s 

medical records have—I’m sorry. Our medical records disappeared. 

It took a year for our personnel records to show back up as well. 

And there were a series of chemical incidents, including one nearby 

to where I was located, where we were—the messages that I was 

logging were that chemical warfare agents were detected, were confirmed, were confirmed again, and then suddenly it all went away. 

And the evidence that Gulf War veterans uncovered through Freedom of Information Act requests showed that over and over and 

over again, the DoD, the CIA, and the VA have all fought all of 

that across the board. And what we—and it’s very clear to all of 

us. We came back home sick. Twenty-five years later, we’ve got a 

stack of volumes that hasn’t helped us. We need to do better. 

Mr. COFFMAN. Mr. Hardie, thank you so much for your testimony. 

Ms. Kuster, you are now recognized. 

Ms. KUSTER. Thank you, Mr. Chair. 

And thank you, Mr. Hardie, for your service, and, Dr. White, for 

your reach, and to the whole panel for being with us today. 

I’m just thinking of my own personal experience, not in wartime, 

but I had an illness that was connected with ingestion of volcanic 

ash. And I was very sick for a very long time. And so my empathy 

is with you and the veterans exposed to a substance like that, that 

you don’t know, I learned later that it was really ground glass, and 

when it gets into your lungs, you do get sick. But it was that same 

feeling of the cloud coming toward you and the helplessness of 

not—not being able to protect yourself. So my goal here is two-fold. 

One is to make sure that we have a sufficient understanding to 

help the veterans from the Gulf War era. And, number two, and 

equally importantly for me, that we have an understanding to protect our servicemembers who are currently serving abroad. 

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And so my question, and I’ll just put this out to Mr. Hardie and 

Dr. White, but if anyone else wants to weigh in, have we—I understand your frustration. And I’m just wondering, have we made any 

progress? Are there individual instances? Are there anecdotal stories of treatments that have been effective that could be more widely used? Let’s start with that. 

Mr. HARDIE. Maybe if I go first and then Dr. White will have 

probably other things to add as well. But so there is hope through 

the efforts of many here in this room, including, thank you, Dr. Roe 

and Mr. Walz for your leadership in—with the Congressionally Directed Medical Research Program, and for many of you who have 

signed on in support of that program. It was created in fiscal year 

2006, and has shown great progress. But, again, outside of and in 

spite of the VA, which is now doing some good things thanks to the 

work of Dr. Kalasinsky, but has a long, long, long ways to go. 

About a third of the studies funded through this program are testing actual treatments that might help the health and lives of ill 

Gulf War veterans. The other two-thirds are studies that are aimed 

at Gulf War illness’ underlying mechanisms. They include critically 

important animal studies that test exposures and measure health 

outcomes, again, the kinds of things that are now threatened by 

this IOM report. They identify treatment targets. They test treatments. There are three that have—three treatments—again, much 

of this is still in the pipeline, but there are three that have been 

shown to be effective in limited numbers as well: Coenzyme Q–10, 

carnosine and acupuncture for pain. I take CoQ10 every day. It 

helps me in a—it helps me a great deal. It’s not a cure, but it certainly makes a difference. I’ve heard the same from other Gulf War 

veterans. I’m pleased to hear that now we have this study coming 

from—that will advance it. But, again, it’s not a cure. I take it 

every day. And I can tell you that we have a long—we have—but 

we’re making the progress now through this program. And we hope 

that VA would finally get onboard with making the systemic 

changes that need to happen, including in its badly broken Office 

of Public Health. 

Ms. KUSTER. So one of the things we’re going to be doing a hearing, a regional hearing, of this Subcommittee actually coming to 

New Hampshire to talk about opiate use and some interesting research that’s going on in White River Junction VA, to bring down 

the use of opiates using alternative remedies, acupuncture, mindfulness, some of the things that you’ve mentioned, because I do believe in that mind/body connection. And I don’t mean to diminish 

anything about it. I know that there’s certainly illnesses, thyroid 

illnesses, that type of thing, where it is so closely connected. So I 

think it’s worth exploring these other treatments. And I guess— 

and because I agree with you that just throwing pills at it, throwing, you know, psychotropic medication that have these down sides 

with certainly suicidal ideation, et cetera. But just going forward, 

I’d love to talk with you all about—we’re going to be looking hopefully at legislation about best practices in the VA on pain management. Maybe there’s a way to bring in some of this research that 

has gone forward. 

And I’d just—Dr. White, I have a very brief time left, but if you 

have any comments. 

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Ms. WHITE. I would say that there’s a number of lines of treatment approaches that have been supported by CDMRP and more 

recently VA through our recommendations and work with them on 

the Research Advisory Committee. Some are aimed at symptoms, 

brain activation, improving general health and wellbeing. Obviously, when chemicals affect the brain, they affect how you feel as 

well as how you think and your immune system. And it is a whole 

body thing. I think what we’re trying to say is that there is physical damage to the brain that is causing emotional as well as cognitive and other symptoms. And you need to approach the whole 

package. One thing that I think is really wonderful about the support we have gotten for the CDMRP programs, and I’m on the integration panel for that, is that we are now working on therapies and 

trying to fund therapies that get to the neuro-inflammatory and 

mitochondrial basis of this disease. If we can find treatments that 

go after the neuro-inflammation, that go after the mitochondrial 

damage, that go after some of the mechanistisms underlying 

pathophysiology of this illness, we will not only help the Gulf War 

veterans, we’ll help other people with exposures in the whole world. 

And these kinds of chemical exposures are very hard to treat, as 

you know from your own illness. So I think that there’s so much 

promise in the mechanistic-based treatment, as well as the symptomatically focused treatment. I would hate to see that lost. We’re finally getting to mechanism. And we were not anywhere close to 

that 10 years ago. 

Ms. KUSTER. No, and I need to yield back. But I agree. And the 

other half of my question, I—we won’t get into it here, but I am 

extremely concerned that we get upstream on understanding the 

exposure, because, obviously, you know, I don’t have to tell my colleagues that war is a dirty business. But at least we can do our 

best to protect our troops from smoke and inhalation and that toxic 

exposure. 

So, thank you, Mr. Chairman, for your indulgence. 

Mr. COFFMAN. Thank you, Ranking Member Kuster. 

Dr. Roe, you’re now recognized for 5 minutes. 

Mr. ROE. Thank you, Mr. Chairman. And for the group here, I 

don’t know whether you know or not, but I’ve sponsored a bill 

called the Desert Storm and Desert Shield War Memorial Act. And 

we’re in the process of—hopefully I’m meeting with Scott Stump in 

just a little while this week—I think sometime this week—to talk 

about how we raise funds for that. But we wanted to do that while 

it was still on everyone’s mind and people forgot about it. 

I think the question that I have, and as a scientist, and it makes 

a difficult when you don’t know the etiology of a disease, it’s very 

difficult. You end up treating symptoms. And they may vary. And 

I found that one of the great things that used to really bother me 

when I was in practice was, if we didn’t know what was wrong 

with you, we either said it was a virus or you were nervous. I 

mean, that’s basically what you’re doing. And I hope we’re not 

doing that here. I don’t think so. I think good, honest people looked 

at the data. I think it’s very, very hard to assimilate this. 

And the question I have for anybody on the panel, have you 

looked at the oil workers who put the fires out? Have we looked 

at the cohorts there in Kuwait? Right now, there are people that 

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still live in Kuwait that were there. Did they have these symptoms? Is there—are there—when we looked at the cohort who were 

in the service but weren’t deployed versus the ones who did—now, 

I think the Institute of Medicine did that. I think that’s the cohort 

they looked at. You have a built-in group of people right there in 

Kuwait who were there during the war in Iraq. And has anyone 

who served in the current conflict in Iraq, now that it’s been— 

we’ve been out of there for a while, have they had any symptoms? 

A lot of questions. 

Ms. WHITE. Well, to answer some of your questions, the—there 

have been studies on subgroups of people within the Gulf theatre 

who had very specific kinds of exposures. So there is a bunch of research out on the pesticide applicators. And we know a lot about 

what pesticides they were exposed to, how much, what it did to 

their health. There is a study that’s being done at Harvard that I’m 

participating in on the Kuwaiti population. They do—the people 

that were there then do have increased symptoms. We’re trying to 

figure out what it means because the surveys that they used and 

so on didn’t exactly address it the way we would address Gulf War 

illness. 

The other point I want to make is that the exposure scenario in 

the Gulf War theatre was very complex. And comparing deployed 

to undeployed veterans does not always tell you what happened to 

people who were in specific places with specific kinds of high exposures. So the standard that we tried to ask for on the Research Advisory Committee (RAC) and in the Cortex paper that I just wrote 

is looking at people within—who were deployed to the Gulf and 

who were exposed versus who were not exposed and who were in 

certain locations. 

Mr. ROE. Well, I was going to say, because I know probably the 

Chairman, when you’re in the military, sometimes you don’t know 

where you are. I know that I have been deployed in places I didn’t 

know where I was. And I’ve—as a matter of fact, I’ve asked that 

question. Where are we? I mean, so are you able to pinpoint—that’s 

a great point you made. Can you do a sort of a spotogram where 

these folks were? Because you’re right: being deployed a hundred 

miles up here might not be the same as being deployed next to a 

chemical burn. 

Ms. WHITE. Yes. 

Mr. ROE. No question that’s true. 

Ms. WHITE. So where that data came from, and I used a lot of 

this data when I was head of an environmental hazards center that 

was funded by the VA, was we asked for data on what troops were 

where. And we got troop level data on locations in the Gulf. And 

we used that for some of our research. That’s how we knew who 

was in the area of the Khamisiyah detonations and certain other 

things. So, yes, those data are there. It took a lot of years to get 

it because it was in paper in a warehouse. But there are data on 

who was where, at least at the troop level. 

Mr. ROE. At least that’s where they think they were supposed to 

be. 

Ms. WHITE. Yes, because not every individual was where their 

unit was supposed to be. 

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Mr. ROE. You get—when you get shot at, you’re not necessarily 

where you’re supposed to be. You move from that place. 

So I guess what I’m—the last question—my time’s about expired. 

But, again, I thank all of you because this is one of the most difficult epidemiologic issues I’ve ever looked at. Because, again, in— 

like in Ebola, we knew what caused Ebola. In other diseases like 

that, where there’s a single agent, you can—we know what a—how 

that goes. We know exactly what an epidemic is going to do. We 

followed them for centuries. We know what they’re going to do. 

This is much more difficult because you haven’t identified a single 

agent or multiple agents. Or maybe there were one agent here and 

somebody else is over here so—and did the treatment contribute to 

it? I mean, did giving the soldier something to prevent it do anything? So I admire you for trying this. This is one of the most different epidemiologic studies I’ve ever seen. 

So I yield back. 

Dr. CLANCY. The only thing I would say very briefly is, I mean, 

I think it’s a particular challenge for a chronic ongoing kind of condition, which is different than a sort of acute epidemic, the way 

that you’ve described. 

The other thing that I would say is, I don’t think that we should 

discount the progress we’ve made. Cancer would be a perfect example, right, where we’ve learned a lot through brunt empiricism, because we didn’t understand underlying etiology, but we tried a 

whole lot of treatments first and eventually made a lot of progress. 

Mr. COFFMAN. Thank you, Dr. Roe. 

Sergeant Major Walz. 

Mr. WALZ. Thank you, Chairman, and I thank you all for being 

here. I think I’ll dovetail on that, Dr. Clancy. First of all, thank you 

for the update on the step pain management plan. I think it’s important information with the hearing that’s going to be next week 

up in New Hampshire with Ms. Kuster that, back in 2007, this 

very issue was out there, and I think great strides were made, and 

I think you have much to add to the conversation because this is 

not a VA issue of opioid use and pain. It is a societal issue. So I 

appreciate that update. 

And I think, going back to what you said, I do think you’re right 

on that. I think much progress was made on some of these very difficult ones. Dr. Roe clearly laid out the epidemiology and the challenge of this. 

My concern is, though, when do we make a decision that we’ve 

tried hard enough or that we’ve reached that point, because I think 

the frustration lies in this that I think many—something’s happening, and again, we have to have the data, but there’s something 

happening. There’s enough people reporting it. All of us are hearing this, and I just wonder—you have to make tough decisions 

about where funding sources go and where those types of things 

happen. I think there’s belief of many of us that this is going to 

be difficult, but we have a responsibility to keep going on it. 

How do you make a decision—‘‘you’’ being the VA, if you can 

speak for that—how do you make a decision on how hard you push 

on a certain area or how much you do in the research? 

Dr. CLANCY. So let me just say, having run a research agency for 

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sions to make, and it’s really an investment question, right, where 

do you place your bets in terms of getting to rapid answers and the 

kind of evidence that you want, and there’s no biblically correct 

strategy in terms of rules to guide you. 

The one recommendation I—the very top line recommendation, 

and I want to emphasize that we’ve not had a chance to go over 

this Institute of Medicine report. It’s still—the ink is still drying, 

so to speak. It’s actually a prepublication version, I think, we’re all 

looking at, and so forth, and are looking forward to going over it 

with our Research Advisory Committee very, very carefully. But 

the notion that we would develop a cohesive, coherent plan with 

the Department of Defense and, frankly, inviting others, like the 

Harvard study that Dr. White referenced and so forth, to find out— 

to really push very hard on this question. 

There’s a huge proportion of people who were deployed for these 

two operations, and we don’t have any answers. We have some 

promising signals, and that’s exciting. I think some additional 

genomic studies, as a paper that I’m looking at from Dr. White has 

pointed out, may help us even more, but that’s not coming up with 

an answer for why our almost a third of these soldiers deployed are 

struggling. 

So I think that this is going to be a tough answer to come up 

with and a tough strategy to come up with, but it’s one that we’d 

be looking forward to giving you full answers on. 

The last thing I would say is, the number I gave you is a very, 

very conservative estimate because it doesn’t count our epidemiological studies. It doesn’t count the investments we’ve made in registries, for example, the Gulf War registry, the burn pits registry, 

and so forth. And so we’re investing more than that, but the question is, have we done enough? And I think the answer to that is 

no. 

Mr. WALZ. No, and I appreciate that because I do think you got 

on it, too, that the broader issue—I think many of us who have followed the issues on Agent Orange, and there’s Vietnam veterans 

sitting in this room that have pushed on this. 

Dr. CLANCY. Sure. 

Mr. WALZ. They’re concerned on the genetic defect issue of how 

many generations down the line, you know, beyond spina bifida of 

what’s happening to these children, what’s happening to the grandchildren, that’s going to come to this, the burn pit, the depleted 

uranium. 

So my question is, are we doing enough? I mean, shame on us 

if we’re not learning that every generation has to come back and 

fight the fights on these things. Is now the time for a center of excellence on toxic wounds? Is this the time to do that? Does that 

make the difference, where it brings the force of all of these issues 

under one? Because the thing I worry about is—I don’t want to put 

Parkinson’s research on Agent Orange exposure against Gulf War 

exposure. And I know you may tell me that’s the choices we have 

to make, the hard ones. So I ask you, is the center of excellence 

the way to go to bring this under one in-house? 

Dr. CLANCY. You know, it may be, and we would love to work 

with you on that, because no matter when we called it—because I 

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20 

agree with you about the X amount here, Y amount there, who’s 

made the most noise recently, to be crass. 

Mr. WALZ. Yes. No, I think that’s a true statement, though. 

Dr. CLANCY. No matter how you cut it, it’s going to have to be 

an entity that coordinates what we’re doing with Defense, with 

what’s going on at HHS, and from a variety of other funders, which 

would be great, actually, because—but I think we can leverage all 

of that. We’ve recently been working with CDC’s agency for toxic 

substances and diseases on the Camp Lejeune issue, and actually, 

that was very, very productive. 

Mr. WALZ. And I think our issue, especially with these toxic 

wound exposures in battle, it differs from cancer in that the private 

sector is not investing as much in this because there’s— 

Dr. CLANCY. Right. 

Mr. WALZ [continued].—not—it’s a limited universe that’s going 

to be treated by this. So, once we treat them, which we need to do, 

and cure them, there’s not a market for the product necessarily. 

Dr. CLANCY. Exactly. 

Mr. WALZ. That may be crass, too, but that’s the reality of the 

economics. But, no, I thank you all for that, and I think the commitment here is, is that something happened to these folks. It’s 

real— 

Dr. CLANCY. Yeah. 

Mr. WALZ [continued].—and they deserve an answer and a treatment. 

So I yield back. 

Mr. COFFMAN. Thank you, Sergeant Major Walz. 

Mr. Huelskamp. 

Mr. HUELSKAMP. Thank you, Mr. Chairman. 

I appreciate the topic of our hearing today. I’m hearing a lot of 

contradictory claims and concerns and maybe a conclusion. I want 

to direct a couple of questions to Dr. Hunt, who I don’t think has 

had an opportunity to participate today on the question and answer, but based on the tenor of a relatively recent presentation you 

gave called, ‘‘A Model for Providing Services for Returning Combat 

Veterans,’’ it’s apparent that, and you others in the VA believe Gulf 

War illness is a mental disorder. Is that correct? 

Dr. HUNT. That is not correct. I’m not sure where you got that 

information. 

Mr. HUELSKAMP. Did you not have a presentation entitled ‘‘A 

Model for Providing Services for Returning Gulf War Veterans’’? 

Dr. HUNT. Presented where? 

Mr. HUELSKAMP. I don’t have that, the place of presentation. 

Dr. HUNT. I don’t believe that, and I have never said that, and 

I don’t—no. 

Mr. HUELSKAMP. So this wasn’t your presentation then? 

Dr. HUNT. It could be. I would have to look at it. I’m not sure. 

Mr. HUELSKAMP. Okay. Well, I don’t know. You never made a 

presentation on ‘‘A Model Providing Services for Returning Gulf 

War Veterans’’? 

Dr. HUNT. I give presentations on that often. 

Mr. HUELSKAMP. All right. 

Dr. HUNT. But I would like to see it because it certainly is a misinterpretation of what I believe and, I suspect, what I said. 

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Mr. HUELSKAMP. So do you believe also or otherwise that psychiatric drugs are the best treatment for veterans with Gulf War 

illness? 

Dr. HUNT. I believe that medications should be used for conditions they’re indicated for, and psychiatric medications are not indicated for Gulf War illness, per se. 

Mr. HUELSKAMP. What kind of treatments would you suggest 

then? 

Dr. HUNT. I think the most—25 years ago, what was going on 

with me was, I was starting to see people coming back in 1992 and 

1993, coming back from the war, and the things that they were 

saying when they came back were not, ‘‘I have Gulf syndrome’’ or 

‘‘I have a mystery illness.’’ What they were saying was: ‘‘I’m not 

doing very well. I’m having a lot of trouble. I’m having trouble at 

home; work’s not going well. I can’t do my PT for Reserves—Guard 

and Reserves,’’ and so on. 

And our response to that was to set up a clinic for returning combat veterans that really was looking at the various ways that the 

deployment impacted their health: how it impacted their health 

physically; how it impacted their health psychologically, emotionally, spiritually; how it affected their families. And we came up 

with a model of integrated care to support Gulf War veterans. It 

became the Gulf War Veterans’ Clinic. 

That eventually morphed into what we call in the VA Deployment Health Clinics, or turned into what we call a Post-Deployment Integrated Care Initiative. I have never—the first veterans 

that came back, I would not have said, ‘‘This is in your head,’’ or 

‘‘I think this is a mental condition.’’ I would have said: ‘‘You’re having trouble. I don’t know exactly what all is going on, but I know 

you’ve been off to war. I know you’ve been exposed to a lot of 

things. I know you’ve had some very difficult experiences, and let’s 

see what we can do to get you back on your feet.’’ 

I’ve had an eye on two things. One is the sort of research that 

Dr. Golomb and Roberta and Lea Steele have been trying to do to 

figure out what’s the cause of this Gulf War illness that’s very discrete. Clearly, we have higher rates of these symptoms and this 

problem in Gulf War veterans than any other cohort I’ve ever seen. 

The research is important. At the same time, we had to have a 

way of helping people, and so our clinical focus has been: How can 

we help you get back on your feet? By providing you with integrated—good integrated care that includes symptom management, 

that includes medications when they’re appropriate, that includes— 

Mr. HUELSKAMP. Are the psychiatric drugs most effective, you believe, or what have you seen in— 

Dr. HUNT [continued]. I think the most effective thing is good 

health care, is appropriate evaluations and treatments for 

diagnosable conditions, getting people resources they need through 

service-connection. This is the first time we’ve given service-connection— 

Mr. HUELSKAMP. Excuse me, sir. That’s general. I’m asking you 

about psychiatric drugs. Are they effective in the treatment or not? 

Dr. HUNT. They are effective in the treatment for indicated conditions. If a person—one of the problems we had—and Anthony, I 

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22 

was thinking about this when you were talking as well—if—because of the suicide issue, if we see Gulf War veterans that have 

unexplained symptoms or Gulf War illness, they may also have 

concurrent or co-occurring depression, and they are at risk for suicide, and so it’s very important that we don’t look at this as either/ 

or, and if a person has a mental health condition, that they get appropriate treatment, which— 

Mr. HUELSKAMP. My concern is, it seeks like the psychiatric drug 

approach seems to be where—the simplest choice for the VA to 

make. 

Dr. HUNT. I would not say that. 

Mr. HUELSKAMP. And I appreciate— 

Dr. HUNT. I would not say that. 

Mr. HUELSKAMP [continued].—you disagreeing with that. 

The last thing, I want to ask a question of Dr. Cory-Slechta. In 

your recommendations, you do suggest no further studies should be 

undertaken on cause-and-effect relationship because you don’t have 

definitive and verifiable individual veteran exposure information. 

Is that correct? Is that your recommendation? 

Ms. CORY-SLECHTA. There were no measures made of internal exposures of veterans, and there were no measures made even of environmental exposure levels. This is basic principles of toxicology 

and pharmacology. 

Mr. HUELSKAMP. So, in your opinion, then—and I understand 

that. In your opinion, then, all the previous studies that attempted 

to determine that, are they invalid then? 

Ms. CORY-SLECHTA. I don’t think you can rely on self-report, because there will be people who were actually exposed who don’t 

even know it. 

Mr. HUELSKAMP. This is not about self-reporting. It’s whether 

you have definitive or verifiable individual veteran exposure. 

Ms. CORY-SLECHTA. I think it’s possible to get those kinds of 

measures, and that’s what I stressed before, that in the future, we 

need biomonitoring devices and GPS tracking devices so we can in 

fact get that kind of information and make those associations. 

Mr. HUELSKAMP. And I understand that. I’m just trying to figure 

out whether you thought we had that in the past, and to me, that 

calls in question a number of these studies, if we don’t have that 

type information. 

Lastly, you did request additional studies of sex-specific and race/ 

ethnicity-specific health conditions. If we don’t have the individual 

exposure information, how do we determine— 

Ms. CORY-SLECHTA. Well, there may be—we know a lot of diseases and disorders differ in their manifestations by sex or by race/ 

ethnicity. 

Mr. HUELSKAMP. If we don’t have the exposure information, 

which is a key variable, how— 

Ms. CORY-SLECHTA. It’s a different point. 

Mr. HUELSKAMP [continued].—do you study that? 

Ms. CORY-SLECHTA. It’s a different point. The exposure information, what this committee has said is that we’ll never be able to understand how those exposures actually related to these health outcomes. We don’t have any objective exposure. 

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Mr. HUELSKAMP. We don’t know whether they have exposure or 

not is your point. 

Ms. CORY-SLECHTA. Sorry? 

Mr. HUELSKAMP. We don’t know whether they have exposure or 

not. Is that the answer? 

Ms. CORY-SLECHTA. We know there were exposures. What we 

don’t have is actual information for individuals that we would look 

at it in relation to health outcomes. 

Mr. HUELSKAMP. I understand. So— 

Ms. CORY-SLECHTA. We know there were exposures. 

Mr. HUELSKAMP [continued].—So I don’t know how you do your 

second round of studies that you recommended. You say abandon 

the first round, but the second round, you’re talking about race and 

sex and— 

Ms. CORY-SLECHTA. We’re just saying for any health outcomes, 

because oftentimes, for many different diseases and disorders, 

there are manifestations, and sometimes their mechanisms differ 

by sex and by race/ethnicity. In order to really understand and/or 

treat them, you may be doing it very differently. Heart attack is 

very different in a man than in a woman, for example. 

Mr. HUELSKAMP. Yeah. 

Ms. CORY-SLECHTA. So we need to break those out and look at 

them. 

Mr. HUELSKAMP. Thank you, Mr. Chairman. I just found it concerning that the basic exposure information is—we’re hearing that, 

well, we don’t know what it is, and so if you take that variable out, 

I mean, that strikes out a lot of information, a lot of data, and a 

lot of research would be thrown out by the Institute of Medicine, 

and we spent a lot of time, attention, and money trying to figure 

this out, so very concerning. 

I yield back. 

Mr. COFFMAN. Thank you, Mr. Huelskamp. 

We’ll have one more round if anybody else has questions. I do 

have two questions. 

Mr. Winnett, could you join us at the table? 

Mr. WINNETT. Sure. Can I get a bottle of water first? I just took 

a Vicodin. Hard to take those on a dry mouth. 

Mr. COFFMAN. Mr. Winnett, on your Facebook group related to 

Gulf War illness, you asked: How many veterans are being referred 

for psychiatric or psychological treatment? 

What kind of response are you getting? 

Mr. WINNETT. In a word, overwhelming, sir. Can you hear me 

okay? 

Mr. COFFMAN. Is that on, microphone on? 

Mr. WINNETT. In a word, the answer to that question, Congressman, is overwhelming. I might add that, yesterday, we hit the 

milestone of 10,000 veterans. This is a closed group, and I approve 

every member and have so for over the last 7 years. Overwhelming. 

And my written statement for the record includes quite a number 

of them, but obviously not all of them, but it took some of those 

that were very compelling, and I think they are self-explanatory if 

you read my statement as to what the prevailing attitude is about 

VA’s treatment of Gulf War illness. 

Mr. COFFMAN. Thank you. 

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Now, Mr. Binns, could you please come to the table? Mr. Binns, 

given VA’s use of IOM reports in the manner we have discussed, 

are you aware of any requirements for such reports? 

Mr. BINNS. Yes, I am. The Congress ordered these IOM reports, 

and in the law, it specified very clearly what it wanted the IOM 

reports to consider. It listed 33 toxic exposures, including all the 

ones that have been mentioned here, and it asked whether in the 

medical literature, there was an association between any of those 

toxic exposures and illness in humans or in animals. 

Congress did not ask whether there was data on the individual 

exposure levels that troops received because it was known, at the 

time the law was passed, that that information was not available, 

but it did want to have the information on animals, because most 

studies of toxic substances are done in animals. 

When VA contracted for these studies, however, they did not contract for considering animal studies. And the Institute of Medicine 

was a willing accomplice in that it removed consideration of animal 

studies from its standards of evidence, which it had used in the 

case of Agent Orange evaluations for Vietnam veterans. So the action taken was exactly the opposite of what Congress ordered, and 

as a result, that entire stack of reports, which you see, no IOM report has ever considered animal studies in its conclusions, and no 

IOM report has ever found an association between a toxic exposure 

and the illnesses that we’re talking about today. 

And I want to just clarify, because there has been a lot of discussion today about how complex this is. And, certainly, going forward, it is complex to find treatments, but well worthwhile. But 

what is not complex is understanding why these veterans are ill. 

You do not have to measure each veteran and have a monitor on 

them to know that. 

Our report, the report of the Research Advisory Committee that 

was done in 2008—here it is—it researches very firm conclusions 

on the fact that these illnesses were caused by toxic exposures, notably the ones Dr. White mentioned, PB and pesticides. There is no 

dispute about that if you consider animal research. But the IOM 

has never considered the animal research. They talk about it, they 

have paragraphs on it, but when you reach the conclusions, they 

use a standard of evidence which excludes animal studies. 

Please read my submission, and you will see that in detail that 

the entire IOM reports—if you read the reports, they’re very clear. 

They’re very honest. They say: We don’t consider these animal 

studies. And we’re talking about basic things here. Here’s 2 pages 

with 23 studies of the effect of low level sarin, such as was experienced in Kamasia that was considered by the Research Advisory 

Committee and has never been considered by the IOM. 

Dr. Cory-Slechta’s report on page 139 says that she didn’t consider the animal studies because they were relying on earlier IOM 

reports. Well, if you read the earlier IOM reports, as I indicated in 

my written submission, they didn’t consider them either. These are 

the basic studies that say the toxic substances are toxic. 

So the whole IOM series of Gulf War and health reports is a 

stack of cards, and the same dishonest standard is being applied 

to current veterans of Iraq and Afghanistan who have been exposed 

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25 

to burn pits. Once again, there is no consideration of the standard 

that Congress itself established. 

Mr. COFFMAN. Thank you, Mr. Binns. 

Ranking Member Kuster, you are now recognized for 5 minutes. 

Ms. KUSTER. Yeah. Thank you. 

This is a question for Dr. Clancy. And, again, my exposure and 

my experience doesn’t compare to anyone serving in wartime, but 

part of the complication that I experienced with my lungs was, I 

was told that I had the lungs of a 90-year-old smoker. And I’ve 

never smoked a day in my life, and I consider myself a healthy person, but that’s the kind of damage that can be done. 

I’m much better now. But I’m curious—and this goes to Dr. 

Clancy, maybe Dr. Hunt—on the long-term impacts—well, we know 

from the IOM and just generally that cancers have a long latency 

period, 20 to 30 years in the case of lung cancer. This is a quote 

from the Lung Cancer Alliance, from the written statement: The 

median age for cancer diagnosis in the United States is 65, 70 for 

lung cancer, and the median age of Gulf War veterans, 1991, was 

28. So, add 25 years, we’re coming up on this cohort of veterans 

being 50 years or older, and I’m wondering, is there any action 

being undertaken by the VA—or could we encourage you to do 

that—where we would be providing lung cancer screening to Gulf 

War veterans that we have on the registry, or at least an initiative 

VA-wide, where we would put the word out for Gulf cancer veterans to get this type of screening? Can you tell me the status and 

just what that would look like and how we can move forward? 

Dr. CLANCY. So, just to be clear, we have pretty well developed 

cancer registries for most of the major cancers, and I think the Institute of Medicine report was very clear that that would probably 

be the most fruitful place to identify an increased incidence. 

We could certainly explore lung cancer screening for some of 

these folks, and I actually think that’s a very intriguing idea. 

About 60,000 people have voluntarily signed up to enroll in the 

burn pits registry. The only caveat—but again, I think this will be 

interesting to learn. The lung cancer screening studies were done 

on smokers. Whether it will be as productive in identifying early 

nodules and so forth in people who have lung damage for another 

reason is an open question. 

Ms. KUSTER. Yeah. 

Dr. CLANCY. I will say it’s something the VA has been looking 

at for a few years, not just can we get veteran screening, but also 

can we do the appropriate follow-up, because the price tag on reducing mortality rate for lung cancer is the only thing we’ve got, 

right, is this new kind of screening; it reduces mortality by 20 percent. Nothing else we’ve ever done works like that. 

Ms. KUSTER. Yeah. 

Dr. CLANCY. The flip side of it, though, is you have a lot of false 

positives, so people need to be followed up very, very carefully, and 

we’ve been looking into that for several years. 

Dr. HUNT. The other important thing for the Committee to know 

is that our approaches to more proactively addressing exposure 

concerns following deployment are sort of demonstrated very clearly through the airborne hazard and open burn pit registry. Now, 

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line; they can document their symptoms, their concerns, their exposures. It goes into the clinical record. They come in, and they have 

an exam, so we’re really starting the moment people come back to 

look at potential sequelae. 

Ms. KUSTER. So maybe what we’re talking about then would be 

to take that approach and go back to the Gulf War veterans to 

bring them in to that. And I understand we don’t have the specificity. I get the frustration— 

Dr. CLANCY. Yeah. 

Ms. KUSTER [continued].—from the science side of wanting to 

know, but I also feel that people have had exposure, and without 

even knowing the specificity, at least we would have an understanding. A 20 percent drop in mortality is significant, so—and I 

just want to associate myself with the remarks of Mr. Walz that 

maybe that is the approach that we need, is a center of excellence 

for toxic exposure, toxic wounds. And I also think that, once again, 

the VA could be on the cutting edge for the civilian population in 

terms of understanding our exposure to all kinds of toxic substances. 

Dr. HUNT. And that’s why engaging people in care is so important, too, because the best way to pick up malignancies is to have 

people involved in regular care so— 

Ms. KUSTER. Right. 

Dr. HUNT [continued].—So prescribed screening occurs, and so 

we—if people have symptoms, we’re more likely to pick up—pick 

things up more quickly. 

Ms. KUSTER. Right. And I think that, this way, you can bring 

people back in and, through their regular care, have the conversation about, we would recommend—and I understand, look, CTs for 

everybody in the world is going to be expensive, but to me, it’s very 

important that we show that kind of care and concern. 

I wasn’t in Congress 25 years ago. I regret that people were 

treated this way, and I think we have a bipartisan support here 

to do better going forward. And, again, thank you for your service 

and, for all of you, for your interest today. 

Mr. COFFMAN. Thank you, Ranking Member Kuster. 

Our thanks to the witnesses. You are now excused. 

Today, we have had a chance to hear about the problems that 

exist within the Department of Veterans Affairs with regard to 

treatment of and current health outcomes for veterans suffering 

from Gulf War illness. The lack of progress that has been made by 

the Department in the 3 years that have passed since many of 

these problems were highlighted by this Subcommittee is both frustrating and disconcerting. 

I believe Gulf War veterans deserve better, so I will be exploring 

options on how to best address these matters in the coming weeks. 

I ask unanimous consent that all Members have 5 legislative 

days to revise and extend their remarks and include extraneous 

material. 

Without objection, so ordered. 

I would like to, once again, thank all of our witnesses and audience members for joining in today’s conversation. 

With that, this hearing is adjourned. 

[Whereupon, at 5:58 p.m., the Subcommittee was adjourned.] 

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A P P E N D I X 

Prepared Statement of Deborah Cory-Slechta, Ph.D. 

Good morning, Chairman Miller, Ranking Member Kuster, and members of the 

Committee. My name is Deborah Cory-Slechta. I am a Professor of Environmental 

Medicine, Pediatrics and Public Health Sciences, and Acting Chair of the Department of Environmental Medicine at the University of Rochester School of Medicine. 

I served as the Chair of the Committee on Gulf War and Health, Volume 10: Update 

of Health Effects of Serving in the Gulf War of the National Academies of Sciences, 

Engineering, and Medicine. The National Academy of Sciences was chartered by 

Congress in 1863 to advise the government on matters of science and technology 

and later expanded to include the National Academies of Engineering and Medicine. 

The Institute of Medicine (IOM), part of the National Academies of Sciences, Engineering, and Medicine, released its 10th report on Gulf War and Health on February 11 of this year. The committee that I chaired was asked to review and evaluate the scientific and medical literature regarding associations between illness and 

exposure to toxic agents, environmental or wartime hazards, or preventive medicines or vaccines associated with Gulf War service and to pay particular attention 

to neurological disorders (e.g., Parkinson’s disease, multiple sclerosis, amyotrophic 

lateral sclerosis, and migraines), cancer (especially brain cancer and lung cancer), 

and chronic multisymptom illness (also known as Gulf War illness). Volume 10 updated two earlier Gulf War and Health reports, Volume 4, published in 2006, and 

Volume 8 published in 2010. The committee made recommendations for future research on Gulf War veterans. I should note that the committee was composed of experts in neurology, epidemiology, pain, psychiatry, neurocognitive disorders, environmental health and toxicology; and clinicians and researchers, none of whom received funding from Gulf War illness research programs. 

For the most part, the Volume 10 committee followed the approach used by earlier 

committees. It held two public sessions at which it heard from representatives of 

VA, several Gulf War veterans and veteran service organizations, Gulf War researchers, and representatives of the VA Research Advisory Committee on Gulf War 

Veterans’ Illnesses. The committee did not address policy issues, such as service 

connection, compensation, or the cause of or treatment for Gulf War illness. The 

committee conducted an extensive literature search and reviewed the Volumes 4 

and 8 primary and secondary epidemiologic studies and the conclusions reached by 

those committees. Other types of studies-such as animal toxicology, neuroimaging, 

and genetics-were also considered. 

Primary studies had to be published in a peer-reviewed journal or other rigorously 

peer-reviewed publication; demonstrate rigorous methods (for example, have an appropriate control group and include adjustments for confounders); include information on a persistent (not acute) health outcome; use appropriate laboratory testing, 

if applicable; and have a study population that was generalizable to and representative of the Gulf War veteran population. Secondary studies were those studies that 

did not necessarily meet all the criteria of a primary study. Many of the secondary 

studies relied on self-reports of various diagnoses rather than an examination by a 

health professional or a medical record review. 

The committee used the same categories of association relating health conditions 

to Gufl War deployment as used by previous Gulf War and Health and other IOM 

committees that have evaluated scientific literature, that is: 

• Sufficient Evidence of a Causal Relationship 

• Sufficient Evidence of an Association 

• Limited/Suggestive Evidence of an Association 

• Inadequate/Insufficient Evidence to Determine Whether an Association Exists 

• Limited/Suggestive Evidence of No Association 

The committee found that in spite of the many millions of dollars that have been 

spent on researching the health of Gulf War veterans there has been little substanLeonard.horne on VACREP0180 with DISTILLER

28 

tial progress in our understanding of their health, particularly of Gulf War illness. 

The Volume 10 committee found little evidence to warrant changes to the Volume 

8 conclusions regarding the strength of the association between deployment to the 

Gulf War and adverse health outcomes. Veterans who were deployed to the Gulf 

War do not appear to have an increased risk for many long-term health conditions 

with the exceptions of PTSD, Gulf War illness, chronic fatigue syndrome, functional 

gastrointestinal conditions, generalized anxiety disorder, depression, and substance 

abuse. The committee’s conclusions are briefly summarized in the Box 1. 

BOX 1 

Summary of Conclusions Regarding Associations Between Deployment 

to the Gulf War and Specific Health Conditions 

Sufficient Evidence of a Causal Relationship 

• Posttraumatic stress disorder (PTSD) 

Sufficient Evidence of an Association 

• Generalized anxiety disorder, depression, and substance abuse (particularly alcohol abuse) 

• Gastrointestinal symptoms consistent with functional gastrointestinal disorders 

such as irritable bowel syndrome and functional dyspepsia 

• Chronic fatigue syndrome 

• Gulf War illness 

Limited/Suggestive Evidence of an Association 

• Amyotrophic lateral sclerosis (ALS) 

• Fibromyalgia and chronic widespread pain 

• Self-reported sexual difficulties 

Inadequate/Insufficient Evidence to Determine Whether an Association Exists 

• Any cancer 

• Cardiovascular conditions or conditions of the blood and blood-forming organs 

• Endocrine, nutritional, and metabolic conditions 

• Neurodegenerative diseases other than ALS 

• Neurocognitive and neurobehavioral performance 

• Migraines and other headache disorders 

• Other neurologic conditions 

• Respiratory conditions 

• Structural gastrointestinal conditions 

• Skin conditions 

• Musculoskeletal system conditions 

• Genitourinary conditions 

• Specific birth defects 

• Adverse pregnancy outcomes (e.g., miscarriage, stillbirth, preterm birth, and low 

birth weight) 

• Fertility problems 

• Increased mortality from any cancer, any neurologic disease (including multiple 

sclerosis, Alzheimer’s disease, Parkinson’s disease, and ALS), respiratory disease, 

or gastrointestinal disease 

Limited/Suggestive Evidence of No Association 

• Objective measures of peripheral neurologic conditions 

• Multiple sclerosis 

• Mortality from cardiovascular, infectious, or parasitic diseases 

• Decreased lung function 

• Mortality due to mechanical trauma or other external causes 

As requested in its statement of task, the committee had additional discussions 

pertaining to Gulf War illness, neurologic conditions, and lung and brain cancer on 

those health conditions and other aspects of Gulf War veteran health. 

Gulf War Illness. Gulf War illness is the signature adverse health outcome of 

having served in the Persian Gulf region. Multiple studies found that some Gulf 

War veterans, regardless of their country of origin and their different deploymentrelated exposures, have persistent, debilitating, and varying symptoms (such as 

joint and muscle pain, fatigue, and cognitive problems) of Gulf War illness. In spite 

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of over 2 decades of research to define, diagnose, and treat Gulf War illness, little 

progress has been made in elucidating the pathophysiologic mechanisms that underlie it, the exposures that may have caused it, or treatments that are generally effective for it. 

Gulf War illness is not an easily defined or diagnosed condition. The committee 

concluded that it is not a psychosomatic illness, but it does present with diverse 

symptoms, many of which overlap with other health conditions such as chronic fatigue syndrome, neurodegenerative disorders, and musculoskeletal problems. Based 

on available research data, it does not appear that a single mechanism can explain 

the multitude of symptoms seen in Gulf War illness, and the committee found it unlikely that a single definitive causal agent would be identified this many years after 

the war. Furthermore, most Gulf War illness studies have excluded the psychological aspects of the condition with regard to both diagnosis and treatment although veterans report symptoms such as chronic pain and sleep disturbances that 

may be amenable to psychological therapies, alone or in conjunction with other 

treatments. 

The committee concluded that although the existence of an animal model would 

be advantageous for identifying and evaluating treatment strategies for Gulf War 

illness, it cautions that developing such an animal model is precluded by the absence of any objective measures of chemical and nonchemical exposures during Gulf 

War service, let alone the frequency, duration, or dose of those exposures, or the 

highly likely interactive effects of multiple exposures. 

Neurologic Conditions. The committee found little new information pertaining 

to multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, or migraines. ALS is 

the only neurologic disease for which the committee found limited/suggestive evidence for an association with deployment to the Gulf War. The committee concluded 

that further follow-up of this uniformly fatal disease is warranted. The Gulf War 

veteran population is still young with respect to the development of other 

neurodegenerative diseases; therefore, the effects of deployment on their incidence 

and prevalence may not yet be obvious. 

Lung Cancer and Brain Cancer. The committee found the evidence for brain 

cancer to be inadequate/insufficient and it found no statistically significant increase 

in the current risk of brain cancer in deployed Gulf War veterans compared with 

their nondeployed counterparts. This finding is mirrored in another recent IOM 

study. With regard to lung cancer, the committee notes that the 10–15 years of follow-up that have been reported may not have been adequate to account for the long 

latency of this disease. Although one new study found an increased incidence of lung 

cancer for deployed versus nondeployed veterans, neither veteran group had a greater risk when compared with the general population, and the study did not indicate 

smoking status. Thus, the committee found that the evidence continues to be inadequate/insufficient to determine whether deployed Gulf War veterans are at increased risk of having any cancer, including lung and brain cancer. The relative rarity of cancers such as brain cancer argues for larger studies with adequate power 

to detect them. 

Other Health Outcomes. The committee finds that sufficient time has elapsed 

to determine that Gulf War deployed veterans do not have an increased incidence 

of circulatory, hematologic, respiratory, musculoskeletal, structural gastrointestinal, 

genitourinary, reproductive, or chronic skin conditions compared with their nondeployed counterparts. As Gulf War veterans age, it will be more difficult to differentiate the effects of deployment from the natural effects of aging on morbidity 

and mortality. Furthermore, the association of deployment to the Gulf War with 

PTSD, anxiety disorders, substance abuse, and depression is well established, and 

further studies to assess whether there is an association are not warranted. 

Although there are well-known differences in disease profiles according to sex and 

race/ethnicity, few studies on Gulf War veterans specifically report outcomes for 

women or minorities, although many veteran studies adjust for sex and race/ethnicity in their analyses. This lack of distinction is important and makes it imperative that researchers report sex-specific and race/ethnicity-specific outcomes, particularly in large cohorts and where population subgroups may be oversampled. 

In conclusion, what is striking about this and prior Gulf War and Health committees’ findings is that the health conditions found to be associated with Gulf War deployment are primarily functional medical disorders such as Gulf War illness and 

irritable bowel syndrome, and mental health disorders such as PTSD and depression. What links these conditions is that they have no objective medical diagnostic 

tests and are diagnosed based on subjective symptom reporting. 

To be clear, the committee recognizes that Gulf War illness is a distinct medical 

condition with symptoms that affect many organs and organ systems including the 

brain; these symptoms include cognitive difficulties, memory problems, and headLeonard.horne on VACREP0180 with DISTILLER

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aches. Many other chronic illnesses from kidney disease to cancer also can affect the 

brain. 

Based on its conclusions regarding the association between deployment to the 

Gulf War and the health conditions seen in Gulf War veterans 25 years after the 

war, the committee made the following recommendations: 

• Recognize the connections and complex relationships between brain 

and physical functioning and should not exclude any aspect of Gulf 

War illness with respect to improving its diagnosis and treatment. • The Department of Veterans Affairs and the Department of Defense 

should develop a joint and cohesive strategy on incorporating emerging diagnostic technologies and personalized approaches to medical 

care into sufficiently powered future research to inform studies of Gulf 

War illness and related health conditions. • The Department of Veterans Affairs should continue to conduct followup assessments of Gulf War veterans for neurodegenerative diseases 

that have long latencies and are associated with aging; these include 

amyotrophic lateral sclerosis, Alzheimer’s disease, and Parkinson’s disease. • The Department of Veterans Affairs should conduct further assessments of cancer incidence, prevalence, and mortality because of the 

long latency of some cancers. Such studies should maximize the use of 

cancer registries and other relevant sources, data, and approaches, and 

should have sufficient sample sizes to account for relatively rare cancers and to be able to report sex-specific and race/ethnicity-specific information. • Further studies to assess the incidence and prevalence of circulatory, 

hematologic, respiratory, musculoskeletal, structural gastrointestinal, 

genitourinary, reproductive, endocrine and metabolic, chronic skin, 

and mental health conditions due to deployment in the Gulf War should 

not be undertaken. Rather, future research related to these conditions 

should focus on ensuring that Gulf War veterans with them receive 

timely and effective treatment. • Without definitive and verifiable individual veteran exposure information, further studies to determine cause-and-effect relationships between Gulf War chemical exposures and health conditions in Gulf War 

veterans should not be undertaken. • Sex-specific and race/ethnicity-specific health conditions should be determined and reported in future studies of Gulf War veterans. In addition, selected prior studies (e.g., large cohort studies) should be reviewed to determine whether reanalysis of the data to assess for possible sex-specific and race/ethnic-specific health conditions is feasible. • Future Gulf War research should place top priority on the identification and development of effective therapeutic interventions and management strategies for Gulf War illness. The Department of Veterans Affairs should support research to determine how such treatments can be 

widely disseminated and implemented in all health care settings. 

The committee believes that it is time that research efforts move forward and 

focus on improving treatment and medical management of veterans for Gulf War 

illness, including all affected organs and systems of the body. Further exploration 

of treatments and management strategies for the symptoms of Gulf War illness, 

even in the absence of a definitive etiology, is warranted. 

Finally, the committee wants to emphasize that it did not recommend that research on the health of Gulf War veterans be stopped. Rather, the committee found 

that research that continues to seek a causal link between Gulf War illness or other 

health conditions found in Gulf War veterans and specific chemical exposures, such 

as PB, sarin, or pesticides, is not likely to yield useful information. Many millions 

of dollars have been spent on this research with few tangible results and those resources are more likely to have an impact if focused on treatment and management 

strategies for these veterans. 

Thank you and I am pleased to answer any questions that you may have. 

f 

Prepared Statement of Roberta F. White, Ph.D 

Gulf War illness and the health of Gulf War veterans: 25 years of progress 

and set-backs 

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It is the 25th anniversary of the Gulf War. Our veterans won this conflict in less 

than a week. However, concern remains high that the troops who produced this victory are and will remain ill, without legitimate acknowledgement of their health 

problems and the associated disabilities, and without effective treatment options 

now or in the future. 

Despite decades of scientific evidence to the contrary, the VA and the Institute 

of Medicine have recently produced documents that minimize the poor health of 

these veterans by terming their illnesses as ‘‘functional ‘‘ disorders, a medical term 

for psychiatric illness. This injustice is then compounded by a treatment guideline 

that suggests ineffective, unproven, purely palliative, and potentially harmful treatments for Gulf War illness that focus on psychiatric symptomatology. 

I speak as a clinician/scientist who has worked with Gulf War veterans clinically 

and in research for over 20 years. My work on Gulf War illness is part of an overall 

clinical and research career in which I have studied the effects of exposures to neurotoxic chemicals on adults and children. For eight years, until last fall, I served 

as scientific director of the Research Advisory Committee on Gulf War Veterans Illnesses. 

Science of Gulf War illness 

It has been known since a year or two after their return from the Gulf that a 

subset of Gulf War veterans was experiencing debilitating physical illness. (In fact, 

the Department of Public Health at VA engaged clinical and research personnel at 

the Boston VA Medical Center, including myself, in trying to figure out what was 

going on with the veterans). 

Research beginning at that time and continuing to the present has produced a 

consensus of scientific knowledge about this illness. 

- Dozens of studies in multiple countries reveal that approximately 30% of the 

1991 Gulf War veteran population suffers from a characteristic pattern of physical health symptoms. This research has further revealed that this pattern of 

health problems was seen in Gulf War veterans, but not veterans of other conflicts (such as Bosnia), and that veteran populations from multiple coalition 

forces from the Gulf War experienced the same disorder. 

The health problems of Gulf War veterans are not vague and extremely variable, 

as is often suggested. There are two case definitions of the illness-the Kansas definition and the Centers for Disease Control definition-that clearly allow researchers 

and clinicians to decide whether an individual Gulf War veteran has the illness. 

These definitions were supported by the Institute of Medicine in its Volume 9 report 

for use in clinical and research work. I cannot think of any illness in which all patients have exactly the same symptoms-diagnosis of diseases and disorders is based 

on critical masses of signs and symptoms that cluster together to fit a case definition. Gulf War illness is not different from any other disorder in this way. 

- This illness is not the result of stress or other psychiatric factors. It has been 

known since the 1990s that post-traumatic stress disorder occurs at far lower 

rates in Gulf War populations than Gulf War illness. Rates are typically less 

than 10%, in contrast to the 30% for Gulf War illness. Furthermore, research 

conducted in veterans with Gulf War illness has repeatedly shown that posttraumatic stress disorder and other psychiatric disorders do not predict whether 

a veteran will have Gulf War illness, that is rates of Gulf War illness are not 

significantly higher in Gulf War veterans with psychiatric diagnoses. 

- Research over the past 20 years has also shown that occurrence of Gulf War 

illness is associated with exposures to chemicals present in the Gulf War theater, especially pesticides and use of pyridostigmine bromide (and possibly other 

chemicals, including nerve gas agent sarin and particulate matter from oil well 

fires). 

Epidemiologic, clinical, and animal research involving Gulf War veterans and 

other populations with similar types of exposures has converged to show that these 

chemicals affect the central nervous and immune systems, producing chronic signs 

and symptoms that affect multiple body systems. 

As suggested by the Institute of Medicine in its recent Volume 10 report, there 

is a mind/body continuum here. However, it is not that these veterans have a psychiatric condition that is affecting their physical health; it is that exposures to the 

chemicals present in the Gulf theater affect brain systems that mediate cognition, 

emotion, and immune function simultaneously. Thus, ill veterans have multiple cognitive, physical and emotional complaints and signs and symptoms. 

The previous Institute of Medicine report, Volume 8, reflected the scientific consensus on Gulf War illness that I have just described, concluding that ‘‘[t]he excess 

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of unexplained medical symptoms reported by deployed Gulf war veterans cannot 

be reliably ascribed to any known psychiatric disorder’’ and that ‘‘it is likely that 

Gulf War illness results from an interplay of genetic and environmental factors.’’ 

Like the reports of the Research Advisory Committee, the Volume 8 Institute of 

Medicine report called for rigorous research to find effective treatments for the illness, including ‘‘studies to identify . . . modifications of DNA structure related to 

environmental exposures, . . . signatures of immune activation, or brain changes 

identified by sensitive imaging measures.’’ 

Effective treatments for Gulf War illness and other illnesses induced by exposures 

that damage the brain do not exist. This is true for exposures such as lead, mercury 

and solvents as well as the pesticides, pyridostigmine bromide, low-level chemical 

warfare agents, and air pollutants to which our Gulf War veterans were exposed. 

However, recent research has identified potential treatments of Gulf War illness 

that target specific nervous system and immunological mechanisms. These treatments are now being piloted. They are consistent with the types of treatments recommended in the Volume 8 Institute of Medicine report and hold promise for effective treatment of Gulf War veterans, other veterans who experience chemical exposures, future troops at risk of similar exposures, and people who are exposed to pesticides occupationally and environmentally. 

The progress made over the past 20 years in understanding the mechanisms and 

causes of Gulf War illness, the physiological effects of exposure to chemicals such 

as pesticides, and the treatment of these effects is extremely exciting for the health 

of the military and the population as a whole. The scientific findings from this research hold great scientific promise. In addition, they are the only source of hope 

for veterans with Gulf War illness who are suffering from the disorder and wish to 

lead healthier, more productive lives. 

VA treatment recommendations 

However, recent recommendations from VA concerning the diagnosis and treatment of ill Gulf War veterans threaten the viability of the promise emanating from 

two decades of research. These recommendations are summarized in a document entitled, VA/DoD Clinical Practice Guideline: Management of Chronic Multi-symptom 

Illness, 2014. 

The recommendations contained in this document are regressive in terms of the 

knowledge that science and medicine have provided on the disorder. They are consistent with the stance that VA has taken since the Gulf War illness issue was first 

discovered in the early 1990s, when VA staff published papers saying that the 

health problems of Gulf War veterans represented post-traumatic stress disorder or 

‘‘effects seen in all wars,’’ statements that were made before any scientific data had 

been collected on ill Gulf War veterans. 

The treatment recommendations include immediate referral for mental health 

evaluation. In addition, cognitive behavioral therapy is suggested. This is a palliative treatment that might allow veterans to manage their lives better but was already found in a major VA study to help less than 6% of GW veteran patients and 

to provide only a 1 point improvement on a scale of 100. 

Even worse, when these palliative therapies do not satisfy the patient, the treatment guidelines recommend eleven drugs, ten of them psychiatric. All eleven drugs 

are noted in the guidelines to have significant adverse side effects, including suicidal ideation. Even more disturbing, these medications have not been studied with 

regard to effectiveness in the treatment of Gulf War illness. They are not the medications or treatment approaches of choice among the VA clinicians with extensive 

clinical treatment experience who have discussed their approaches with the Research Advisory Committee on Gulf War Veterans Illnesses. And the advice of such 

experts does not seem to have been solicited for this treatment document. 

In my experience as a neuropsychologist, I have had many patients whose neurological illnesses were initially thought to be psychiatric-the term ‘‘functional’’ was, 

in fact, sometimes used to describe them. These patients include people with multiple sclerosis, small vessel strokes, dementias and exposures to chemicals such as 

solvents or mercury. Treating Gulf War illness with an antidepressant is akin to 

treating multiple sclerosis with one. The patient might feel a little more optimistic, 

but the medication will do nothing to reverse or prevent the brain damage that the 

multiple sclerosis disease process is inflicting on his or her brain. 

Furthermore, the VA treatment document says its advice is also appropriate for 

mild traumatic brain injury, suggesting that recent Iraq and Afghanistan veterans 

who suffered blast injuries from improvised explosive device (IED) exposures should 

also be treated as psychiatric cases. 

IOM report Volume 10 

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The recent Volume 10 Institute of Medicine report further contributes to the worsening plights of ill Gulf War veterans by minimizing their health problems and 

again placing a psychiatric cast on them. 

This report was written by a committee that (purposefully) included no one with 

clinical experience treating Gulf War veterans or in-depth epidemiological expertise 

in the phenomenology of Gulf War illness. 

The report supports the VA stance that Gulf War illness is a functional disorder 

without evaluating the extensive scientific evidence that demonstrates just the opposite. 

Although the Volume 10 Institute of Medicine report states that the science has 

not changed since the Volume 8 report, its conclusions fly in the face of the scientific 

consensus on Gulf War illness that I have described, a consensus that was embraced 

in the Volume 8 report. The Volume 10 report distorts and disavows the Volume 

8 report’s finding that Gulf War illness ‘‘cannot be reliably ascribed to any known 

psychiatric disorder’’ by saying that the illness ‘‘cannot be fully explained by any 

.psychiatric disorder.’’ 

Unlike prior reports that support mechanistic scientific research on Gulf War illness, Volume 10 suggests that ‘‘it is time research efforts focus on the [mind-body] 

interconnectedness’’ and that ‘‘further research to determine the relationships between Gulf War exposures and health conditions in Gulf War veterans should not 

be undertaken.’’ 

To recommend stopping research into the mechanisms underlying the disease, 

just as research into these mechanisms has begun to make real progress, is 

shockingly short-sighted. And to suggest that psychiatric research has been neglected could not be further from the truth. 

During the fifteen years after the war, federal Gulf War research focused mainly 

on psychiatric issues. For example, 51% of VA research funding in 2003 for Gulf 

War illness focused on psychological stress and psychiatric illness. This research revealed that the answer to the Gulf War illness problem could not be found in the 

psychiatric arena. It is unthinkable that the scientific progress now being made 

should be halted and to return to that era. 

Conclusion 

When I think of the problem of Gulf War illness and the health problems and disabilities of the many Gulf War veterans whom I know or have evaluated, I am painfully reminded of the veterans of World War I who were exposed to mustard gas 

in the trenches of Europe. The gas was known to be present and widespread and 

it was known that mustard was designed to make people very sick or kill them. 

However, these veterans did not receive support for their health problems or the 

hardships their families endured due to their disabilities when they returned from 

combat. 

We are experiencing the same phenomenon with the 1991 Gulf War. It is well 

known and established that Gulf War veterans were exposed to poisons such as pesticides, pyridostigmine bromide, sarin gas and air pollutants from oil well fires that 

are harmful to health. However, groups like the Institute of Medicine and VA state 

that with current technology we cannot identify exactly which chemicals and which 

dosages each individual veteran was exposed to. This leads them to claim that we 

do not know enough to conclude that the Gulf War veteran population was overexposed to toxic chemicals and that individual veterans are ill. This is not the approach to population environmental health problems that we should expect. 

f 

Prepared Statement of Anthony Hardie 

Thank you, Chairman Coffman, Ranking Member Kuster, and Members of the 

Committee for today’s hearing and for this opportunity to appear before you. 

I’m Anthony Hardie, a 1991 Gulf War and Somalia veteran, and Director of Veterans for Common Sense. I’ve provided testimony on several previous occasions, but 

today is especially notable. 

Twenty-five years ago tonight, we launched the ground war of Operation Desert 

Storm and successfully liberated Kuwait. Tonight, I would like us to remember and 

honor of the nearly 300 of our fellow Gulf War men and women who made the ultimate sacrifice. I would also like us to remember and honor the nearly 700,000 veterans of the Persian Gulf War, who under the direction of our military leaders led 

our broad international Coalition to decisive military victory. 

‘‘Our’’ war was relatively short: just a five-month buildup, and then a six-week 

war before a swift military victory. However, you’ve heard my personal experiences 

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before, and you’ve heard the stories of many other Gulf War veterans, and as this 

Committee knows, between one-fourth and one-third of us returned home with serious and debilitating health issues now known as Gulf War Illness. And, we faced 

a new battle, a much longer war - a war to obtain effective healthcare and VA assistance from entrenched government officials who seemed intent on proving there 

was nothing wrong with so many Gulf War veterans, that it was all in our heads, 

just stress, the same as after every war. 

1998 PERSIAN GULF WAR VETERANS LEGISLATION 

It took almost eight years after the war before our major legislative victory, with 

the enactment of the Persian Gulf War Veterans Act of 1998 (Title XVI, PL 105– 

277) and the Veterans Programs Enhancement Act of 1998 (PL 105–368, Title I- 

‘‘Provisions Relating to Veterans of Persian Gulf War and Future Conflicts’’) - two 

landmark bills that set the framework for Gulf War veterans’ healthcare, research, 

and disability benefits. 

For those of us involved in fighting for the creation and enactment of these laws, 

they seemed clear and straightforward, with a comprehensive, statutorily-mandated 

plan that would guarantee research, treatments, appropriate benefits, and help ensure that lessons learned from our experiences would result in never again allowing 

what happened to us to happen to future generations of warriors. 

The legislation included a long list of known Gulf War exposures. VA was to presume our exposure to all of these, and then, with the assistance of the National 

Academy of Sciences (NAS), evaluate each exposure for associated adverse health 

outcomes in humans and animals. In turn, the VA Secretary would consider the reports by the NAS’s Institute of Medicine (IOM), ‘‘and all other sound medical and 

scientific information and analyses available,’’ and make determinations granting 

presumptive conditions. There was a new guarantee of VA health care. There would 

also be a new national center for the study of war-related illnesses and post-deployment health issues, which would conduct and promote research regarding their etiologies, diagnosis, treatment, and prevention and promote the development of appropriate health policies, including monitoring, medical recordkeeping, risk communication, and use of new technologies. There was to be an effective methodology for 

treatment development and evaluation, a medical education curriculum, and outreach to Gulf War veterans. Research findings were to be thoroughly publicized. To 

ensure the federal government’s proposed research studies, plans, and strategies 

stayed focused and on track, VA was to appoint a research advisory committee that 

included Gulf War veterans - presumably those who were ill and affected - and their 

representatives. 

Instead, we learned that enactment of those laws was just another battle in our 

long war. 

From the beginning, VA officials fought against implementing these laws, dragging their feet and upending their implementation. 

The creation of the ‘‘national center’’ never met Gulf War veterans’ expectations. 

The long list of toxic exposures never led to a single exposure-related presumption. 

Many of the exposures were never even considered, and those that were didn’t include evaluation of the health effects in laboratory animals with respect to likely 

health outcomes in ill Gulf War veterans. The research never led to effective, evidence-based treatments and indeed had little treatment focus until after Congress 

established a treatment-focused research program outside of VA. 

And only after significant pressure and a change in Administrations did VA finally establish the research advisory committee (RAC) - more than three years after 

the statutorily mandated January 1, 1999 deadline. But, VA then systematically ignored its recommendations, and diminished its findings. When it sharpened its criticism of VA’s failures related to Gulf War veterans, VA staff led measures to substantially diminish its charter and discharge all of its members. 

As a last ditch effort to call attention to VA’s myriad failures of Gulf War veterans, I led Gulf War veterans’ resignations from the RAC in June 2013. Subsequently, the House unanimously passed legislation that would have restored and enhanced the research advisory committee and helped Gulf War veterans, for which 

we remain grateful. Unfortunately, the Senate failed to take action and the bill died 

in Congress. 

I served on the RAC for eight years and remain deeply impressed by the broad 

knowledge, demonstrated commitment, and impressive accomplishments aimed at 

solving Gulf War Illness of the scientists and doctors who served on and appeared 

before the panel. And, I remain proud of the work of dozens of researchers and Gulf 

War veteran stakeholders who came together to produce a comprehensive strategic 

plan aimed at solving Gulf War Illness, identifying other health conditions in Gulf 

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tion. Sadly for ill Gulf War veterans, nearly all of the provisions of that research 

strategic plan remain unimplemented, like so much of the rest of VA’s half steps 

in implementing and achieving the goals of the 1998 legislation. 

And in a 2013 hearing by this Committee, we learned from a top VA epidemiologist-turned-whistleblower many of the sordid details of officials within the VA’s Office of Public Health who failed to ask the right questions in research that would 

lead to showing the real post-deployment health outcomes for Gulf War and other 

veterans, and often obfuscated research findings when they showed results that 

might show significant health outcomes. 

That leads us to today. 

NEW IOM REPORT 

Two weeks ago, the NAS’s Institute of Medicine (IOM) released its newest and 

supposedly final report in the extended, ‘‘Gulf War and Health,’’ series under VA 

contract as directed by the 1998 legislation. Entitled, ‘‘Gulf War and Health, Volume 

10: Update of Health Effects of Serving in the Gulf War, 2016,’’ it is highly problematic. While IOM’s Volume 10 acknowledged that Gulf War illness is the signature 

adverse health outcome of the 1991 Gulf War - a fact that has been known by Gulf 

War veterans since the early 1990s and definitively shown by science since at least 

2004 - its research and treatment recommendations range from disappointing to potentially damaging to the health and lives of Gulf War veterans with Gulf War Illness. IOM’s Volume 10 recommends no further research using animal models of Gulf 

War toxic exposures (p. 251). While the IOM Volume 10 panel acknowledged that 

an animal model would be advantageous for identifying and evaluating Gulf War 

Illness treatment strategies, they then suggested that the precise frequency, duration, dose of Gulf War exposures must be known in order to do so. This amounts 

to ‘‘rolling up the sidewalk’’ on this promising avenue of Gulf War Illness research, 

just when it is beginning to unravel the underlying biological mechanisms of Gulf 

War illness and point to treatment targets. 

Past IOM review panels have been limited by VA’s systemic failures in monitoring, assessing, and reporting the incidence and prevalence of health symptoms 

and diagnosed diseases in Gulf War (and other cohorts of) veterans. The IOM Volume 10 panel was similarly limited. As one example, IOM’s Volume 10 report reads, 

‘‘Because cancer incidence in the last 10 years has not been reported [by VA], additional follow-up is needed.’’ (p.102). IOM’s Volume 10 panel was tasked with reviewing published medical literature since the last major review six years ago, but due 

to one of VA’s many failures couldn’t do so because this new data hasn’t been reported by VA. 

However, unlike the panel’s recommendation for additional follow-up with cancer 

incidence, IOM’s Volume 10 committee instead inflicted damage when they recommended that, ‘‘further studies to assess the increased incidence and prevalence 

of circulatory, hematologic, musculoskeletal, gastrointestinal, genitourinary, reproductive, endocrine and metabolic, respiratory, chronic skin, and mental health conditions due to deployment in the Gulf War should not be undertaken’’ (pp. 9–10). Unlike IOM panels that are limited by VA’s ‘‘don’t look, don’t find’’ failures, we must 

not mistake absence of VA evidence for evidence of absence of long histories of these 

adverse health outcomes in Gulf War veterans. 

Like the earlier IOM reports, the Volume 10 panel found no new associations between Gulf War exposures and adverse health outcomes. It also found no new associations between Gulf War service and ill health. 

While recommending greater effort towards treatment and acknowledging Gulf 

War Illness as the signature condition of the 1991 Gulf War, it recommended that 

research and treatment for Gulf War Illness now focus on, ‘‘brain-body interconnectedness.’’ It also suggests focusing on ‘‘management’’ of Gulf War Illness. Together, 

these are an apparent departure from the optimism of the 2010 IOM report, which 

said, ‘‘effective treatments, cures, and, it is hoped, preventions . can likely be found.’’ 

The promising new science that is providing keys to Gulf War Illness’s underlying 

mechanism and promising avenues towards treatment hasn’t shifted course since 

2010, it has just provided even greater evidence for the role of toxic exposures in 

Gulf War Illness and provided increasing detail in closing in on effective treatments. 

What has changed, however is that the IOM Volume 10 panel and reviewers included some of the same people and the same mindsets as the dark days of the 

1990’s, when everything about Gulf War veterans’ exposures and symptoms was 

characterized as utterly unknowable, when Gulf War veterans’ health issues were 

marginalized, and when VA and DOD officials seemed intent on restricting Gulf 

War Illness discussions to ‘‘stress’’ causation and mental health management rather 

than focusing on evidence-based treatments for Gulf War veterans’ toxic wounds. 

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Those VA and DOD officials denied Gulf War veterans’ toxic exposures, failed to develop treatments or preventions, redirected Gulf War veterans away from the goal 

of real healthcare, shut down research, and denied benefits. This new IOM recommendation amounts to little more than the same tired old themes from the 1990’s 

- again, just when Gulf War Illness treatment research is finally making real 

progress to understand the illness and identify treatments 

As I walked through the airport headed home following the meeting where this 

latest IOM report was released, my shoulder was heavy with a bag full of past IOM 

Gulf War reports. My heart was even heavier. Twenty-five years after our war, and 

nearly two decades after the enactment of the 1998 laws, these IOM Gulf War reports nearly fill a small shelf. But despite millions of dollars and countless panel 

members’ work, the collective weight of these volumes have not associated animal 

exposures with human health outcomes, have found precious few health outcomes 

associated with Gulf War service, have not evaluated many of the exposures listed 

in the 1998 laws, and have added little toward the development of effective, evidence-based treatments for Gulf War Illness. Together, the IOM and its VA taskmaster have had little impact in improving the health or lives of Gulf War veterans 

with Gulf War Illness or achieving the goals set forth in the 1998 Gulf War legislation. 

VA/DOD CLINICAL PRACTICE GUIDELINE (CPG) 

As if the massive, multi-volume failure of Gulf War veterans wasn’t enough, VA 

and DoD have now developed a highly problematic Clinical Practice Guideline for 

Gulf War Illness that goes back to the darkest days of the 1990s. In this Guideline, 

VA and DOD lump Gulf War Illness together with psychosomatic and other conditions that together, its authors call, ‘‘Chronic Multisymptom Illness’’ (CMI). It is 

worth noting that CMI is an overly broad and inappropriate catch-all label that 

IOM panels have rightly told VA to stop using for Gulf War Illness. 

This Clinical Practice Guideline is intended for all healthcare providers - DOD, 

VA, and beyond. Its primary treatment recommendations for GWI are cognitive behavioral therapy (CBT), exercise, and psychotropic drugs. Suicidal ideation is listed 

in the Guide as a known ‘‘notable adverse effect’’ for every single one of those medications. 

Despite public statements by VA officials, including before this Committee, that 

Gulf War Illness is not a psychological, psychiatric, or psychosomatic condition, this 

VA–DoD guide specifically compares ‘‘CMI’’ with a group of, ‘‘similar ‘overlapping’ 

symptom syndromes’’ and ‘‘somatization disorder’’. The terms ‘‘somatization disorder’’, and use the terms ‘‘somatization’’, ‘‘somatization disorder’’, ‘‘somatoform’’, 

and ‘‘somatoform disorder’’, and ‘‘psychosomatic’’ a stunning 52 times in the guide. 

The term, ‘‘hypochondriasis’’ is also used and referenced. 

While the Clinical Practice Guideline authors use the term, ‘‘evidence-based’’, 19 

times throughout the document in an apparent attempt to increase its credibility, 

they go on to state, ‘‘treatment of CMI is as much an art as it is a science’’ (p.8). 

Showing its failure to rely on scientific evidence, a growing body of promising scientific research related to inflammatory cytokines, mitochondria and mitochondrial 

dysfunction (for example), including Coenzyme Q10 as a potential therapy. Yet, the 

term ‘‘cytokine’’ and variants appear only twice, and no reference whatsoever is 

made to mitochondria or word variants. 

It would seem hard to believe, given the large body of peer-reviewed science on 

Gulf War Illness that has been published in more recent years, that a DOD or VA 

clinical guideline produced in 2014 would rely on the old ‘‘psychosomatic’’ fictions 

of the 1990s or on the VA and DOD officials that championed them. What’s not surprising, however, is that the list of people who developed this guide that relies on 

psychosomatic artfulness rather than evidence-based treatments included some of 

the same old names from the dark days of the 1990s. 

This guide is another example of VA’s systemic research failures. From, ‘‘Don’t 

look, don’t find,’’ to a renewed reliance on psychosomatic explanations and ‘‘treatments’’ for Gulf War Illness, the intent of the 1998 laws remain out of reach at VA 

past and present. 

GULF WAR ILLNESS CDMRP 

As many of the members of this Committee know, despite the serious problems 

noted above, there is a great deal of encouragement and hope for ill Gulf War veterans in the science being conducted and published in recent years. Much of this 

promising new research is in the treatment-focused Gulf War Illness Congressionally Directed Medical Research Program (CDMRP), which exists outside VA or the 

rest of DoD thanks to Congress, including many of the Members on this Committee. 

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One-third of the studies funded through this program are testing treatments that 

might help improve the health and lives of veterans with GWI. Two-thirds of the 

studies are aimed at Gulf War Illness’s underlying mechanisms, including critically 

important animal studies that test exposures and measure health outcomes, identify 

treatment targets, and test treatments. 

Three CDMRP-funded treatment studies have already shown promise in reducing 

certain GWI symptoms, including Coenzyme Q10, Carnosine, and acupuncture. Others have found powerful links between Gulf War toxic exposures and adverse health 

outcomes and are helping pave the way for treatment development. 

The vast majority of this research is still in the pipeline. However, this powerfully 

encouraging progress could be at risk, by the IOM Volume 10 recommendations and 

by another IOM panel aimed at all the CDMRPs that is chaired and directed by 

some of the same former VA and DOD officials of the 1990s who have done so much 

harm to Gulf War veterans. 

CONCLUSIONS 

If we measure VA’s success by how it has improved Gulf War veterans’ health 

twenty-five years after the war, VA still has no evidence-based treatments for Gulf 

War Illness. VA has circumvented or ignored most of the aims of the 1998 laws. 

Instead, some of those same old VA and DOD officials from the dark days of the 

1990s have joined together in their usual old cabal and are once again pushing longdiscredited theories of psychosomatic causation and ‘‘treatment’’ in new and potentially influential ways. 

In twenty-five years, VA has made little progress on Gulf War Illness, and now 

appears to be working to roll back the clock to the dark days of the 1990’s. 

fi Instead of following recommendations on Gulf War Illness research that would 

lead to improving ill Gulf War veterans’ health and lives, VA eliminated the Research Advisory Committee’s (RAC) ability to evaluate the effectiveness of all federal Gulf War research efforts, limited its scope from all federal research to just 

VA’s, eliminated its treatment focus mandate, and more. 

fi VA admitted to ‘‘losing’’ its registry for Gulf War spouses and children. It is unclear what VA has done to recover that data. 

fi VA continues make reports to Congress that inflate ‘‘Gulf War research’’ spending by including studies that are not specific to Gulf War veterans. 

fi VA has the authority to develop new presumptives for these ill and suffering 

veterans, but unlike with Agent Orange, has failed to identify any new conditions 

beyond a set of rare endemic infectious diseases that affect almost no one. 

fi IOM’s latest report, shaped by VA’s contract, argues that individual Gulf War 

exposures are forever unknowable. We knew that when seeking the 1998 legislation, 

aimed at connecting generic exposure data with health outcomes. VA has stymied 

those efforts. 

fi VA has not linked a single adverse health outcome to any Gulf War exposures 

nor created a single new presumptive condition under the 1998 laws to help suffering veterans beyond the largely irrelevant endemic infections noted earlier. 

Twenty-five years later, one-fourth to one-third of us Gulf War veterans continue 

to struggle with the health and life effects of Gulf War Illness. Others among us 

have died of ALS, brain cancer, other diseases, suicide. Yet VA, with the aid of DoD 

and the complicity of the IOM, has made little progress in developing evidencebased treatments or improving the health and lives of veterans suffering from signature injury of the 1991 Gulf War - Gulf War Illness. 

Twenty-five years later, one-fourth to one-third of us continues to battle the signature injury of the 1991 Gulf War: Gulf War Illness. Others among us have died of 

ALS, brain cancer, other diseases, suicide. Yet VA, with the aid of DoD and the complicity of the IOM, has made little progress in developing evidence-based treatments 

or improving the health and lives of veterans suffering from signature injury of the 

1991 Gulf War - Gulf War Illness. 

Twenty-five years later, ill Gulf War veterans are still in pain. They are suffering. 

They have been begging for help for years and years. Twenty-five years later, Gulf 

War veterans are battling against VA and DOD bureaucrats, including some of the 

very same ones who fought against the 1998 laws in the first place. 

We must not continue to allow VA and DoD to substitute ‘‘risk communication’’ 

for evidence-based healthcare, psychosomatic drugs for treatment-focused research, 

spin for substance, or ‘‘Don’t look, don’t find’’ for the objective collection, analysis, 

and reporting of deployment health outcomes. The letter, the spirit, and the intent 

of the 1998 Persian Gulf War laws have yet to be achieved. 

On this 25th anniversary of the war, our Gulf War veterans deserve the best that 

modern science and the U.S. government can offer to improve their health and lives. 

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Mr. Chairman, as one of us Gulf War veteran, and Members of this powerful Committee, please join together with your colleagues on both sides of the aisle and in 

both houses and help fix these serious issues, once and for all. 

f 

Statements For The Record 

LUNG CANCER ALLIANCE 

Lung Cancer Alliance (LCA) thanks the chairman and the committee for allowing 

the submission of the following comments for the record of this hearing. 

LCA, the leading national lung cancer policy, advocacy and patient support organization, is deeply concerned by the lack of updated disease specific incidence and 

mortality data from the Department of Veterans Affairs in the Gulf War and Health 

Volume 10 Report. 

Without this critical information, the Vol. 10 report, perforce, had to conclude: 

‘‘...that there is insufficient/adequate evidence to determine whether an association 

exists between deployment to the Gulf War and any form of cancer, including lung 

cancer and brain cancer.’’ 

The Vol.8 report indicated that at that point in time, only lung cancer showed a 

statistically relevant excess between Gulf War deployed veterans and non-deployed 

veterans, based on a published 2010 study by Young et al which linked Defense 

Manpower Data Center datasets with files from 28 state cancer registries and the 

Department of Veterans Affairs Central Cancer Registry. 

The study concluded that the 15% excess of lung cancer diagnoses in deployed veterans over the years 1991–2006 warranted additional follow-up studies. Indeed, the 

Vol.10 report concluded that additional follow-up was necessary. 

The Vol.10 report gives no indication that this was done. In fact, on page 102, 

the Vol. 10 Report states: 

Because cancer incidence in the past 10 years has not been reported, additional follow-up is needed. 

Many cancers have long latency periods, 20–30 years in the case of lung cancer 

as both Vol. 8 and 10 accurately report. The median age for a cancer diagnosis in 

the United States is 65 (70 for lung cancer) and the median age of Gulf War veterans in 1991 was 28. Thus, the impact of Gulf War deployment on cancer incidence 

and mortality cannot be accurately evaluated without long term follow-up and accurate incidence and mortality statistics. 

Updating the 2010 Young study would have been the most logical, cost-effective 

and statistically significant resource in preparing for Vol.10. 

The only other Primary study cited in Vol.10 was the 2015 update (Sim et al.) 

on the Australian Gulf War veterans which did not show elevated cancer incidence 

or mortality rates. However, while the survey included all 1,871 Australia Gulf war 

veterans, 84% were Navy, not deployed ground forces, and 87% were under the age 

of 55 at the time of the update. 

The Vol. 10 report conceded that telephone/web surveys of U.S. Gulf War veterans 

by committee member (Dursa et al., 2015) and the VA showing no disparity of impact did not qualify as primary studies and were not sufficiently powered or crosschecked with actual mortality and incidence data to be considered statistically significant. 

When queried by LCA, the committee staff indicated that they did not ask the 

VA for disease-specific mortality data. Clearly this has to be done. 

Lung cancer is the leading cause of all cancer deaths. Its annual mortality is 

equivalent to all deaths from breast, prostate, colon and pancreatic cancers combined. Veterans, especially those who served in combat, are at highest risk due to 

the combination of smoking rates and exposure to carcinogens. 

CT screening for a defined high risk population ages 55–80 has been validated 

by one of the largest randomized controlled trials ever carried out by the National 

Cancer Institute, given a B recommendation by the U.S. Preventive Services Task 

Force, a required preventive service covered by commercial insurance and Medicare 

with no co-pays, deductibles or co-insurance. 

Yet the VA , whose population is at highest risk, still refuses to implement this 

life-saving benefit system-wide. 

Since the median age of Gulf War veterans is now the mid-50’s, LCA would urge 

the committee to require the VA to immediately implement CT lung cancer screening. Indeed, CT screening will provide more concrete and accurate data on lung canLeonard.horne on VACREP0180 with DISTILLER

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cer, as well as data on heart disease and other lung diseases, than the $500,000,000, 

18-year Gulf War study has to date. 

f 

NATIONAL GULF WAR RESOURCE CENTER 

STATEMENT FOR THE RECORD OF RONALD E. BROWN, GULF WAR 

VETERAN & PRESIDENT, NATIONAL GULF WAR RESOURCE CENTER 

Thank you, Chairman Coffman, Ranking Member Kuster, and Members of the 

House Veterans’ Affairs Subcommittee on Oversight and Investigations. I thank you 

for holding this investigative hearing on Gulf War health issues on the eve of the 

25th anniversary of our successful ground invasion to liberate Kuwait. 

My name is Ronald Brown; I’m President of the National Gulf War Resource Center (NGWRC). The NGWRC is a small 501 (c) (3) non-profit veteran service organization, which is comprised of sick Persian Gulf War veterans who volunteer our 

time to advocate for our fellow veterans suffering from the complexities of modern 

warfare. We specialize in Gulf War Illness claims, we work with veterans to educate 

and assist them in the claims process. We also work with policy makers inside the 

VA, in an attempt to accomplish two goals: first, to insure clinicians are better 

trained about conditions facing this group of veterans to insure the veterans receive 

the best health care possible. 

Secondly, we are working to address and correct issues affecting this group of veterans, such as the high denial rate of Gulf War illness related claims. 

We also strive to inform veterans concerning ongoing research being conducted by 

both the Department of Veterans Affairs and the Congressionally Directed Medical 

Research Programs (CDMRP). We strive to get veterans involved in the research as 

participants. 

In my view, the Congressionally Directed Medical Research Program (CDMRP) is 

by far leading the way on research for our sick Gulf War veterans. Many studies 

funded by the CDMRP have shown promise that may provide insight into Gulf War 

illness.These studies may eventually identify ways to diagnose and treat Gulf War 

Illness. Additional follow-up (replication on a larger scale) is needed on these promising pilot studies. Unfortunately, in our view, the VA Office of Research and Development (ORD) have been slow to replicate any of these promising pilot studies. 

Until this is done, these studies will not benefit veterans by providing effective 

treatments or new presumptive conditions for benefits. 

Recently, I attended the public briefing for The Gulf War and Health, Volume 10: 

Update of Health Effects of Serving in the Gulf War. While I agree with the committee’s recommendation to use the term Gulf War Illness (GWI), overall I was shocked 

and troubled by the conclusions and recommendations this committee reached. 

This committee suggest that the ‘‘conditions associated with Gulf War deployment 

are primarily mental health disorders and functional medical disorders and that 

these associations emphasize the interconnectedness of the brain and body (page 11, 

IOM vol 10).’’ This committee also stated ‘‘Veterans who were deployed to the Gulf 

War do not appear to have an increased risk for many long term health conditions 

with the exceptions of Post-Traumatic Stress Disorder (PTSD), Gulf War Illness 

(GWI), Chronic Fatigue Syndrome (CFS), Functional Gastrointestinal conditions, 

generalized anxiety disorder, depression and substance abuse.’’ 

The committee added further insult to sick Desert Storm veterans when they recommended: ‘‘Further studies to assess the increased incidence and prevalence of circulatory, hematologic, musculoskeletal, gastrointestinal, genitourinary, reproductive, 

endocrine and metabolic, respiratory, chronic skin, and mental health conditions due 

to deployment in the Gulf War should not be undertaken. Rather, future research 

related to these conditions should focus on ensuring that Gulf War veterans receive 

timely and effective treatment (page 9, IOM vol 10).’’ This committee recommended 

that future research should focus on treating and managing Gulf War illness rather 

than its causes. 

I agree treatments and managing Gulf War illness is important; however, I also 

believe that we should understand the causes of this illness in Desert Storm veterans if we are to prevent toxic illness and injury to future generations of our 

Armed forces. This committee recommended individual and environmental biomonitoring during future conflicts. I agree with this recommendation with skepticism 

based on DOD’s history of reluctance to release information concerning exposures 

during Desert Storm. 

I strongly disagree with this committee’s recommendation that ‘‘further studies to 

assess the increased incidence and prevalence of health conditions due to deployLeonard.horne on VACREP0180 with DISTILLER

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ment in the Gulf War should not be undertaken.’’ If this committee has their way, 

I’m afraid we never will learn what caused our illness, how to treat ill Persian Gulf 

Veterans, and we will never have the evidence to warrant adding new presumptive 

conditions. 

Since 2002, sick Desert Storm veterans who have attended, or listen in by phone, 

to the Research Advisory Committee (RAC) meetings have listened to presentations 

that show VA epidemiological studies have shown that deployed Desert Storm veterans have higher prevalence of: 

• Migraine headaches (20.3% deployed vs 16.1% non-deployed). • Chronic obstructive pulmonary disease (8.4% deployed vs 6.3% non-deployed). • Dermatitis (27.4% deployed vs 21.1% non-deployed). • Functional dyspepsia (27.7% deployed vs 15.9% non-deployed). • Tachycardia (8.1% deployed vs 5.9% non-deployed). • Irritable bowel syndrome (24.4% deployed vs 14.3% non- deployed). 

Yet, the IOM committee puts many of these issues listed above in its Inadequate/ 

Insufficient Evidence to Determine Whether an Association Exist category. 

There is most definitely a problem with this committee’s report as the VA’s own 

research shows one thing, and the IOM committee is saying something completely 

different. This report is an injustice to sick Desert Storm veterans. This report 

winds the clock backwards to the 1994 mindset. In 1994 the VA as well as the Department of Defense (DOD) said that GWI was nothing more than combat stress, 

PTSD, or psychological illnesses. Desert Storm veterans thought we had escaped the 

‘‘it’s all in your head’’ mindset with the ground breaking 2008 Research Advisory 

Committee report. Yet here we are twenty-five years after the war, and sick Desert 

Storm veterans are still waiting for treatments, many are still waiting on service 

connection for presumptive conditions per current law, and we still wait and hope 

new presumptive conditions will be added. 

My reasoning for my belief that there is a problem with this committee’s report 

is during the briefing when I asked why studies that showed cancer at higher rates 

weren’t considered by this committee, URMC Professor Deborah Cory-Slechta referenced the 2004 GOA report that stated the Khamisiyah plume model was flawed 

that was used in VA’s research. This same GOA report also stated that the VA and 

DOD’s hospital rate study was also flawed, yet this committee still used this study 

to reach their conclusions (page 200, IOM vol 10). 

This IOM committee retrieved over 280 studies of potential relevance to this report. 204 studies that ‘‘did not appear to have immediate relevance, based on an assessment of the title and abstract’’ were deleted without consideration leaving only 

76 potential relevant studies considered and discussed by this committee (page 25, 

IOM vol 10). Nowhere in this report are these 204 deleted studies listed. My question is how many of these deleted studies were VA and CDMRP studies? An additional 100 papers dealing with animal models were reviewed and half were deleted 

for further consideration (page 26, IOM vol 10). Of the half that was not considered, 

how many were VA and CDMRP papers? 

The NGWRC honestly feels this report is flawed. We are grateful that the House 

Veterans’ Affairs Subcommittee on Oversite and Investigation has decided to investigate this matter. 

Recommendations: 

(1). Ensure any future contract between the VA and IOM is made public for 

Desert Storm veterans. This would ensure transparency. 

(2). To further ensure transparency Veterans Service Organizations (VSO) should 

be invited to the IOM’s briefing to the Department of Veterans Affairs. 

(3). Veterans Service Organizations should receive a copy of future IOM reports 

prior to the public briefing. This will allow the VSOs to form reasonable questions 

for the committee. 

(4). Ensure the IOM committee list all studies they deem not relevant in its report. A reasonable explanation as to why the study was found irrelevant should be 

provided. This would ensure researchers knowledge of the IOM’s definition of ‘‘immediate relevance’’. 

(5). Desert Storm veterans and our researchers need help in regards to replication 

on a larger scale of studies that have shown promise. Unfortunately, the VA Office 

of Research and Development (ORD) have been slow to replicate any of these promising pilot studies. If the VA is unable to replicate this amazing and promising research, then perhaps increased funding should be provided to the CDMRP to replicate these promising studies on a larger scale. Until this is done, these small 

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1 Veterans Benefits Act of 2010, Sec. 805, http://library.clerk.house.gov/reference-files/PPL— 

111—275—VeteransBenefitsAct—2010.pdf 2http://www.scribd.com/doc/150949964/WHITE–PAPER–IOM–CMI–Panel-Membership-Analysis 3Public Law 110–389, Section 804 

4http://www.va.gov/RAC–GWVI/docs/Committee—Documents/CommitteeDocJune2012.pdf (Appendix E) 

promising pilot studies will not benefit veterans by providing effective treatments 

or new presumptive conditions for benefits. 

Respectfully, 

Ronald E. Brown President 

National Gulf War Resource Center 

f 

JAMES BINNS 

With respect to Gulf War veterans’ health, VA pays no more attention to Congress 

than it does to science. As described below, Congress has ordered report after report 

from the Institute of Medicine (IOM), specifying in law the work to be done. However, VA has consistently failed to contract for what Congress actually ordered. The 

IOM has been a willing accomplice, changing its own standards of evidence and appointing biased committees to accommodate VA’s purposes. As a result, the reports 

inevitably produce conclusions that deny any connection between toxic exposures 

and the shattered health of Gulf War veterans, and promote the discredited 1990’s 

VA position that their illness is largely psychiatric. 

These same corrupt practices have been employed to deny the effect of toxic exposures from burn pits on the health of recent Iraq and Afghanistan veterans. 

1. Public Laws 105–277 and 105–368, enacted in 1998, are the foundation for the 

IOM Gulf War and Health reports. Congress required VA to contract with the IOM 

to evaluate the health risks of thirty-three toxic substances and medications to 

which troops were exposed in the war. The law required consideration of animal 

studies because most studies of the effects of toxic substances are necessarily done 

in animals. 

But VA did not contract for consideration of animal studies, and the IOM actually 

changed its standards of evidence to exclude animal studies - the exact opposite of 

what Congress ordered. As a result, these studies - the basic studies that show 

these toxic substances are toxic—have never been considered in any IOM report, 

and no IOM report has ever found sufficient evidence that any of the thirty-three 

toxic agents are associated with health problems. 

The entire IOM Gulf War series of reports is a house of cards, as detailed in Appendix A. 

These same corrupt practices have been employed to deny the effect of toxic exposures from burn pits on the health of recent Iraq and Afghanistan veterans. (below, 

pp. 12–13) 

2. In 2010, in Public Law 111–275, Congress required VA to contract with the 

IOM for a ‘‘comprehensive review of the best treatments for chronic multisymptom 

illness in Gulf War veterans.’’ 

The statute directed that the IOM ‘‘shall convene a group of medical professionals 

who are experienced in treating [Gulf War veterans] who have been diagnosed with 

chronic multisymptom illness or another health condition related to chemical and 

environmental exposures . . .’’ 1

VA ignored this direction and instead contracted with the IOM for a literature review of largely psychiatric diseases by a committee with no experience in treating 

Gulf War veterans, heavily weighted with specialists in psychosomatic medicine and 

stress. 2 Rather than capturing the valuable treatment experience of Gulf War veterans’ doctors, as Congress intended, the resulting 2013 IOM treatment report was 

a restatement of government fictions from the 1990’s, foreshadowing the 2016 IOM 

report and the new VA/DoD Clinical Practice Guideline. 

3. In 2008, Congress enacted Public Law 110–389 requiring VA to contract with 

the IOM ‘‘to conduct a comprehensive epidemiological study . [to] identify the incidence and prevalence of diagnosed neurological diseases, including multiple sclerosis, Parkinson’s disease, and brain cancers . . .’’ in 1991 Gulf War veterans, Post9/11 Global Operations veterans, and non-deployed comparison groups. 3

For seven years, VA refused to contract for the study, despite repeated urging by 

the Research Advisory Committee on Gulf War Veterans Illnesses. 4 In 2015, VA fiLeonard.horne on VACREP0180 with DISTILLER

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5http://iom.nationalacademies.org/Reports/2015/Considerations-for-Designing-EpidemiologicStudy-for-Multiple-Sclerosis-and-other-Neurological-disorders-Veterans.aspx 6 2016 IOM Gulf War and Health report, pp. 102,145,149. 

nally contracted with the IOM, but wrote in the contract that the IOM could only 

use VA data. The IOM committee declined to proceed with the study because the 

VA data was insufficient for a rigorous study. 5

In the absence of the study ordered by Congress in 2008, the 2016 report found 

the evidence insufficient to reach conclusions that these conditions are associated 

with Gulf War service. 6

4. The membership of IOM Gulf War report committees has usually been biased 

toward VA’s discredited position, including the 2016 committee. 

See the November 2014 letter to Dr. Victor Dzau, president of the IOM, attached 

as Appendix B below (pp. 37–42), objecting to the makeup of the 2016 Gulf War and 

Health committee. ‘‘[T]he membership is grossly imbalanced toward the 1990’s government position that Gulf War veterans have no special health problem - just what 

happens after every war, related to psychiatric issues, and not environmental exposures.’’ 

The letter documented that eight the members of the committee were associated 

with the 1990’s government position, including the former 1990’s VA Undersecretary 

for Health, Dr. Kenneth Kizer, who was the chief advocate for the position. Eight 

members were neutral. Subsequent to the letter, one neutral member resigned and 

one individual with current Gulf War research experience was added, the only person on the committee with such experience. 

The last two pages of the letter analyze the 2016 committee membership. (below, 

pp. 45–46) 

The letter predicted that: ‘‘Reviving this discredited fiction will cause veterans’ 

doctors to prescribe inappropriate psychiatric medications, and will misdirect research to find effective treatments down blind alleys - an unconscionable breach of 

the duty owed to veterans and expected of the Institute of Medicine. ‘‘ 

APPENDIX A 

VA AND IOM COLLABORATION TO EXCLUDE CONSIDERATION OF ANIMAL STUDIES

REQUIRED BY LAW

Public Laws 105–277 and 105–368 are the foundation for the Institute of Medicine 

(IOM) Gulf War and Health reports. Congress required VA to contract with the IOM 

to evaluate the health risks of thirty-three toxic substances and medications to 

which troops were exposed in the war. The law required consideration of animal 

studies on a par with human studies because most studies of toxic substances are 

necessarily done in animals for ethical reasons. 

But VA did not contract for consideration of animal studies, and the IOM actually 

changed its standards of evidence to exclude animal studies - the exact opposite of 

what Congress ordered. As a result, these studies - the basic studies that show 

these toxic substances are toxic—have never been considered in any IOM report, 

and no IOM report has ever found sufficient evidence that any of the thirty-three 

listed toxic agents are associated with health problems. 

Consider, for example, the twenty-three animal studies on pages 160–161 of the 

2008 report of the Research Advisory Committee on Gulf War Veterans Illnesses, 

showing that low levels of nerve gas, below the level that causes symptoms at the 

time of exposure, cause long-term adverse health effects, contrary to what was believed at the time of the war. Because of these studies, an update report on the effects of sarin was ordered from the IOM, but as described below, VA and IOM staff 

conspired to ensure that the report would not consider animal studies in its conclusions, even though new animal studies were the only reason for ordering the report. 

http://www.va.gov/RAC–GWVI/docs/Committee—Documents/ 

GWIandHealthofGWVeterans—RAC–GWVIReport—2008.pdf 

The entire IOM Gulf War series of reports is a house of cards, as detailed below. 

These same corrupt practices have been employed to deny the effect of toxic exposures from burn pits on the health of recent Iraq and Afghanistan veterans. (below, 

pp. 12–13) 

* * * 

These 1998 statutes required the IOM to identify illnesses experienced by Armed 

Forces members who served in the war, ‘‘including diagnosed illnesses and 

undiagnosed illnesses’’ (the term then used for what is now called ‘‘Gulf War IllLeonard.horne on VACREP0180 with DISTILLER

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ness’’). The statutes then asked, for each of the thirty-three agents and each illness, 

‘‘whether a statistical association exists between exposure to an agent . . . and an 

increased risk of illness in human or animal populations.’’ 

Congress required consideration of studies in animals because most studies of 

toxic substances and drugs are necessarily done in animals for ethical reasons. It 

did not ask for information on how much of an agent Gulf War troops were exposed 

to. It was well known that no such information exists. 

These basic animal studies have never been considered in any IOM report. The 

2016 report discusses some animal studies involving exposures to combinations of 

agents, but it acknowledges that ‘‘studies examining single exposures are not considered here’’ because ‘‘[e]arly volumes of the Gulf War and Health series described 

animal studies . . . on the association between exposure to a single toxicant and the 

health outcomes that may result. . .’’ 

2016 IOM Gulf War and Health report, Vol. 10, p. 239 

But the earlier IOM reports make clear they did not consider these animal studies 

in their conclusions. The chairman of the 2016 committee, Dr. Deborah CorySlechta, was a member of the committee for the 2003 IOM Gulf War report on Insecticides and Solvents, so she is familiar with the procedures used. While the 2003 

report ‘‘described’’ numerous animal studies, it admitted that ‘‘animal studies had 

a limited role in the committee’s assessment between exposure and a health outcome. Animal data . . . were not used as part of the weight-of-evidence . . .’’ 

2003 IOM Gulf War and Health report, Vol. 2, p. 3 

The same admission can be found in every IOM Gulf War report on the health 

effects of toxic substances. Thus, the 2016 report did not consider these basic animal 

studies in their conclusions, relying on the earlier reports, but the earlier reports 

didn’t consider them either. As a result, since most studies of toxic exposures are 

done in animals, no IOM report has ever found sufficient evidence that any of the 

thirty-three listed toxic exposures and medications are associated with adverse 

health outcomes. 

The whole IOM Gulf War series of reports is a house of cards. 

In her preface to the 2016 report, Dr. Cory-Slechta points to the ‘‘ever unknowable 

impact of the various chemical exposures that occurred. . .’’, because ‘‘[o]bjective exposure data gathered during and after the war have been, and are expected to continue to be, unavailable.’’ 2016 IOM Gulf War and Health report, Vol. 10, p. ix 

But Congress never asked for consideration of exposure data. It was well known 

that data did not exist. What it did ask for was consideration of animal data. But 

it has never gotten it. It has never gotten it because VA did not contract for the 

reports that Congress ordered. 

The IOM has been a willing collaborator in this deceit, changing its own standards of evidence to exclude animal studies - exactly the opposite action from what 

the law required. 

It made this change quietly, and has deceitfully implied that nothing changed. As 

presented in the 2003 report, ‘‘[t]he committee used the [standards of evidence] from 

previous IOM studies because they have gained wide acceptance over more than a 

decade by Congress, government agencies, researchers, and veterans groups.’’ ‘‘The 

[standards of evidence] closely resemble those used by . . . IOM committees that 

have evaluated . . . herbicides used in Vietnam.’’ 2003 IOM Gulf War and Health 

report, Vol. 2, p. 3 

(See the similar language on p. 3 of the 2016 report.) 

In fact, however, the standards were subtly changed from the Agent Orange 

standards to exclude consideration of animal studies. Animal studies are discussed 

in the Gulf War reports, but when it comes to arriving at the reports’ conclusions, 

they are not considered, applying the doctored standards of evidence (what the IOM 

calls the ‘‘categories of association’’). 

For sixteen years, VA, DoD, and IOM staff have manipulated IOM Gulf War reports on the health effects of veterans’ toxic exposures. As a result, the reports have 

consistently found ‘‘insufficient evidence’’ that the exposures are associated with illness, leading to VA determinations that the illness does not qualify for benefits as 

service-connected. Of equal importance, these dishonest reports have also misled researchers seeking to understand the causes of Gulf War illness in order to identify 

treatments to improve veterans’ health and preventive measures to protect future 

US forces. 

In recent years, the same techniques have been applied to IOM reports on the 

health effects of toxic substances released by burn pits on recent Iraq and Afghanistan veterans. 

The balance of this Appendix will review in detail these corrupt practices. 

1. The governing statute expressly requires consideration of animal studies. 

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In PL 105–277 and PL 105–368, Congress in 1998 directed the Department of 

Veterans Affairs to contract with the National Academy of Sciences (NAS, the parent organization of the Institute of Medicine, IOM), to review the scientific literature regarding substances to which troops were exposed in the 1991 Gulf War 

to determine if these substances are associated with an increased risk of illness. 

These reports were to be used by the Secretary of Veterans Affairs in determining 

whether the illness should be presumed service-connected for the purpose of veterans’ benefits. 

The law directed the NAS (IOM) to identify the ‘‘biological, chemical, or other 

toxic agents, environmental or wartime hazards, or preventive medicines or vaccines’’ to which members of the Armed Forces may have been exposed during the 

war. 38 USC Sec. 1117, note Sec. 1603 (c). [attached to this Appendix below at p. 

14] The law listed thirty-three specific ‘‘toxic agents, environmental or wartime hazards, or preventive medicines or vaccines associated with Gulf War service’’ to be 

considered, including various pesticides; pyridostigmine bromide, a drug used as a 

nerve agent prophylaxis; low-level nerve agents; other chemicals, metals, sources of 

radiation; and infectious diseases. 38 USC Sec. 1117, note Sec. 1603 (a), (d). [below, 

pp. 15–16] The law further required the NAS (IOM) to identify illnesses, ‘‘including 

diagnosed illnesses and undiagnosed illnesses,’’ experienced by Armed Forces members who served in the war. 38 USC Sec. 1117, note Sec. 1603 (c) [below, p. 14] 

‘‘For each agent, hazard, or medicine or vaccine and illness identified,’’ the law 

provided that: 

‘‘The National Academy of Sciences shall determine . 

(A) whether a statistical association exists between exposure to the agent . and 

the illness . . . 

(B) the increased risk of the illness among human or animal populations exposed 

to the agent . and 

(C) whether a plausible biological mechanism or other evidence of a causal relationship exists .’’ 

38 USC Sec. 1117, note Sec. 1603 (e) [below, p. 16, emphasis added] 

The statute went on to provide that the Secretary of Veterans Affairs should consider both human and animal studies in determining whether a presumption of 

service connection is warranted. He was to consider ‘‘the exposure in humans or animals’’ to an agent and ‘‘the occurrence of a diagnosed or undiagnosed illness in humans or animals.’’ 

38 USC Sec. 1118 (b)(1)(B) [below, p. 21, emphasis added] 

Congress thus expressly required consideration of animal as well as human studies by both the National Academy of Sciences (the Institute of Medicine) and the 

Secretary of Veterans Affairs. This statutory requirement reflects the fact that most 

studies on the biological effects of hazardous substances are necessarily done in animals, for ethical reasons. Consider, for example, the twenty-three studies on the 

long-term effects of low level sarin exposure, or the eighteen studies evaluating the 

combined effects of pyridostigmine bromide, pesticides and insect repellant listed on 

pages 160–161 and 170–171 of the 2008 Research Advisory Committee on Gulf War 

Veterans Illnesses report, all of which were done in animals. http://www.va.gov/ 

RAC–GWVI/docs/Committee—Documents/GWIandHealthofGWVeterans—RAC– 

GWVIReport—2008.pdf 

When the first IOM report was conducted under the law, however, animal studies 

were omitted from the standard for determining whether an association exists between an exposure and a health effect. The report states: 

‘‘For its evaluation and categorization of the degree of association between each 

exposure and a human health effect, however, the [IOM] committee only used evidence from human studies.’’ 

Gulf War and Health, Volume 1, (2000), p. 72 [below, p. 23] 

Considering only human studies, and not the much larger relevant literature on 

animal studies, the IOM committees have never found sufficient evidence of an association for the exposures and illnesses experienced by Gulf War veterans. Following 

the reports of the IOM, the Secretary of Veterans Affairs has made no determinations of service-connection for these exposures and illnesses for veterans’ benefits. 

(VA asserts that it covers Gulf War veterans on other grounds for their 

‘‘undiagnosed illnesses,’’ but VA statistics show that over 80% of such veterans’ 

claims are denied. http://www.scribd.com/doc/241661207/Binns-Parting-Thoughts093014) 

This pattern has been followed in all IOM Gulf War reports to date. More recently, it has been applied to IOM reports on the effects of toxic exposures fromburn 

pits on the health of recent Iraq and Afghanistan veterans. 

2. The exclusion of animal studies was deliberate. 

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A close examination of what occurred makes clear that the exclusion of animal 

studies was not an oversight. It was deliberate. 

To express conclusions as to whether an association between an exposure and an 

illness exists, the first IOM Gulf report defined five standards of evidence, which 

it called the ‘‘Categories of Association.’’ Gulf War and Health, Vol. 1, pp. 83–84. 

[below, pp. 25–26] The same categories have been used in all subsequent IOM Gulf 

War exposure reports: 

- Sufficient Evidence of a Causal Relationship 

- Sufficient Evidence of an Association 

- Limited/Suggestive Evidence of an Association 

- Inadequate/Insufficient Evidence to Determine Whether an Association Does or 

Does Not Exist 

- Limited/Suggestive Evidence of No Association. 

Each substance was ranked according to these categories. How a substance is 

ranked becomes the all-important conclusion of the report as to whether an association exists between an exposure and illness. 

Where did these categories come from? The report explained: ‘‘The committee used 

the established categories of association from previous IOM studies, because they 

have gained wide acceptance for more than a decade by Congress, government agencies, researchers, and veteran groups.’’ ‘‘The categories closely resemble those used 

by several IOM committees that evaluated .. herbicides used in Vietnam .’’ Gulf War 

and Health, Volume I, p. 83. [below, p. 25] 

IOM Gulf War reports have repeatedly emphasized over the years that their 

methodology is based on the IOM Agent Orange reports. However, it is revealing 

to compare a category of association used in the Agent Orange reports with the 

same category used in the Gulf War reports. 

Agent Orange: 

‘‘Sufficient Evidence of an Association. Evidence is sufficient to conclude that 

there is a positive association. That is, a positive association has been observed between herbicides and the outcome in studies in which chance, bias, and confounding 

could be ruled out .’’ Veterans and Agent Orange: 1996 Update, p. 97 [below, p. 27, 

emphasis added] 

Gulf War: 

‘‘Sufficient Evidence of an Association. Evidence is sufficient to conclude that 

there is a positive association. That is, a positive association has been observed between an exposure to a specific agent and a health outcome in human studies in 

which chance, bias, and confounding could be ruled out . . .’’ 

Gulf War and Health: Volume I, p. 83 [below, p. 25, emphasis added] 

The Gulf War category does indeed ‘‘closely resemble’’ the Agent Orange category—with a conspicuous exception. The word ‘‘human’’ has been inserted in the 

Gulf War category. This addition obviously did not occur by accident. It was deliberate, as was the misleading language that these were the ‘‘established categories 

of association from previous IOM reports.’’ 

Thus, not only have the IOM Gulf War studies been conducted in violation of the 

direction Congress provided in the statute; this violation has been deliberate, with 

intent to conceal. 

As to why it was done, one can speculate based on the knowledge that the Agent 

Orange language, just a few years earlier, had produced an IOM report that found 

that Agent Orange exposure was associated with cancer (after two decades of government denial of any health consequence). This finding led to a presumption of 

service connection for thousands of Vietnam veterans with cancer. 

It should be noted that the IOM Gulf War reports state that animal studies were 

considered for purposes of ‘‘biological plausibility’’: ‘‘For its evaluation and categorization of the degree of association between each exposure and a human health 

effect, . the committee only used evidence from human studies. Nevertheless, the 

committee did use nonhuman studies as the basis for judgments about biological 

plausibility, which is one of the criteria for establishing causation.’’ Gulf War and 

Health, Volume 1, p. 72 [below, p. 25] 

The terms of the Gulf War categories of association make clear, however, that biological plausibility and causation only relate to the highest category of evidence, 

‘‘sufficient evidence of a causal relationship,’’ and are not considered unless there 

has been a previous finding of ‘‘sufficient evidence of association’’: 

‘‘Sufficient Evidence of a Causal Relationship. Evidence is sufficient to conclude 

that a causal relationship exists between the exposure to a specific agent and a 

health outcome in humans. The evidence fills the criteria for sufficient evidence of 

association (below) and satisfies several of the criteria used to assess causality: 

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strength of association, dose-response relationship, consistency of association, temporal relationship, specificity of association, and biological plausibility.’’ 

‘‘Sufficient Evidence of an Association. Evidence is sufficient to conclude that 

there is a positive association. That is, a positive association has been observed between an exposure to a specific agent and a health outcome in human studies in 

which chance, bias, and confounding could be ruled out with reasonable confidence.’’ 

Gulf War and Health, Volume 1, p. 83. [below, p. 25, emphasis added] 

Thus, only if there has already been a finding of ‘‘sufficient evidence of association’’ do the issues of causality and biological plausibility arise, and a finding of ‘‘sufficient evidence of association’’ depends solely on human studies. Unless an association is found based on human studies, biological plausibility—and animal studies— 

are not considered. 

It is notable that the statute does not require evidence of a ‘‘casual relationship’’ 

to trigger a presumption of service connection. It only requires evidence of a ‘‘positive association’’: 

‘‘[T]he Secretary shall prescribe regulations providing that a presumption of service connection is warranted [if the Secretary makes a] determination based on sound 

medical and scientific evidence that a positive association exists between—— 

(i) the exposure of humans or animals to a biological, chemical, or other toxic 

agent, environmental or wartime hazard, or preventive medicine or vaccine known 

or presumed to be associated with service in the Southwest Asia theater of operations during the Persian Gulf War; and 

(ii) the occurrence of a diagnosed or undiagnosed illness in humans or animals.’’ 

38 USC Sec. 1118 (b)(1) [emphasis added, below pp. 20–21] 

In short, in direct contravention of the law, the methodology established for the 

IOM Gulf War reports deliberately excluded animal studies from consideration as 

to whether an association exists between an exposure and an illness, the only question that matters in the determination of veterans’ benefits. 

3. VA and IOM staff privately collaborated to produce these results. 

As to how this was done, the history of one of the IOM Gulf War reports provides 

an indication. The 2004 IOM Updated Literature Review of Sarin is the most egregious example of the distortion of science produced by excluding animal studies from 

the evidence considered in these reports’ conclusions. In late 2002, a number of new 

studies on sarin nerve gas, sponsored by the Department of Defense, revealed that 

contrary to previous belief, low level exposures (below the level required to produce 

symptoms at the time of exposure) produced long-term effects on the nervous and 

immune systems. Naturally, these studies were done in animals, not humans. 

A previous IOM report on sarin in 2000 had found insufficient evidence of an association between low-level sarin and long-term health effects based on scientific 

knowledge as of that date. On January 24, 2003, then-VA Secretary Anthony 

Principi wrote the president of the Institute of Medicine: ‘‘Recently, a number of 

new studies have been published on the effects of Sarin on laboratory animals.’’ He 

asked the IOM to report back ‘‘on whether this new research affects earlier conclusions of IOM . . . about possible long-term health consequences of exposure to low 

levels of Sarin.’’ [attached, p. 29] 

In 2004, the IOM delivered its report. The Updated Literature Review of Sarin 

discussed the new animal studies in its text. However, true to form, the report did 

not consider animal studies in the all-important categories of association, even 

though the new animal studies were the only reason for doing the report. 

‘‘As with previous committees, this committee used animal data for making assessments of biological plausibility . rather than as part of the weight of evidence 

to determine the likelihood that an exposure to a specific agent might cause a longterm outcome.’’ Updated Literature Review of Sarin (2004), p. 18 [below, p. 30] Accordingly, the report found insufficient evidence of an association. 

To understand this bizarre outcome, it is revealing that following Secretary 

Principi’s letter, an IOM proposal was prepared which became the basis for a contract between the IOM and VA. 

The proposal for the sarin update was sent to VA on March 11, 2003, with a cover 

letter from Susanne Stoiber, executive director of the IOM, to Dr. Mark Brown, director of the VA Environmental Agents Service, part of the Office of Public Health. 

The cover letter stated: ‘‘This proposal follows a request from Secretary Anthony J. 

Principi and discussions with yourself requesting an update of the health effects of 

the chemical warfare agent sarin.’’ [below, p. 31] 

The proposal contained the following ‘‘Statement of Task’’: [below, p. 34] 

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‘‘The committee will conduct a review of the peer-reviewed literature published 

since earlier IOM reports on health effects associated with exposure to sarin and 

related compounds. Relevant epidemiologic studies will be considered. With regard 

to the toxicological literature, the committee will generally use review articles to 

present a broad overview of the toxicology of sarin and to make assessments of biologic plausibility regarding the compound of study and health effects; individual 

toxicology research papers will be evaluated as warranted. 

The committee will make determinations on the strength of the evidence for associations between sarin and human health effects. If published peer-reviewed information is available on the dose of sarin exposure in Gulf War veterans, the committee may address the potential health risks posed to the veterans . . . ‘‘ 

In other words, the Statement of Task established that the update report would 

use the same ‘‘categories of association’’ as the earlier Gulf War reports. The ‘‘determinations on the strength of the evidence’’ would be made on the basis of the ‘‘associations between sarin and human health effects’’. ‘‘With regard to the toxicological 

literature’’ (which included the new animal studies), its use would be confined to the 

assessment of ‘‘biological plausibility’’ to which animal studies had previously been 

relegated. Thus, the update report would exclude animal studies from its key conclusions, even though animal studies were the only reason for doing the report. 

Moreover, the Statement of Task set up another fundamental constraint for the 

report. The IOM committee would be permitted to address the potential health risks 

posed to the veterans ‘‘[i]f published peer-reviewed information is available on the 

dose of sarin exposure in Gulf War veterans.’’ As anyone familiar with Gulf War 

research would know, including Dr. Brown and his IOM counterparts, there is no 

published peer-reviewed information available on the dose of sarin exposure in Gulf 

War veterans, for the reason that no such information was collected during the war. 

As noted in the previous 2000 IOM report on sarin, ‘‘as discussed throughout this 

report, there is a paucity of data regarding the actual agents and doses to which 

individual veterans were exposed.’’ Gulf War and Health, Volume 1, p. 84. [below, 

p. 26] In order for the IOM committee to address the health risks posed to veterans, 

it had to meet a condition that was impossible to meet. 

These constraints in the Statement of Task were not contained in the letter from 

Secretary Principi requesting the report. (To the contrary, they appear to contradict 

it.) They must have come from the ‘‘conversations with yourself’’ referred to in Ms. 

Stoiber’s letter to Dr. Brown. Thus, conversations between VA and IOM staff determined the outcome of the report before the IOM committee to prepare the report 

was ever appointed. 

In summary, VA and the IOM have not complied with the law requiring the IOM 

Gulf War reports, restricting the scientific evidence required to be considered. This 

action has been deliberate. Conversations between VA and IOM staff have shaped 

the methodology of the reports so as to predetermine their outcome. Dr. Brown and 

Ms. Stoiber are long gone, and their successors are more careful regarding what 

they put in writing, but the corrupted Categories of Asssociation and all the IOM 

reports based on them still stand. 

4. The IOM has recently applied this same corrupt standard to the health of recent 

Iraq and Afghanistan veterans, denying the adverse effects of toxic substances released by burn pits. 

In 2007 on-site military officers with environmental health responsibilities reported dangerous health effects of toxic exposures from burn pits on U.S. bases in 

Iraq and Afghanistan, particularly Joint Base Balad (JBB). A draft executive summary of a study, dated December 2007, showed dioxin levels at 51 times acceptable 

levels, particulate exposure at 50 times acceptable levels, volatile compounds at two 

times acceptable levels, and cancer risk from exposure to dioxins at two times acceptable levels for people at Balad for a year and at eight times acceptable levels 

for people at the base for more than a year. 

DoD Washington said the draft summary contained ‘‘incorrect data’’ due to a ‘‘software error’’ and was ‘‘prematurely distributed.’’ Officials in Washington in the DoD 

Office of Force Health Protection and Readiness denied any lasting health effects: 

‘‘While exposure to burn pit smoke may cause temporary coughing and redness or 

stinging of the eyes, extensive environmental monitoring indicates that smoke exposures not interfering with breathing or requiring medical treatment at the time of 

exposure usually do not cause any lasting health effects or medical follow-up.’’ http:// 

www.armytimes.com/article/20081027/NEWS/810270315/Burn-pit-at-Balad-raiseshealth-concerns 

An IOM report was ordered by VA to study the subject. ‘‘[T]he Institute of Medicine has embarked on a comprehensive study with noted experts in environmental 

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and occupational health to study the issue.’’ ‘‘Is Burn Pit Smoke Hazardous To Your 

Health?’’, Force Health Protection and Readiness magazine, vol. 5, issue 2, 2010, 

page 11. 

http://home.fhpr.osd.mil/Libraries/FHPR—Online—Magazine/Volume—5—Issue— 

2.sflb.ashx 

Following the pattern established in the IOM Gulf War reports, the IOM burn pit 

report first pointed out the known health risks of the exposures: ‘‘Chemicals in all 

three major classes of chemicals detected at JBB . . . have been associated with 

long-term health effects. A wide array of health effects have been observed in humans and animals after exposure to the specific pollutants detected at JBB . . . The 

health-effects data on the other pollutants detected include: neurological effects, 

liver toxicity and reduced liver function, cancer, respiratory toxicity and morbidity, 

kidney toxicity and reduced kidney function, blook effects, cardiovascular toxicity 

and morbidity, reproductive and developmental toxicity.’’ http://books.nap.edu/ 

openbook.php?record—id=13209&page=5 

But then, when it came to arriving at conclusions, the IOM committee applied the 

Categories of Association that allowed only for consideration of human studies. It 

stated that it was ‘‘[f]ollowing the methods and criteria used by other IOM committees that have prepared reports for the Gulf War and Health Series and the Veterans and Agent Orange Series . . .’’) http://books.nap.edu/openbook.php?record— 

id=13209&page=6). 

There were no published studies of service members exposed to burn pits, so the 

committee relied on studies of groups like firefighters and incinerator workers. Accordingly, as reported on VA’s website, the committee found only ‘‘limited but suggestive evidence of a link between exposure to combustion products and reduced 

lung function’’ and ‘‘inadequate or insufficient evidence of a relation to combustion 

products and cancer, respiratory diseases, circulatory diseases, neurological diseases, and adverse reproductive and developmental outcomes.’’ It did not find the 

‘‘sufficient evidence of an association’’ required for service connection. 

http://www.publichealth.va.gov/exposures/burnpits/health-effects-studies.asp 

Thus, rigging IOM reports by corrupting the Categories of Association has been 

extended to a new generation of veterans, as well as continuing for Gulf War veterans. 

ATTACHMENTS TO APPENDIX A 

TITLE 38—VETERANS’ BENEFITS, 

PART II—GENERAL BENEFITS 

CHAPTER 11—COMPENSATION FOR SERVICE–CONNECTED DISABILITY 

OR DEATH, SUBCHAPTER II—WARTIME DISABILITY COMPENSATION 

Sec. 1117. Compensation for disabilities occurring in Persian Gulf War veterans 

* * * 

Agreement With National Academy of Sciences Regarding Toxic Drugs and Illnesses Associated With Gulf War 

Pub. L. 105–277, div. C, title XVI, Sec. 1603–1605, Oct. 21, 1998, 112 Stat. 2681– 

745 to 2681–748, as amended by Pub. L. 107–103, title II, Sec. 202(d)(2), Dec. 27, 

2001, 115 Stat. 989, provided that: 

‘‘SEC. 1603. AGREEMENT WITH NATIONAL ACADEMY OF SCIENCES. 

‘‘(a) Purpose.—The purpose of this section is to provide for the National Academy 

of Sciences, an independent nonprofit scientific organization with appropriate expertise, to review and evaluate the available scientific evidence regarding associations 

between illnesses and exposure to toxic agents, environmental or wartime hazards, 

or preventive medicines or vaccines associated with Gulf War service. 

‘‘(b) Agreement.—The Secretary of Veterans Affairs shall seek to enter into an 

agreement with the National Academy of Sciences for the Academy to perform the 

activities covered by this section. The Secretary shall seek to enter into the agreement not later than two months after the date of enactment of this Act [Oct. 21, 

1998]. 

‘‘(c) Identification of Agents and Illnesses.—(1) Under the agreement under subsection (b), the National Academy of Sciences shall—— 

‘‘(A) identify the biological, chemical, or other toxic agents, environmental or wartime hazards, or preventive medicines or vaccines to which members of the Armed 

Forces who served in the Southwest Asia theater of operations during the Persian 

Gulf War may have been exposed by reason of such service; and 

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‘‘(B) identify the illnesses (including diagnosed illnesses and undiagnosed illnesses) that are manifest in such members. 

‘‘(2) In identifying illnesses under paragraph (1)(B), the Academy shall review and 

summarize the relevant scientific evidence regarding illnesses among the members 

described in paragraph (1)(A) and among other appropriate populations of individuals, including mortality, symptoms, and adverse reproductive health outcomes 

among such members and individuals. 

‘‘(d) Initial Consideration of Specific Agents.—(1) In identifying under subsection 

(c) the agents, hazards, or preventive medicines or vaccines to which members of 

the Armed Forces may have been exposed for purposes of the first report under subsection (i), the National Academy of Sciences shall consider, within the first six 

months after the date of enactment of this Act [Oct. 21, 1998], the following: 

‘‘(A) The following organophosphorous pesticides: 

‘‘(i) Chlorpyrifos. 

‘‘(ii) Diazinon. 

‘‘(iii) Dichlorvos. 

‘‘(iv) Malathion. 

‘‘(B) The following carbamate pesticides: 

‘‘(i) Proxpur. 

‘‘(ii) Carbaryl. 

‘‘(iii) Methomyl. 

‘‘(C) The carbamate pyridostigmine bromide used as nerve agent prophylaxis. 

‘‘(D) The following chlorinated hydrocarbon and other pesticides and repellents: 

‘‘(i) Lindane. 

‘‘(ii) Pyrethrins. 

‘‘(iii) Permethrins. 

‘‘(iv) Rodenticides (bait). 

‘‘(v) Repellent (DEET). 

‘‘(E) The following low-level nerve agents and precursor compounds at exposure 

levels below those which produce immediately apparent incapacitating symptoms: 

‘‘(i) Sarin. 

‘‘(ii) Tabun. 

‘‘(F) The following synthetic chemical compounds: 

‘‘(i) Mustard agents at levels below those which cause immediate blistering. 

‘‘(ii) Volatile organic compounds. 

‘‘(iii) Hydrazine. 

‘‘(iv) Red fuming nitric acid. 

‘‘(v) Solvents. 

‘‘(vi) Uranium. 

‘‘(G) The following ionizing radiation: 

‘‘(i) Depleted uranium. 

‘‘(ii) Microwave radiation. 

‘‘(iii) Radio frequency radiation. 

‘‘(H) The following environmental particulates and pollutants: 

‘‘(i) Hydrogen sulfide. 

‘‘(ii) Oil fire byproducts. 

‘‘(iii) Diesel heater fumes. 

‘‘(iv) Sand micro-particles. 

‘‘(I) Diseases endemic to the region (including the following): 

‘‘(i) Leishmaniasis. 

‘‘(ii) Sandfly fever. 

‘‘(iii) Pathogenic escherechia coli. 

‘‘(iv) Shigellosis. 

‘‘(J) Time compressed administration of multiple live, ‘attenuated’, and toxoid vaccines. 

‘‘(2) The consideration of agents, hazards, and medicines and vaccines under paragraph (1) shall not preclude the Academy from identifying other agents, hazards, 

or medicines or vaccines to which members of the Armed Forces may have been exposed for purposes of any report under subsection (i). 

‘‘(3) Not later than six months after the date of enactment of this Act [Oct. 21, 

1998], the Academy shall submit to the designated congressional committees a report specifying the agents, hazards, and medicines and vaccines considered under 

paragraph (1). 

‘‘(e) Determinations of Associations Between Agents and Illnesses.—— 

(1) For each agent, hazard, or medicine or vaccine and illness identified under 

subsection (c), the National Academy of Sciences shall determine, to the extent that 

available scientific data permit meaningful determinations—— 

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‘‘(A) whether a statistical association exists between exposure to the agent, hazard, or medicine or vaccine and the illness, taking into account the strength of the 

scientific evidence and the appropriateness of the scientific methodology used to detect the association; 

‘‘(B) the increased risk of the illness among human or animal populations exposed 

to the agent, hazard, or medicine or vaccine; and 

‘‘(C) whether a plausible biological mechanism or other evidence of a causal relationship exists between exposure to the agent, hazard, or medicine or vaccine and 

the illness. 

‘‘(2) The Academy shall include in its reports under subsection (i) a full discussion 

of the scientific evidence and reasoning that led to its conclusions under this subsection. 

‘‘(f) Review of Potential Treatment Models for Certain Illnesses.——Under the 

agreement under subsection (b), the National Academy of Sciences shall separately 

review, for each chronic undiagnosed illness identified under subsection (c)(1)(B) and 

for any other chronic illness that the Academy determines to warrant such review, 

the available scientific data in order to identify empirically valid models of treatment for such illnesses which employ successful treatment modalities for populations with similar symptoms. 

‘‘(g) Recommendations for Additional Scientific Studies.—(1) Under the agreement 

under subsection (b), the National Academy of Sciences shall make any recommendations that it considers appropriate for additional scientific studies (including studies relating to treatment models) to resolve areas of continuing scientific uncertainty relating to the health consequences of exposure to toxic agents, environmental or wartime hazards, or preventive medicines or vaccines associated with 

Gulf War service. 

‘‘(2) In making recommendations for additional studies, the Academy shall consider the available scientific data, the value and relevance of the information that 

could result from such studies, and the cost and feasibility of carrying out such 

studies. 

‘‘(h) Subsequent Reviews.—(1) Under the agreement under subsection (b), the National Academy of Sciences shall conduct on a periodic and ongoing basis additional 

reviews of the evidence and data relating to its activities under this section. 

‘‘(2) As part of each review under this subsection, the Academy shall—— 

‘‘(A) conduct as comprehensive a review as is practicable of the evidence referred 

to in subsection (c) and the data referred to in subsections (e), (f), and (g) that became available since the last review of such evidence and data under this section; 

and 

‘‘(B) make determinations under the subsections referred to in subparagraph (A) 

on the basis of the results of such review and all other reviews previously conducted 

for purposes of this section. 

‘‘(i) Reports.—(1) Under the agreement under subsection (b), the National Academy of Sciences shall submit to the committees and officials referred to in paragraph (5) periodic written reports regarding the Academy’s activities under the 

agreement. 

‘‘(2) The first report under paragraph (1) shall be submitted not later than 18 

months after the date of enactment of this Act [Oct. 21, 1998]. That report shall 

include—— 

‘‘(A) the determinations and discussion referred to in subsection (e); 

‘‘(B) the results of the review of models of treatment under subsection (f); and 

‘‘(C) any recommendations of the Academy under subsection (g). 

‘‘(3) Reports shall be submitted under this subsection at least once every two 

years, as measured from the date of the report under paragraph (2). 

‘‘(4) In any report under this subsection (other than the report under paragraph 

(2)), the Academy may specify an absence of meaningful developments in the scientific or medical community with respect to the activities of the Academy under 

this section during the 2-year period ending on the date of such report. 

‘‘(5) Reports under this subsection shall be submitted to the following: 

‘‘(A) The designated congressional committees. 

‘‘(B) The Secretary of Veterans Affairs. 

‘‘(C) The Secretary of Defense. 

‘‘(j) Sunset.—This section shall cease to be effective on October 1, 2010. 

‘‘(k) Alternative Contract Scientific Organization.—(1) If the Secretary is unable 

within the time period set forth in subsection (b) to enter into an agreement with 

the National Academy of Sciences for the purposes of this section on terms acceptable to the Secretary, the Secretary shall seek to enter into an agreement for purposes of this section with another appropriate scientific organization that is not part 

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of the Government, operates as a not-for-profit entity, and has expertise and objectivity comparable to that of the National Academy of Sciences. 

‘‘(2) If the Secretary enters into an agreement with another organization under 

this subsection, any reference in this section and section 1118 of title 38, United 

States Code (as added by section 1602(a)), to the National Academy of Sciences shall 

be treated as a reference to such other organization. 

‘‘SEC. 1604. REPEAL OF INCONSISTENT PROVISIONS OF LAW. 

‘‘In the event of the enactment, before, on, or after the date of the enactment of 

this Act [Oct. 21, 1998], of section 101 of the Veterans Programs Enhancement Act 

of 1998 [Pub. L. 105–368, 112 Stat. 3317], or any similar provision of law enacted 

during the second session of the 105th Congress requiring an agreement with the 

National Academy of Sciences regarding an evaluation of health consequences of 

service in Southwest Asia during the Persian Gulf War, such section 101 (or other 

provision of law) shall be treated as if never enacted, and shall have no force or effect. 

‘‘SEC. 1605. DEFINITIONS. 

‘‘In this title [enacting section 1118 of this title, amending this section and section 

1113 of this title, and enacting this note and provisions set out as a note under section 101 of this title]: 

‘‘(1) The term ‘toxic agent, environmental or wartime hazard, or preventive medicine or vaccine associated with Gulf War service’ means a biological, chemical, or 

other toxic agent, environmental or wartime hazard, or preventive medicine or vaccine that is known or presumed to be associated with service in the Armed Forces 

in the Southwest Asia theater of operations during the Persian Gulf War, whether 

such association arises as a result of single, repeated, or sustained exposure and 

whether such association arises through exposure singularly or in combination. 

‘‘(2) The term ‘designated congressional committees’ means the following: 

‘‘(A) The Committees on Veterans’ Affairs and Armed Services of the Senate. 

‘‘(B) The Committees on Veterans’ Affairs and National Security [now Armed 

Services] of the House of Representatives. 

‘‘(3) The term ‘Persian Gulf War’ has the meaning given that term in section 

101(33) of title 38, United States Code.’’ 

[Pub. L. 105–368, title I, Sec. 101, Nov. 11, 1998, 112 Stat. 3317, enacted provisions similar to those in sections 1603 and 1605 of Pub. L. 105–277, set out above. 

See section 1604 of Pub. L. 105–277, set out above.] 

From the U.S. Code Online via GPO Access 

[www.gpoaccess.gov] 

[Laws in effect as of January 3, 2007] 

[CITE: 38USC1118] 

TITLE 38—VETERANS’ BENEFITS 

PART II—GENERAL BENEFITS 

CHAPTER 11—COMPENSATION FOR SERVICE–CONNECTED DISABILITY 

OR DEATH 

SUBCHAPTER II—WARTIME DISABILITY COMPENSATION 

Sec. 1118. Presumptions of service connection for illnesses associated with service 

in the Persian Gulf during the Persian Gulf War 

(a)(1) For purposes of section 1110 of this title, and subject to section 1113 of this 

title, each illness, if any, described in paragraph (2) shall be considered to have been 

incurred in or aggravated by service referred to in that paragraph, notwithstanding 

that there is no record of evidence of such illness during the period of such service. 

(2) An illness referred to in paragraph (1) is any diagnosed or undiagnosed illness 

that—— 

(A) the Secretary determines in regulations prescribed under this section to warrant a presumption of service connection by reason of having a positive association 

with exposure to a biological, chemical, or other toxic agent, environmental or wartime hazard, or preventive medicine or vaccine known or presumed to be associated 

with service in the Armed Forces in the Southwest Asia theater of operations during 

the Persian Gulf War; and 

(B) becomes manifest within the period, if any, prescribed in such regulations in 

a veteran who served on active duty in that theater of operations during that war 

and by reason of such service was exposed to such agent, hazard, or medicine or 

vaccine. 

(3) For purposes of this subsection, a veteran who served on active duty in the 

Southwest Asia theater of operations during the Persian Gulf War and has an illness described in paragraph (2) shall be presumed to have been exposed by reason 

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of such service to the agent, hazard, or medicine or vaccine associated with the illness in the regulations prescribed under this section unless there is conclusive evidence to establish that the veteran was not exposed to the agent, hazard, or medicine or vaccine by reason of such service. 

(4) For purposes of this section, signs or symptoms that may be a manifestation 

of an undiagnosed illness include the signs and symptoms listed in section 1117(g) 

of this title. 

(b)(1)(A) Whenever the Secretary makes a determination described in subparagraph (B), the Secretary shall prescribe regulations providing that a presumption 

of service connection is warranted for the illness covered by that determination for 

purposes of this section. 

(B) A determination referred to in subparagraph (A) is a determination based on 

sound medical and scientific evidence that a positive association exists between—— 

(i) the exposure of humans or animals to a biological, chemical, or other toxic 

agent, environmental or wartime hazard, or preventive medicine or vaccine known 

or presumed to be associated with service in the Southwest Asia theater of operations during the Persian Gulf War; and 

(ii) the occurrence of a diagnosed or undiagnosed illness in humans or animals. 

(2)(A) In making determinations for purposes of paragraph (1), the Secretary shall 

take into account—— 

(i) the reports submitted to the Secretary by the National Academy of Sciences 

under section 1603 of the Persian Gulf War Veterans Act of 1998; and 

(ii) all other sound medical and scientific information and analyses available to 

the Secretary. 

(B) In evaluating any report, information, or analysis for purposes of making such 

determinations, the Secretary shall take into consideration whether the results are 

statistically significant, are capable of replication, and withstand peer review. 

(3) An association between the occurrence of an illness in humans or animals and 

exposure to an agent, hazard, or medicine or vaccine shall be considered to be positive for purposes of this subsection if the credible evidence for the association is 

equal to or outweighs the credible evidence against the association. 

(c)(1) Not later than 60 days after the date on which the Secretary receives a report from the National Academy of Sciences under section 1603 of the Persian Gulf 

War Veterans Act of 1998, the Secretary shall determine whether or not a presumption of service connection is warranted for each illness, if any, covered by the report. 

(2) If the Secretary determines under this subsection that a presumption of service connection is warranted, the Secretary shall, not later than 60 days after making 

the determination, issue proposed regulations setting forth the Secretary’s determination. 

(3)(A) If the Secretary determines under this subsection that a presumption of 

service connection is not warranted, the Secretary shall, not later than 60 days after 

making the determination, publish in the Federal Register a notice of the determination. The notice shall include an explanation of the scientific basis for the determination. 

(B) If an illness already presumed to be service connected under this section is 

subject to a determination under subparagraph (A), the Secretary shall, not later 

than 60 days after publication of the notice under that subparagraph, issue proposed regulations removing the presumption of service connection for the illness. 

(4) Not later than 90 days after the date on which the Secretary issues any proposed regulations under this subsection, the Secretary shall issue final regulations. 

Such regulations shall be effective on the date of issuance. 

(d) Whenever the presumption of service connection for an illness under this section is removed under subsection (c)—— 

(1) a veteran who was awarded compensation for the illness on the basis of the 

presumption before the effective date of the removal of the presumption shall continue to be entitled to receive compensation on that basis; and 

(2) a survivor of a veteran who was awarded dependency and indemnity compensation for the death of a veteran resulting from the illness on the basis of the 

presumption before that date shall continue to be entitled to receive dependency and 

indemnity compensation on that basis. 

(e) Subsections (b) through (d) shall cease to be effective on September 30, 2011. 

(Added Pub. L. 105–277, div. C, title XVI, Sec. 1602(a)(1), Oct. 21, 1998, 112 Stat. 

2681–742; amended Pub. L. 107–103, title II, Sec. 202(b)(2), (d)(1), Dec. 27, 2001, 

115 Stat. 989.) 

References in Text 

Leonard.horne on VACREP0180 with DISTILLER

53 

Section 1603 of the Persian Gulf War Veterans Act of 1998, referred to in subsecs. 

(b)(2)(A)(i) and (c)(1), is section 1603 of Pub. L. 105-277, which is set out in a note 

under section 1117 of this title. 

Amendments 

2001—Subsec. (a)(4). Pub. L. 107–103, Sec. 202(b)(2), added par. (4). 

Subsec. (e). Pub. L. 107–103, Sec. 202(d)(1), substituted ‘‘on September 30, 2011’’ 

for ‘‘10 years after the first day of the fiscal year in which the National Academy 

of Sciences submits to the Secretary the first report under section 1603 of the Persian Gulf War Veterans Act of 1998’’. 

Effective Date of 2001 Amendment 

Amendment by section 202(b)(2) of Pub. L. 107–103 effective Mar. 1, 2002, see 

section 202(c) of Pub. L. 107–103, set out as a note under section 1117 of this title. 

Gulf War and Health, Vol. 1, p. 72 [emphasis added] 

studies often focus on one agent at a time, they more easily enable the study of 

chemical mixtures and their potential interactions. 

Research on health effects of toxic substance includes animal studies that characterize absorption, distribution, metabolism, elimination, and excretion. Animal studies may examine acute (short-term) exposures or chronic (long-term) exposures. Animal research may focus on the mechanism of action (i.e., how the toxin exerts its 

deleterious effects at the cellular and molecular levels). Mechanism-of-action (or 

mechanistic) studies encompass a range of laboratory approaches with whole animals and in vitro systems using tissues or cells from humans or animals. Also, 

structure-activity relationships, in which comparisons are made between the molecular structure and chemical and physical properties of a potential toxin versus a 

known toxin, are an important source of hypotheses about mechanism of action. 

In carrying out its charge, the committee used animal and other nonhuman studies in several ways, particularly as a marker for health effects that might be important for humans. If an agent, for example, was absorbed and deposited in specific 

tissues or organs (e.g., uranium deposition in bone and kidney), the committee 

looked especially closely for possible abnormalities at these sites in human studies. 

One of the problems with animal studies, however, is the difficulty of finding animal models to study symptoms that relate to uniquely human attributes, such as 

cognition, purposive behavior, and the perception of pain. With the exception of fatigue, many symptoms reported by veterans (e.g., headache, muscle or joint pain) 

are difficult to study in standard neurotoxicological tests in animals (OTA, 1990). 

For its evaluation and categorization of the degree of association between each exposure and a human health effect, however, the committee only used evidence from 

human studies. Nevertheless, the committee did use nonhuman studies as the basis 

for judgments about biologic plausibility, which is one of the criteria for establishing 

causation (see below). 

HUMAN STUDIES

EPIDEMIOLOGIC STUDIES

Epidemiology concerns itself with the relationship of various factors and conditions that determine the frequency and distribution of an infectious process, a disease, or a physiological state in human populations (Lilienfeld, 1978). Its focus on 

populations distinguishes it from other medical disciplines. Epidemiologic studies 

characterize the relationship between the agent, the environment, and the host and 

are useful for generating and testing hypotheses with respect to the association between exposure to an agent and health or disease. The following section describes 

the major types of epidemiologic studies considered by the committee. 

Gulf War and Health, Vol. 2, p. 13 [emphasis added] 

general use in the United States (PAC, 1996) at that time. However, EPA has 

since placed restrictions on some of the insecticides used during the Gulf War. 

USE OF SOLVENTS IN THE GULF WAR 

To determine the specific solvents used in the Gulf War the committee gathered 

information from several sources, including veterans, OSAGWI (2000), and DOD’s 

Defense Logistics Agency. As a result of its research, the committee ultimately identified 53 solvents for review (Appendix D). 

There is little information to characterize the use of solvents in the Gulf War. 

Wartime uses of solvents (such as vehicle maintenance and repair, cleaning, and 

degreasing) probably paralleled stateside military or civilian uses of solvents, but 

Leonard.horne on VACREP0180 with DISTILLER

54 

operating conditions in the Gulf War (such as ventilation and the use of masks) may 

have varied widely from stateside working conditions. 

The most thoroughly documented solvent exposure involved spray-painting with 

chemical-agent-resistant coating (CARC) (OSAGWI, 2000). Thousands of military 

vehicles deployed to the Gulf War were painted with tan CARC to provide camouflage protection for the desert environment and a surface that was easily decontaminated. Not all military personnel involved in CARC painting were trained in spraypainting operations, and some might not have had all the necessary personal protective equipment (OSAGWI, 2000). 

Personnel engaged in CARC painting were exposed to solvents in the CARC formulations, paint thinners, and cleaning products. As noted in the OSAGWI report, 

some of the solvents used to clean painting equipment might have been purchased 

locally and therefore not identified. 

COMPLEXITIES IN ADDRESSING GULF WAR HEALTH ISSUES 

Investigations of the health effects of past wars often focused on narrowly defined 

hazards or health outcomes, such as infectious diseases (for example, typhoid and 

malaria) during the Civil War, specific chemical hazards (for example, mustard gas 

and Agent Orange) in World War I and Vietnam, and combat injuries. Discussion 

of the possible health effects of the Gulf War, however, involves many complex 

issues, such as exposure to multiple agents, lack of exposure information, nonspecific illnesses that lack defined diagnoses or treatment protocols, and the experience 

of war itself. The committee was not charged with addressing those issues, but it 

presents them here to acknowledge the difficulties faced by veterans and their families, researchers, policy-makers, and others in trying to understand Gulf War veterans’ health. 

MULTIPLE EXPOSURES AND CHEMICAL INTERACTIONS

Military personnel were potentially exposed to numerous agents during the Gulf 

War. The number of agents and the combination of agents to which the veterans 

may have been exposed make it difficult to determine whether any one agent or 

combination of agents is the cause of the veterans’ illnesses. These include preventive measures (such as use of pyridostigmine bromide, vaccines, and insecticides), 

hazards of the natural environment 

Gulf War and Health, Vol. 1, p. 83 [emphasis added] 

mittee evaluated the strength of the evidence for or against associations between 

health effects and exposure to the agents being studied. 

CATEGORIES OF ASSOCIATION

The committee used five previously established categories to classify the evidence 

for association between exposure to a specific agent and a health outcome. The categories closely resemble those used by several IOM committees that evaluated vaccine safety (IOM, 1991, 1994a), herbicides used in Vietnam (IOM, 1994b, 1996, 

1999), and indoor pollutants related to asthma (IOM, 2000). Although the categories 

imply a statistical association, the committee had sufficient epidemiologic evidence 

to examine statistical associations for only one of the agents under study (i.e., depleted uranium), there was very limited epidemiologic evidence for the other agents 

examined (i.e., sarin, pyridostigmine bromide, and anthrax and botulinum toxoid 

vaccines). Thus, the committee based its conclusions on the strength and coherence 

of the data in the available studies. In many cases, these data distinguished differences between transient and long-term health outcomes related to the dose of the 

agent. Based on the literature, it became incumbent on the committee to similarly 

specify the differences between dose levels and the nature of the health outcomes. 

This approach led the committee to reach conclusions about long- and short-term 

health effects, as well as health outcomes related to the dose of the putative agents. 

The final conclusions expressed in Chapters 4–7 represent the committee’s collective 

judgment. The committee endeavored to express its judgments as clearly and precisely as the available data allowed. The committee used the established categories 

of association from previous IOM studies, because they have gained wide acceptance 

for more than a decade by Congress, government agencies, researchers, and veteran 

groups. 

- Sufficient Evidence of a Causal Relationship. Evidence is sufficient to conclude 

that a causal relationship exists between the exposure to a specific agent and a 

health outcome in humans. The evidence fulfills the criteria for sufficient evidence 

of an association (below) and satisfies several of the criteria used to assess causality: 

Leonard.horne on VACREP0180 with DISTILLER

55 

strength of association, dose-response relationship, consistency of association, temporal relationship, specificity of association, and biological plausibility. 

- Sufficient Evidence of an Association. Evidence is sufficient to conclude that 

there is a positive association. That is, a positive association has been observed between an exposure to a specific agent and a health outcome in human studies in 

which chance, bias, and confounding could be ruled out with reasonable confidence. 

- Limited/Suggestive Evidence of an Association. Evidence is suggestive of an association between exposure to a specific agent and a health outcome in humans, but 

is limited because chance, bias, and confounding could not be ruled out with confidence. 

Gulf War and Health, Vol. 1, p. 84 [emphasis added] 

- Inadequate/Insufficient Evidence to Determine Whether an Association Does or 

Does Not Exist. The available studies are of insufficient quality, consistency, or statistical power to permit a conclusion regarding the presence or absence of an association between an exposure to a specific agent and a health outcome in humans. 

- Limited/Suggestive Evidence of No Association. There are several adequate studies, covering the full range of levels of exposure that humans are known to encounter, that are mutually consistent in not showing a positive association between exposure to a specific agent and a health outcome at any level of exposure. A conclusion 

of no association is inevitably limited to the conditions, levels of exposure, and 

length of observation covered by the available studies. In addition, the possibility 

of a very small elevation in risk at the levels of exposure studied can never be excluded. 

These five categories cover different degrees or levels of association, with the 

highest level being sufficient evidence of a causal relationship between exposure to 

a specific agent and a health outcome. The criteria for each category incorporate key 

points discussed earlier in this chapter. A recurring theme is that an association is 

more likely to be valid if it is possible to reduce or eliminate common sources of 

error in making inferences: chance, bias, and confounding. Accordingly, the criteria 

for each category express varying degrees of confidence based upon the extent to 

which it has been possible to exclude these sources of error. To infer a causal relationship from a body of evidence, the committee relied on long-standing criteria for 

assessing causation in epidemiology (Hill, 1971; Evans, 1976). 

COMMENTS ON INCREASED RISK OF ADVERSE HEALTH OUTCOMES 

AMONG GULF WAR VETERANS 

As discussed in the beginning of this chapter, the committee reviewed the available scientific evidence in the peer-reviewed literature in order to draw conclusions 

about associations between the agents of interest and adverse health effects in all 

populations. The committee placed its conclusions in categories that reflect the 

strength of the evidence for an association between exposure to the agent and 

health outcomes. The committee could not measure the likelihood that Gulf War 

veterans’ health problems are associated with or caused by these agents. To address 

this issue, the committee would need to compare the rates of health effects in Gulf 

War veterans exposed to the putative agents with the rates of those who were not 

exposed, which would require information about the agents to which individual veterans were exposed and their doses. However, as discussed throughout this report, 

there is a paucity of data regarding the actual agents and doses to which individual 

Gulf War veterans were exposed. Further, to answer questions about increased risk 

of illnesses in Gulf War veterans, it would also be important to know the degree 

to which any other differences beVeterans and Agent Orange: Update 1996, p. 97 [emphasis added] 

Summary Of The Evidence 

Categories of Association 

The categories of association used by the committee were those used in VAO. Consistent with the charge to the Secretary of Veterans Affairs in P.L. 102–4, the distinctions between the categories are based on ‘‘statistical association,’’ not on causality. Thus, standard criteria used in epidemiology for assessing causality (Hill, 

1971) do not strictly apply. The distinctions between the categories reflect the committee’s judgment that a statistical association would be found in a large, well-designed epidemiologic study of the outcome in question in which exposure to herbicides or dioxin was sufficiently high, well-characterized, and appropriately measured. The categories of association are: 

Leonard.horne on VACREP0180 with DISTILLER

56 

- Sufficient Evidence of an Association Evidence is sufficient to conclude that 

there is a positive association. That is, a positive association has been observed between herbicides and the outcome in studies in which chance, bias, and confounding 

could be ruled out with reasonable confidence. For example, if several small studies 

that are free from bias and confounding show an association that is consistent in 

magnitude and direction, there may be sufficient evidence for an association. 

- Limited/Suggestive Evidence of an Association Evidence is suggestive of an association between herbicides and the outcome but is limited because chance, bias, and 

confounding could not be ruled out with confidence. For example, at least one highquality study shows a positive association but the results of other studies are inconsistent. 

- Inadequate/Insufficient Evidence to Determine Whether an Association Exists 

The available studies are of insufficient quality, consistency, or statistical power to 

permit a conclusion regarding the presence or absence of an association. For example, studies fail to control for confounding, have inadequate exposure assessment, 

or fail to address latency. 

- Limited/Suggestive Evidence of No Association There are several adequate studies, cover the full range of levels of exposure that human beings are known to encounter, that are mutually consistent in not showing a positive association between 

exposure to herbicides and the outcome at any level of exposure. A conclusion of ‘‘no 

association’’ is inevitably limited to the conditions, level of exposure, and length of 

observation covered by the available studies. In addition, the possibility of a very 

small elevation in risk at the levels of exposure studied can never be excluded. 

Gulf War and Health, Vol. 1, p. 72 [emphasis added] 

studies often focus on one agent at a time, they more easily enable the study of 

chemical mixtures and their potential interactions. 

Research on health effects of toxic substance includes animal studies that characterize absorption, distribution, metabolism, elimination, and excretion. Animal studies may examine acute (short-term) exposures or chronic (long-term) exposures. Animal research may focus on the mechanism of action (i.e., how the toxin exerts its 

deleterious effects at the cellular and molecular levels). Mechanism-of-action (or 

mechanistic) studies encompass a range of laboratory approaches with whole animals and in vitro systems using tissues or cells from humans or animals. Also, 

structure-activity relationships, in which comparisons are made between the molecular structure and chemical and physical properties of a potential toxin versus a 

known toxin, are an important source of hypotheses about mechanism of action. 

In carrying out its charge, the committee used animal and other nonhuman studies in several ways, particularly as a marker for health effects that might be important for humans. If an agent, for example, was absorbed and deposited in specific 

tissues or organs (e.g., uranium deposition in bone and kidney), the committee 

looked especially closely for possible abnormalities at these sites in human studies. 

One of the problems with animal studies, however, is the difficulty of finding animal models to study symptoms that relate to uniquely human attributes, such as 

cognition, purposive behavior, and the perception of pain. With the exception of fatigue, many symptoms reported by veterans (e.g., headache, muscle or joint pain) 

are difficult to study in standard neurotoxicological tests in animals (OTA, 1990). 

For its evaluation and categorization of the degree of association between each exposure and a human health effect, however, the committee only used evidence from 

human studies. Nevertheless, the committee did use nonhuman studies as the basis 

for judgments about biologic plausibility, which is one of the criteria for establishing 

causation (see below). 

HUMAN STUDIES

EPIDEMIOLOGIC STUDIES

Epidemiology concerns itself with the relationship of various factors and conditions that determine the frequency and distribution of an infectious process, a disease, or a physiological state in human populations (Lilienfeld, 1978). Its focus on 

populations distinguishes it from other medical disciplines. Epidemiologic studies 

characterize the relationship between the agent, the environment, and the host and 

are useful for generating and testing hypotheses with respect to the association between exposure to an agent and health or disease. The following section describes 

the major types of epidemiologic studies considered by the committee. 

Leonard.horne on VACREP0180 with DISTILLER

57 

Leonard.horne on VACREP0180 with DISTILLER


Insert offset folio 18 here 25103.001

T!-;'E S!:CR ET ,I ilY OF \•FTFJIA 'IS Arr A!RS 

l"lASHINGTON 

harv~y F,neberg, IXD .. rh.D. 

P:V.5tc1ant 

11stitute of lvl ~;tlic e 

I h11 N;:ltJO:lal Ac.1damrfl~ 

500 Fif!l' Street, NW 

Vli <~snirlg on, OS 2Coi)01 

Dear Dr. Flr eb~ rg : 

J2m,;:.uy 1!4, 1!:)0:3 

f tlc t.:eparht ~en ' of -J dTl'~ .'\II;; irs npp c:;intc~ nr.d :espects the 

ex~ fe nt work -::umaineci ,n e Institute o' Medici.1e (!OM) report on "Gu 'f War 

Health." As }'Ou· know, this repon Y;as completed in 2.000 in response to a 

Cm qress tcnal rt:..>qUire:nent. H :e !OM, nt tha: lim!'. rr.vicwc·1 f! r1 !r~1 1 :1r.d 

sc ier.til ic Jit<Yatt.ne on the lleulth effe::ts of cerla 'n matt>riats, includi:lg Sarin, tt:al 

Gulf ·v,'ar ve:;rans rnay I: ave l)ean exposed to du.;ng the t991 Gut~ W ar. 

ece nll~· . a nun1ber cf r·ew stud.e-s ha'le l:ieen f::l.lblished on the efle::ts of 

Sarir. on laboratory ar.lmals. These studies have ra!s.ed ccncerru; witil G.1~ 'Nar 

vr,tn:'llm. nnr. o:hflf Am nr.<~nr. fll\} 'lrrtin(J lfll::! ~d rliun;h p u { llv:!Se $\Ltdies lo 

;:JOssil.Jle ~til lk lX!I'19elp_IE'<Ir;es of h:Jma:J expo!;U'"eS. 

Wrth this in m,oo, I <liT, rHtl:JP.,::;t.r'l!) IOtvl t•«::HHH::.' lhe trtel.lical aad sci~ntilic 

litEr3lure on health d'ects of &. rin pubr.siled since the 20-JO Report. I ask that 

10.\1 report bsc ); to VA .. as soon as pcssiblo:;, on whether' ;his r ew ffiS{<adt 

alf ;<;l~ . '""rlier cflrw·;l,,:;.:·""; of 101.~ . Spt.!t:..if;catl·~. l-Ithe jnlert>.:>t o f v0tcr~ns: heal'.h, 

we would !ike tc kr.e~w i.l ttois new <;;cien~flc information al:ers tt.e cc:-tclu.sions 

abovl p.:-ssible !eng-term h'ea!lh cor.sequencas o! «xoosur'e ro ;:;w _leve-1,:; ol S:Hin. 

We !r;ol< h.:rw;_mJ '·'-' !1t-:::e lin3 wilh you to discuss additronal speci1ics ar.d 

"·- uming for this report. :t I'OU have a'ly que <~ tions about thls request, plea&e 

cc:ntacr Or. S san r.1 .;~me r, Chief Oft ce r, Of lice of Public HcGI!h and 

Erwi ;c;.n rocnloJI aza d~. nt (202) :273-8575. 

' l 

{t~} I //' "-? J~ ---~/~-~-

~ 1 

,\,llltl'IY J . Pr t!t:'iJi 

29 
58 

Updated Literature Review of Sarin (2004), p. 20 [emphasis added] 

OP insecticide data in its conclusion, the committee reviewed the OP epidemiology 

literature. The committee responsible for GW2 (IOM, 2003a) reviewed the literature 

on OP compounds. The present committee reviewed relevant epidemiology studies 

published since the preparation of that report. 

Animal studies had a small role in the committee’s assessment of association between putative agents and health outcomes. As with previous committees, this committee used animal data for making assessments of biologic plausibility in support 

of the epidemiologic data rather than as part of the weight of evidence to determine 

the likelihood that an exposure to a specific agent might cause a long-term outcome. 

The committee classified the evidence of an association between exposure to sarin 

and cyclosarin and a specific health outcome into five categories (Box 1–1). The categories closely resemble those used by previous committees that evaluated the effects of chemicals related to the Gulf War (IOM, 2000a, 2003a) and those used by 

several IOM committees that have evaluated vaccine safety (IOM, 1991, 1994a), herbicides used in Vietnam (IOM, 1994b, 1996, 1999, 2001, 2003b), and indoor pollutants related to asthma (IOM, 2000b). The committee’s conclusions, presented in 

Chapter 4, represent its collective judgment. 

The committee endeavored to express its judgment as clearly and precisely as the 

available data allowed, and it used the established categories of association from 

previous IOM studies because they have gained wide acceptance over more 

BOX 1–1fi CATEGORIES OF EVIDENCE

Sufficient Evidence of a Causal Relationship 

Evidence from available studies is sufficient to conclude that a causal relationship 

exists between exposure to a specific agent and a specific health outcome in humans, and the evidence is supported by experimental data. The evidence fulfills the 

guidelines for sufficient evidence of an association (below) and satisfies several of 

the guidelines used to assess causality: strength of association, dose-response relationship, consistency of association, biologic plausibility, and a temporal relationship. 

Sufficient Evidence of an Association 

Evidence from available studies is sufficient to conclude that there is a positive 

association. A consistent positive association has been observed between exposure 

to a specific agent and a specific health outcome in human studies in which chance1 

and bias, including confounding, could be ruled out with reasonable confidence. For 

example, several high-quality studies report consistent positive associations, and the 

studies are sufficiently free of bias, including adequate control for confounding. 

Leonard.horne on VACREP0180 with DISTILLER

59 

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q~s of~rmcn: w U:c Per:.ir.n Gulf. .Most nc~1bly, !~ Tns[J.c::: tial AO.vip-ory Couuiz.ittec 

c.u. C.J."JJ.i..:' Wa: \'eterwrf Illness~" (PAC'l •>ia' e~~blisl:cd 'J)' Pres:! don Chntoo ;,. 1by I !'»95. The 

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r

. md ~rhi<t.:y md JOOI!.:i.lizy. Srlb.cq-J~tl v, t'.>,o puhliG bows (J'.~ 105-368 o:nd P.L.. 105-217) 

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r~vk\!. ~ un L<e pl.l~~liVc a~ents and 1<i u~t-mnirv. p05S'.bl.e b.ealtb Ololrx>m!'.'l r~lat.......l lo tbo..~':. ,g::n(:s . 

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cof1Clt:m'l.. tb:.l "'~ •'j)d..Jcd o:..~ilr. hmioo o: ~.a, "nile cond1.1ctc:d. Tbj:; p1o;msat is f;,. k s:arUJ 

up<Wconly 

33 
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Leonard.horne on VACREP0180 with DISTILLER


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T'LAN OF ACnO:'-i 

SUV.'OWlt of Task 

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u tliU2Ttrl Exptn<llturcs 

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34 
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35 
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Leonard.horne on VACREP0180 with DISTILLER


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65 

APPENDIX B 

LETTER TO IOM PRESIDENT REGARDING IMBALANCED MEMBERSHIP OF 2016 REPORT

COMMITTEE

November 28, 2014 

Dr. Victor J. Dzau, M.D. 

President 

Institute of Medicine 

500 Fifth St., NW ? 

Washington, DC 20001 

Dear Dr. Dzau, 

As former members of the VA Research Advisory Committee on Gulf War Veterans Illnesses, we are gravely concerned by the makeup of the committee that IOM 

staff has chosen for the upcoming review of Gulf War health literature. The membership is grossly imbalanced toward the 1990’s government position that Gulf War 

veterans have no special health problem - just what happens after every war, related to psychiatric issues, and not environmental exposures. 

Reviving this discredited fiction will cause veterans’ doctors to prescribe inappropriate psychiatric medications, and will misdirect research to find effective treatments down blind alleys - an unconscionable breach of the duty owed to veterans 

and expected of the Institute of Medicine. 

Science has conclusively demonstrated that this government position has no scientific validity. Just four years ago, an IOM committee chaired by Dr. Stephen 

Hauser, former president of the American Neurological Association, reviewed the 

scientific literature and concluded that the chronic multisymptom illness suffered by 

an estimated 250,000 Gulf War veterans (over one-third of the 697,000 who deployed) is a physical illness associated with Gulf War service, a ‘‘diagnostic entity’’ 

that ‘‘cannot be reliably ascribed to any known psychiatric disorder,’’ and that ‘‘it 

is likely that Gulf War illness results from an interplay of genetic and environmental factors.’’ http://books.nap.edu/openbook.php?record—id=12835, pages 262, 

210, 204, 109, 261 

These conclusions reinforced the similar findings and recommendations of our 

former committee’s 452-page 2008 report. Our committee went further to identify 

the specific environmental exposures responsible, including pesticides, 

pyridostigmine bromide pills given to troops as a prophylaxis against nerve gas, and 

possibly low level nerve gas released by the destruction of Iraqi facilities, oil well 

fires, and multiple vaccinations. In April 2014, our committee published an update 

report which concluded that ‘‘[s]cientific research published since . 2008 . supports 

and further substantiates the conclusions of the 2008 report.’’ http://www.va.gov/ 

RAC–GWVI/RACReport2014Final.pdf, page 5 

Yet, as the attached analysis shows, fully half the individuals selected for the new 

committee are predisposed toward the discredited 1990’s government position, either 

because they promoted it themselves, or because they are professionally oriented to 

view such problems as psychiatric and/or unrelated to environmental exposures. The 

rest of the committee are neutral figures with a background in other neurological 

conditions like Alzheimer’s disease and traumatic brain injuries. No member of the 

committee has been actively engaged in Gulf War health research in the past decade. 

Given that the committee is charged with producing a consensus report, it is 

wholly foreseeable that its conclusions will end up between the group predisposed 

to 1990’s fictions and those who are neutral but unfamiliar with the subject. Compared to the 2010 IOM report, it will be a reversal toward the discredited 1990’s 

position. 

For three years, VA has been engaged in a surreptitious campaign to revive the 

1990’s government position. Since no scientific support for the position exists, VA 

staff has resorted to manipulating Gulf War research and reports. The Research Advisory Committee has documented this manipulation in forty-six pages of findings 

and recommendations in June 2012 and in a draft section of its April 2014 report 

which had to be removed because VA eliminated the committee’s oversight authority. http://www.va.gov/RAC–GWVI/docs/Committee—Documents/ 

CommitteeDocJune2012.pdf https://veterans.house.gov/sites/republicans.veterans.house.gov/files/Binns%2C%20ExhibitBtestimony.pdf 

In September, VA’s Director of Epidemiology, Dr. Robert Bossarte, and his staff 

presented findings of two new VA studies to the Research Advisory Committee. One 

showed that diagnoses given to Gulf War veterans in VA hospitals over a ten-year 

period were no different than those given to veterans of the same era who did not 

Leonard.horne on VACREP0180 with DISTILLER

66 

deploy. The other, a large survey, showed that rates of PTSD and depression were 

dramatically higher than previously reported by Gulf War veterans. 

To an inexperienced observer, it might seem that the research on Gulf War veterans’ health was changing. However, Research Advisory Committee members 

quickly pointed out that Dr. Bossarte and his staff were not telling the whole story. 

http://www.va.gov/RAC–GWVI/RAC—Recommendation092314.pdf 

The diagnoses study presentation failed to mention that VA had no diagnostic 

code for Gulf War illness or chronic multisymptom illness, that VA doctors at this 

time were trained to consider the illness as psychosomatic, and that veterans who 

served during the period of greatest toxic exposures were inexplicably excluded from 

the study. Similarly, the survey presentation did not disclose that the survey was 

overweighted with mental health questions to the extent that the Committee had 

repeatedly recommended against sending it out, http://www.va.gov/RAC–GWVI/docs/ 

Committee—Documents/CommitteeDocJune2012.pdf, Appendix F, and that the survey’s principal investigator had testified to Congress that his superiors lied to thenVA Chief of Staff John Gingrich to induce him to release the survey. https://veterans.house.gov/witness-testimony/dr-steven-s-coughlin The presentation did not 

mention that people suffering from chronic health problems often become depressed 

after 23 years, but it is not the cause of their illness. 

Dr. Bossarte and his staff will be presenting to the new IOM committee on December 3. Very likely they will be presenting their new research findings. But no 

one on the IOM committee will know that they are not being told the whole story, 

because there are no members with the necessary background. Thus, misleading VA 

studies will be presented to an imbalanced IOM committee, which will include the 

findings in its new report, and science will be ‘‘revised’’. 

The motivation behind VA’s manipulation of science is clear: to hold down benefits 

costs and claims wait times. In April, Military Times reported that VA Undersecretary for Benefits Allison Hickey was concerned that even using the term ‘‘Gulf War 

illness’’ ‘‘might imply a causal link between service in the Gulf and poor health 

which could necessitate legislation for disability compensation for veterans who 

served in the Gulf.’’ http://archive.militarytimes.com/article/20140422/BENEFITS04/ 

304220036/Top-VA-official-questions-use-term-Gulf-War-illnessShe also recently testified to Congress that VA would meet its 2015 claims processing target of 125 days unless she had to add a quarter million new claims to her 

inventory overnight, as happened in 2010 when Agent Orange coverage was expanded: ‘‘That will kill us.’’ http://www.veterans.senate.gov/hearings/va-claims-system-review-of-vas-transformation-progress [1:38:50 mark] 

While VA says that it provides care and benefits to veterans suffering from Gulf 

War illness under the category ‘‘undiagnosed illnesses,’’ http:// 

www.publichealth.va.gov/exposures/gulfwar/medically-unexplained-illness.asp, the 

reality is otherwise. A 2014 VA report to Congress revealed that only 11,216 Gulf 

War-related claims have been approved, while 80 percent are denied. http:// 

www.scribd.com/doc/241661207/Binns-Parting-Thoughts-093014, page 7. VA’s September 2014 press release that ‘‘nearly 800,000 Gulf War era Veterans are receiving 

compensation benefits for service-connected issues’’ is grossly misleading. http:// 

www.91outcomes.com/2014/09/va-press-release-va-secretary-mcdonald.html VA 

counts every veteran in the area from 1990 to the present as ‘‘Gulf War era,’’ not 

just those who served in 1990–91. 

We are appalled that the government has been able to influence the workings of 

the Institute of Medicine, the most revered institution in American medical science, 

to further its shameful campaign to manipulate science to deny veterans care and 

benefits. Regrettably, however, we are not surprised, as this has been more common 

than not where Gulf War veterans’ health has been concerned. For example: 

1. For fourteen years, in response to a law passed by Congress in 1998, VA has 

ordered and the IOM has prepared reports on the health effects of thirty-three toxic 

substances to which Gulf War veterans were exposed. The law repeatedly specified 

that the reports must consider studies in both humans and in animals. For fourteen 

years, however, these IOM reports have considered only human studies. To do this, 

VA and the IOM not only have had to disregard the law; they also had to manipulate the standard established in the IOM reports on Agent Orange, inserting the 

word ‘‘human’’ in the standard. As a result, since most research studies of toxic substances are necessarily done in animals, these IOM Gulf War reports have never 

found sufficient evidence of an association between these substances and Gulf War 

veterans’ health problems. In turn, VA has never recognized any toxic exposure as 

a reason for granting these ill veterans care and benefits. https://veterans.house.gov/ 

witness-testimony/james-h-binns-0 

2. The most egregious of these IOM Gulf War reports was the Updated Literature 

Review of Sarin, in which animal studies were not considered even though new aniLeonard.horne on VACREP0180 with DISTILLER

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mal studies were the only reason that then-Secretary Principi ordered the report. 

The outcome of the report was predetermined before the VA–IOM contract was ever 

signed, by understandings between VA and IOM staff discussed in a cover letter 

from the then executive director of the IOM to the then head of the VA Environmental Agents Service. https://veterans.house.gov/witness-testimony/james-h-binns-0 

3. The Research Advisory Committee recommended in 2008 that these IOM reports be redone in accordance with the law. http://www.va.gov/RAC–GWVI/docs/ 

Committee—Documents/GWIandHealthofGWVeterans—RAC–GWVIReport— 

2008.pdf, pages 53–55, 57. However, they have not been redone. Worse, the manipulated standard is now being employed in VA-ordered IOM studies of the health of 

post-9/11 veterans. The 2011 IOM report on the long-term health effects of burn pits 

used to incinerate waste in Iraq and Afghanistan used the manipulated Gulf War 

standard (limited to human studies), not the Agent Orange standard. As a consequence, the IOM burn pits committee found ‘‘inadequate/insufficient evidence of 

an association between exposure to combustion products and cancer, respiratory disease, circulatory disease, neurologic disease, and adverse reproductive and developmental outcomes.’’ http://books.nap.edu/openbook.php?record—id=13209&page=6 

4. In 2006, the IOM did a general Gulf War literature review for VA, similar to 

the current task. Most of the report was a straightforward summary of the research, 

but IOM’s press release and press conference focused on one conclusion that echoed 

the familiar government theme that there is ‘‘no unique Gulf War syndrome.’’ Technically, this only means that others have similar symptoms, but the press release 

and conference spun the message to imply that Gulf War veterans have no major 

health problem. http://www.nbcnews.com/id/14801666/ns/health-health—care/t/ 

study-gulf-war-syndrome-doesnt-exist/#.VHLDjUuBNH8 

5. The 2013 IOM treatments report was a recent glaring example of VA and IOM 

collaboration to disregard the law and promote the 1990’s government position. A 

2010 law required VA to contract with the IOM for a comprehensive review of the 

best treatments for ill Gulf War veterans by a group of doctors experienced in treating Gulf War veterans ‘‘diagnosed with chronic multisymptom illness or another 

health condition related to chemical and environmental exposures that may have occurred during [their] service.’’ 

Instead, VA contracted for a literature review of treatments for all ‘‘populations 

with a similar constellation of symptoms,’’ and the IOM appointed a committee with 

no experience in treating Gulf War veterans but extensive experience in psychiatric 

and psychosomatic medicine—though the 2010 IOM report had just concluded that 

the illness ‘‘cannot be ascribed to any known psychiatric disorder.’’ Analysishttps:// 

veterans.house.gov/sites/republicans.veterans.house.gov/files/ 

Binns%2C%20ExhibitBtestimony.pdf http://www.scribd.com/doc/150949964/WHITE– 

PAPER–IOM–CMI–Panel-MembershipThe individuals selected to give background briefings to the committee were largely familiar advocates for the 1990’s position, who told the committee the problem 

was psychiatric. http://www.va.gov/RAC–GWVI/docs/Committee—Documents/ 

CommitteeDocJune2012.pdf, pages 24–30. Half the illnesses whose therapies were 

reviewed were psychiatric. The report revived 1990’s themes that that ‘‘[t]hroughout 

modern history, many soldiers returning from combat have experienced postcombat 

illnesses. . . that cannot now be attributed to any diagnosable pathophysiologic entity or disease,’’ and that ‘‘[c]linicians should approach [chronic multisymptom illness] 

with ‘a person-centered model of care . . . that helps patients understand that the 

word psychosomatic is not pejorative.’’’ https://veterans.house.gov/sites/republicans.veterans.house.gov/files/Binns%2C%20ExhibitBtestimony.pdf 

6. The person who identified the individuals to be invited to brief the treatment 

committee was the chief scientist of the VA Office of Public Health, according to 

Congressional testimony by a senior VA epidemiologist who worked for him. https:// 

veterans.house.gov/witness-testimony/dr-steven-s-coughlin 

7. One of the psychiatric-oriented briefers was a member of the IOM Board on 

the Health of Select Populations, the IOM board that oversees veterans’ studies. Dr. 

Kurt Kroenke, an Army doctor and psychiatric-oriented Gulf War researcher in the 

1990’s, is a leading figure in somatic medicine. He co-chaired the ‘‘Conceptual Issues 

in Somatoform and Similar Disorders’’ project that laid the groundwork for the controversial expansion of the definition of somatoform disorders in the recently revised 

Diagnostic and Statistical Manual of Mental Disorders (DSM–5) of the American 

Psychiatric Association. http://www.ncbi.nlm.nih.gov/pubmed/17600162 http:// 

dxrevisionwatch.com/dsm-5-drafts/dsm-5-ssd-work-group/ He has co-authored publications with two members of the IOM treatment committee and two members of the 

new IOM committee that begins work December 3. 

8. Two other members of the IOM Board of the Health of Select Populations were 

also leading proponents of the government position on Gulf War health in the 

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1990’s. Dr. Francis Murphy held the position equivalent to chief scientist in VA’s 

Office of Public Health, and Dr. Greg Gray was a Navy doctor who published numerous papers in 1996–2001 that dismissed the idea that Gulf War veterans have 

any special health problems. Conversely, as of June 2013, no one on the IOM Board 

of the Health of Select Populations represented current scientific understanding of 

Gulf War illness. http://www.scribd.com/doc/150949964/WHITE–PAPER–IOM–CMI– 

Panel-Membership-Analysis. It is currently undisclosed who serves on this board, as 

its membership has been removed from the IOM website, although the membership 

of all other IOM boards continues to be listed. http://www.iom.edu/About-IOM/Leadership-Staff/Boards.aspx 

In summary, there has been a long-term corrupt relationship between the government and the Institute of Medicine to deny the true state of Gulf War veterans’ 

health, of which the makeup of the new committee is only the latest example. 

We are confident that neither you nor VA Secretary McDonald, as newcomers to 

Washington and to your respective institutions, is aware of this problem. At one 

point, none of us would have believed it possible either. But it is a cancer that 

threatens to destroy the integrity and reputations of both organizations. And it 

makes a mockery of the mission of the IOM ‘‘to provide unbiased and authoritative 

advice to decision makers and the public.’’ http://www.iom.edu/About-IOM.aspx 

We urge you to conduct a thorough investigation of this problem and to fix it. The 

most effective and rapid approach is for the IOM to handle this itself. If it does not, 

however, we will work with veterans’ organizations to show Congress the need to 

conduct an investigation and enact legislative solutions. 

As part of putting IOM on solid ground going forward, we urge you to replace the 

eight provisional members predisposed to the government’s scientifically discredited 

1990’s position with individuals representing current scientific knowledge of Gulf 

War research and the health effects of neurotoxic exposures. We also urge you to 

replace those members of the Board on the Health of Select Populations identified 

with this position, with individuals representing current scientific knowledge regarding veterans’ health and environmental exposures. 

Respectfully, 

James Binns 

Former Chairman, Research Advisory Committee on Gulf War Veterans Illnesses 

Beatrice A. Golomb, MD, PhD 

Professor of Medicine, University of California San Diego 

Current Member, Research Advisory Committee; former Committee Scientific Director 

Rev. Joel C. Graves, DMin, 

CPT U.S. Army (Ret.) 

Former Member, Research Advisory Committee 

Marguerite L. Knox, MN, ARNP–FNP/ACNP 

COL, South Carolina Army National Guard 

Former Member, Research Advisory Committee 

William J. Meggs, MD, PhD 

Professor and Chief, Division of Toxicology, Brody School of Medicine, East Carolina University 

Former Member, Research Advisory Committee 

cc: Institute of Medicine Council 

Analysis of the Provisional Committee Membership 

November, 2014 

The provisional committee is grossly imbalanced in favor of the 1990’s government 

position that Gulf War veterans have no special health problem-just what happens 

after every war, related to psychiatric issues, and not environmental exposures. 

The following committee members are predisposed toward this position, either because they personally supported it, or because they are professionally oriented to 

view these kinds of health problems as psychiatric and unrelated to environmental 

exposures. 

Dr. Kenneth Kizer, as VA Undersecretary for Health, 1994–1999, was the chief 

promulgator of this position, including this 1997 Congressional testimony: ‘‘The 

overall frequency of unexplained symptoms among Gulf War veterans appears to be 

about the same as in a general medical practice.’’ http://www.va.gov/OCA/testimony/ 

hvac/sh/hvac61.asp 

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Dr. Howard Kipen, a member of the VA Persian Gulf Expert Scientific Committee, 

1993–1997, has published ‘‘Military deployment to the Gulf War as a risk factor for 

psychiatric illness among U.S. troops’’ (2005) http://bjp.rcpsych.org/content/188/5/ 

453.long and that ‘‘[c]oncerns . . . of a unique Gulf War syndrome, remind us that 

military personnel returning from wars have regularly described disabling symptoms’’ (co-authored with Dr. Kroenke). Unexplained Symptoms after Terrorism and 

War: An Expert Consensus Statement. Journal of Occupational and Environmental 

Medicine 45(10):1040–8, 2003 

Dr. Herman Gibb runs a private consulting firm. The NIH reportedly terminated 

its contract with his previous firm, while he was president, on grounds that his firm 

was working for three chemical companies at the same time it was reviewing their 

chemicals for the government. http://www.washingtonpost.com/wp-dyn/content/article/2007/04/13/AR2007041301979.html 

Dr. Nancy Woods is an expert on midlife and aging women’s health; her background relevant to Gulf War illness was as a member of the IOM committee that 

authored a 1996 report, ‘‘The Health Consequences of Service During the Persian 

Gulf War,’’ which concluded: ‘‘Men and women served side by side in conditions that 

increased the stresses of serving in these grim surroundings . . . Studies of Gulf War 

veterans suggest that these veterans suffer from a variety of recognized diseases, 

. . . not the existence of a new disease. ‘‘ http://books.nap.edu/openbook.php?record— 

id=5272&page=R6 

Dr. Javier Escobar is a professor of psychiatry at the Robert Wood Johnson Medical School, where his work ‘‘focuses on the somatic presentations of psychiatric disorders in primary care . . . as director of the ‘Medically Unexplained Physical Symptoms Research Center.’’’ http://www.physicianfacultyscholars.org/nac/escobar.html 

With Dr. Kroenke he was a member of the ‘‘Conceptual Issues in Somatoform and 

Similar Disorders’’ project that laid the groundwork for the controversial expansion 

of the definition of somatoform disorders in the recently revised Diagnostic and Statistical Manual of Mental Disorders (DSM–5) of the American Psychiatric Association, and was a member of the task force that wrote DSM–5. http:// 

www.ncbi.nlm.nih.gov/pubmed/17600162 http://dxrevisionwatch.com/dsm-5-drafts/ 

dsm-5-ssd-work-group/ http://www.dsm5.org/MeetUs/Pages/TaskForceMembers.aspx 

He was a member of the 2013 IOM treatment report committee. 

Dr. Scott Fishman is board certified in psychiatry and pain medicine. His research 

includes a focus on ‘‘psychiatric issues of chronic illness and pain.’’ http:// 

www.ucdmc.ucdavis.edu/publish/facultybio/search/faculty/508 

Dr. Alberto Caban-Martinez studies musculoskeletal pain in workers related to 

their occupational risk factors. http://www.cabanmartinezlab.com/#!about/c46c He 

has studied ‘‘The prevalence of Somatic Disfunctions in a Multi-Center Outpatient 

Osteopathic Medicine Clinic’’ http://nhsn.med.miami.edu/documents/cv/a— 

cabanmartinez—cv—09.pdf and has published that ‘‘[c]onstruction workers struggle 

with a high prevalence of mental distress, and this is associated with their pain and 

injuries.’’ J Occup Environ Med 2013 Oct;55(10):1197–204 

Dr. Deborah Cory-Slecta, the committee chair, has not done Gulf War health research herself but stated in 2013, in connection with service on another IOM Gulf 

War committee, that she does not believe Gulf War illness research has produced 

adequate data to show what caused the illness. http://www.forbes.com/sites/ 

rebeccaruiz/2014/03/12/experts-cant-decide-on-definition-for-gulf-war-illness/ She also 

served on the 2003 IOM Gulf War committee that concluded there was insufficient 

evidence to show an association between any illness affecting Gulf War veterans and 

exposure to pesticides, applying the manipulated standard that excluded animal 

studies. http://www.nap.edu/openbook.php?record—id=10628&page=R5 

The other half of the committee are neutral, people who have not been engaged 

in Gulf War health research themselves, but who have a background in studying 

other neurological conditions and expertise in relevant subjects like neuroimaging, 

neuropsychology, and neuroepidemiology. They include Dr. Robert Brown, Dr. Ellen 

Eisen, Dr. Mary Fox, Dr. Clifford Jack, Dr. Joel Kramer, Dr. Francine Laden, Dr. 

James Noble, and Dr. Anbesaw Selassie. 

Conspicuously absent from the committee are any doctors or scientists who have 

studied Gulf War health in the past decade, who have studied or treated other 

groups subjected to neurotoxic exposures like farmers or pesticide applicators, or 

who have studied the effects of Gulf War exposures in animals. 

f 

MONTRA DENISE NICHOLS 

Submitted by Montra Denise Nichols, MAJ USAFR(RET), RN(ret), MSN 

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Vice Chair of National Vietnam and Gulf War Veterans Coalition 

Good afternoon Committee members and Veterans. I am Montra Denise Nichols,Maj, Retired USAF NURSE, Gulf War veteran and Vice Chairman of National 

Vietnam and Gulf War Veterans Coalition. I am also one of the ill gulf war veterans. I have attended all but two of the VA RAC GWIR meetings except for 2, attended all the VA advisory committee meetings on Gulf War Health and Benefits, 

have attended in person or by phone the IOM NAS public meetings on GWI, served 

on the first DOD–CDMRP Peer review process at DOD CDMRP, PAC meetings, 

PSOB meeting, town hall meetings by OSIGWI meetings, CDC meeting in 1999, 

hearings on the hill and have testified in person or by written submission since 

1994, and in addition have attended medical conferences that have direct connections to our illnesses. I have also participated in 8 research projects as a research 

subject for 6 researchers on gulf war illness. Ialso was listed as a coauthor on the 

Hypercoagulation peer reviewed paper published in 2000. 

Over the last 22 years since our return home from Operation Desert Storm we 

have continued to advocate for all gulf war veterans that are ill. It has been a long 

trudge through this mass of activity and now our journey that seems to have a perpetual loop between VA , Institute of Medicine reports from the National Academy 

of Science, hearings here on the hill on an irregular basis, and the VA RAC GWIR. 

It is disappointing to say the least that the situation never seems to get on the 

Right Path to unify and address the real physical damage that veterans of Operation Desert Storm encountered after toxic exposures. The VA RAC GWIR and the 

DOD CDMRP has been the leaders in this effort to get answers thru real medical 

research to find the right diagnostic tests, biomarkers and finally real treatment options that are not palliative. The VA seems to be the road block over and over. The 

veterans of the gulf war are suffering because of the Actions of the VA or shall I 

say the INACTION. I have witnessed first hand how the VA RAC GWIR Advisory 

committee has labored since 2002 and have seen the intransigent activity of the VA. 

This is occurring at the top and seen clearly at the bottom re the clinical care of 

the gulf war veterans or the lack thereof and there is a problem that has not been 

solved for 22 years. I left the VA angry when my female hematologist primary care 

told me her hands were tied, and she even got tears in her eyes. I left because I 

both in the information on the hypercoagulation problem that I feel as a nurse can 

relate to early needless deaths of gulf war veterans who are ill. I had my own test 

results and she would not call the Drs and researchers that had done this study 

independently. They were concerned about my own elevated values and had suggested treatment that she refused to consider. What really made me madder was 

when I found out the editor of that journal that published our peer review research 

was the head of the VA lab at the Denver VA the one I was going to for care. That 

was in 2000. Since then I have tried to go back to the VA and told during 2003– 

4 time period it would take 6 months to a year to get an appointment. I continued 

as many of us have to suffered and seek care when I could. I was lucky to have 

health care insurance through my husband but I lived in fear of loosing it if they 

the doctors deemed it war related. I certainy did not want to risk the insurance we 

had for my husband and my child. I struggle finding doctors that want to delve into 

this because they also do not have the knowledge on toxic exposure effects and they 

are hesitant to get involved when their might be government forces at work. I know 

the doctors that have suffered retaliation from the VA for trying to help, I know 

some of the researchers that are hesitant also because of that same potential, and 

we even had a county corner fired when she ruled a death of a veteran due to gulf 

war exposures. I have had a benefactor that helped several veterans get care 

through environmental medicine doctors, and I return to them when I can afford 

to travel and pay out of pocket for their fees and tests. I know of other civilian doctors I would like to get to but again it involves travel and cost factors. I was recruited for research at WRIIS at DC and received good research testing and caring 

doctors but yet they did not put me through the 2 day WRIIS protocol. I have said 

I will pay for my travel but I want to get thru that evaluation, I am being denied 

that until I can get back into the VA medical appointment system in Denver and 

get a doctor to refer me to WRIIS. And since what I got was research those test 

have not been entered in my record, I was told yes I failed the testing which to me 

was no big surprise. But it doesn’t help with getting further care or a claim that 

is service connected. 

I have participated in research projects and even recruited others to participate 

and know the researchers are finding clues and when their papers are published 

-those results will help hopefully to better diagnosis and treatment potentials. But 

when doctors are not being educated on those findings then the interface with research and care is failing. 

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We the veterans see the continued battles that have occurred thru the years. It 

is a shame and a disgrace that the VA has not taken the advice of the RAC GWIR. 

That interference has stymied for years the beneficial work of scientific researchers, 

doctors, and researchers. It has blocked actively the improvements that could of 

have been made over the last 22 years in the actual clinical care that could have 

made a difference in the quality of care, diagnostic abilities, and yes real treatment. 

And yes they could have saved countless lives of gulf war veterans that have died 

in an early age group under the age of 50! 

I was one of roughly 20 fellow veterans that took part in the public meetings of 

the last IOM/NAS report. Each offered public comment and offered the IOM committee real insight into our situation. ALL of us were in anguish listening to their 

first public meeting that concentrated on the psychology-stress aspect yet again! 

After listening, then offering public comment, and debriefing with my fellow ill veterans and spouses that were on line, I immediately called the chairman of the VA 

RAC GWIR, Mr. Binns. I wanted to give him our feedback, what had been covered, 

and our very deep concerns that this marked yet again a back tracking effort on 

the part of the VA that institutes the charter and guidance when they contract a 

literature review from the IOM/NAS. It was like all the work that had been done 

on gulf war illness research had not even been considered. 

Our input seemed to not even be heard. These committee members I wonder if 

they have ever seen and cared for even 100 of the gulf war vets with the multitude 

of health issues. After 22 years and excellent research from outstanding doctors and 

researchers that had proven that physical damage has occurred to hundreds of thousands of veterans it appeared we were back to step one all over again. The IOM/ 

NAS never ever in their hearings heard presentations from the doctors and researchers that have studied us or group of gulf war veterans to be able to comprehend their findings. This is wrong. 

Their definition the IOM committee used is so broad that it creates confusion yet 

again. Patients that have had chemotherapy could easily fit the definition and have 

had no military exposures much less other categories of patients. This definition 

does not even have relevance to the definitions already being used for the RAC 

GWIR reports of 04-thru current year. They did not even utilize guidance that the 

DOD CDMRP process has used since 2006 in peer review and awarding of gulf war 

illness research. Their definition truly creates havoc in the work that has been developed by researchers over the past 10 years. The IOM NAS committee did not 

hear from the range of researchers that have been involved thru the years examples 

include UTSW Medical , Wright State, University of Miami, to name just a few. 

Again and again the VA and IOM/NAS work seems to set us further behind in 

the goals to get better diagnostic testing of gulf war veterans who have suffered for 

22 yrs. The goal of getting true treatment gets pushed back yet again. Right now 

we basically have COQ10(that the VA hospitals will not provide) and CPAP (used 

in sleep apnea) as real physical treatment. I put acupuncture and cognitive behavior 

techniques as supportive palliative treatment. As an analogy I would use a cardiac 

patient with significant blockages of the cardiac arteries that need stents/bypass/ 

medications being ordered to just use exercise, acupuncture, and stress reduction as 

their total care. The situation is dire. 

More and more of the results from research are showing significant damage to the 

brain and the autonomic nervous system. This should help make sense of what 

health care providers are seeing at each VA hospital. When you have brain and autonomic nervous system and hypercoagulation of the blood involved it affects every 

other organ in the body. 

The care of our gulf war veterans is impacted by the VA that still resists the significance of the damage done to hundreds of thousands of gulf war veterans. When 

the doctors and health care providers are not updated/educated on all the significance findings of this effort in research it is truly unacceptable. When the veteran 

patient/client is even providing hand carried copies of the reports and research papers to their health care provider at the VA and for those efforts to be ignored is 

truly showing some type of mind set to ignore, delay, and deny. The VA even when 

they have misspent money on conferences in the past number of years have not 

even focused on education for the clinicians on what is being found in research on 

gulf war illness and seeking to institute a true intergradation of research into the 

clinical practice of health care providers that are seeing the gulf war veterans who 

are ill daily. Legislation is needed. 

The clinicians on the whole don’t even know of the WRIISC and the referral method that shows you why most veterans give their health care provider a D or F in 

grading. The clinicians could also be asked to give feedback to the RAC GWIR or 

headquarters VA Health care on information and findings they are finding on their 

gulf war veterans but that is not done. There is no interface between the VA health 

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care providers and the Researchers and Doctors that have worked with gulf war veterans in civilian or VA practice. This needs urgent action at the highest priority! 

It is unconscionable to see that some gulf war veterans have found civilian doctors 

and resources that can do testing and help gulf war veterans but the majority of 

gulf war veterans cannot pay out of their pocket to travel and get to these doctors 

and pay those civilian doctors. WE know there are places like the Mayo Clinic that 

can provide autonomic nervous system testing but 99% cannot get that important 

testing. The VA has not had training programs or the equipment in order to perform 

this testing. There is now a commercially available test for the hypercoagulation 

problem that was first researched and published in 2000, and we have research currently on that area by Dr. Bach at VA Minneapolis on this topic. Again a critical 

need that could possibly save gulf war veterans lives from pulmonary embolism, cardiac incidents, strokes, deep vein thrombus, and other death potential diagnoses. 

Where is the priority to truly help gulf war veterans and get the diagnostic testing 

and lifesaving treatment? Legislation is needed. 

Then we have only 3 WRIIS serving as second opinion but there are hundreds 

of thousands of gulf war veterans not getting the highest quality of care that should 

be available at each VA hospital or at least one in each VA region. The majority 

of the veterans asked said their VA primary care personnel had no knowledge of 

gulf war related illnesses and physical problems. The veterans that gave an A or 

a B were the ones that had gotten to the WRIIS or had struggled to get a change 

of doctor or a referral to a specialist like rheumatology. (these are still in the low 

minority , seeing that the WRIIS only see limited number of gulf war veterans(2 

a week)) . When asked to grade the education of the providers on exposures and 

effects, gulf war illness, and care from the VA providers the grades given were predominately D and F. 

Additionally care also involves helping the spouse or loved one trying to take care 

of the veteran at home. Unfortunately, although we served in Iraq as did the current OIF, OEF veterans no provision was made to cover caregivers for the Operation 

Desert Storm Veterans of 1990–91. A percentage of our veterans need that help too! 

The spouses are suffering and trying to be the bread winners of the family while 

caring for their adult veteran spouse that have become housebound to varying degrees. With the significant neurocognitive, the debilitating CFIDS, or development 

of MS, Cancers, or other devastating illnesses in a group of younger veterans below 

the age of 50 there needs to be consideration to including the spouses from 1990– 

91 who may still have young children school age at home( and some of these have 

developmental type problems.) The door to caregiver assistance needs to be consider 

for these cases including ALS veterans. Legislative effort will be needed to amend 

that law. 

The need is there for the providers of health care in the VA to have the gulf war 

veterans seen by designated trained physicians at each VA hospital/clinic. WE need 

our gulf war clinics back that we had in the nineties. WE need to have support 

groups at each VA hospital for gulf war veterans and their spouses with care providers and social workers. WE need gulf war veteran task forces at each VA or at 

least at one VA hospital in the state to have the interaction that is needed to be 

heard and improvements made. Legislation will be needed. 

WE need an active sharing of data on deaths, age, unit, cause of death and statistics in comparison to the normal non- military age groups. This is needed for our 

researchers and for us the veterans. This will need legislation. 

WE need a robust accounting like we had with GWVIS data that is produced 

every three months. The data needs to show diagnoses and ages. Again researchers 

and veterans need this information. Legislation will be needed. 

WE need to have you all reconsider registry for the family members that feel their 

symptoms are the same as the veterans. WE had that in the ninties but it was allowed to expire time wise. Again legislation needed. 

WE need the VA to hire consultants in the area of environmental medicine and 

integrative medicine to be involved in updating the VA system in dealing with exposures effects. Again legislation will be needed. 

WE need all data from the DOD declassified. It has been 22yrs and some of that 

massive data could possible provide insights into the potential causes. This may 

have a direct impact on our health. Again legislation is needed. 

WE need newsletters that are not just PR pieces for the VA but informative and 

that includes all research findings and recruitment not just from VA research but 

DOD CDMRP research or other civilian research that might match conditions/diagnoses that the veterans are receiving. Legislation is needed. 

WE need our records clearly identified as Gulf War in theater or non-deployed 

and unit assigned to in order to also have data that would show if particular units 

are more ill or have a higher death rate. Legislation will be needed, 

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Our veterans are actively seeking a means to relocate their fellow veterans that 

served in the same unit. There should be a means to help veterans to find each 

other to facilitate buddy letters if needed. And this would also assist our researchers. Legislation is needed. 

The other item is to provide fee basis to get the testing that is commercially available ie hypercoagulation test . The need for autonomic nervous system testing that 

the VA cannot provide needs to be funded not only for those in the VA system but 

those other gulf war veterans not being seen at the VA. Specific legislation is needed. 

There needs to be another time period extended for gulf war veterans that missed 

the initial time period allowed after operation desert storm or those that got fed up 

and left the VA and have struggled to find help in the civilian medical field. Currently I am living through that and have had a number of veterans communicate 

with me this past week of not being allowed in VA if they did not meet the means 

test. Much less those with insurance that they paid for being billed for health effects 

of service while they continue to try to get their claims through the system. Legislation is needed. 

The VA still wants to label this with a name or diagnosis that does not even relate to military, war time, or hazardous exposures and that in itself is viewed as 

an insult to the veterans! The VA still wants to push treatment that centers on Psychological and stress, we deserve better. We started out with many VA gulf war 

clinics in the nineties and then they were closed! Legislation is needed. 

The gulf war veterans when they try to discuss their exposures and relationship 

to their service and effect on changes in their body systems with their health care 

provider they are verbally or nonverbally shut down. We gulf war veterans have 

guided other veterans experiencing these problems to ask for change of doctors or 

provider at VA and we have provided the education to the veterans about the 

WRIIS program and guided them to inform and educate their doctor of the information on the VA’s own website about the WRIIS and how the doctors are to refer 

them electronically. Legislation is needed for mandatory CME education for our 

health providers seeing ill gulf war veterans. Legislation is needed. 

We have provided the flow of information even the actual research papers and 

RAC GWIR reports to our fellow gulf war veterans and encouraged them to share 

it with their VA health care providers. We have done the outreach to the veterans 

not the VA, we do this as our continued duty to each other as former military personnel that do care for each other even when we have not met them in person. WE 

listen and read what they are experiencing and their frustrations at getting sicker 

and having less quality of life and do our best to try to help our fellow gulf war 

veterans even as we are also ill and struggling to get care that we deserve. 

WE have tried but as you see after 22 years we need firm legislative efforts and 

laws that will be enforced to make a difference! 

And most of all the VA RAC GWIR needs to be recognized and VA must be held 

accountable for their intransience that has led to poor diagnostic testing, biomarker 

development, care and potential breakthroughs for treatment. This must stop. And 

the cycle ongoing between VA and IOM NAS must be but under great scrutiny. 

WE also need hearings more frequently with the House and Senate VA committees. I suggest joint hearings to elevate the priority and to gain unity on the hill 

on this effort. I also suggest that other gulf war veterans and a few spouses be allowed to testify to truly give more insight to our elected representatives of what we 

are living through. WE also need an ongoing VA advisory committee on health and 

benefits for gulf war veterans in law so it is not a one time 18 month advisory committee. These issues need just as much attention as the Research. Legislation similar to the legislation that set up the VA RAC GWIR is needed. Until the situation 

is improved we need this effort. WE need transparency and reports publicly available for any and all Task Force activities concerning gulf war veterans’ illnesses 

that VA has conducted! Please legislate and enforce these efforts so direly needed. 

Our claims are likewise in poor condition because VSO’s and VA rating officials 

have not been trained to adequately deal with the claims of gulf war illnesses. WE 

need urgent help 22 years is too long to have waited. 

f 

KIMBERLY SULLIVAN, PHD 

25 Years after the Gulf War: Gulf War Illness, Brain Cancer and Future Research 

Research Assistant Professor, Department of Environmental Health 

Boston University School of Public Health 

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Former Associate Scientific Director 

VA Research Advisory Committee on Gulf War Veterans’ Illnesses 

On this week marking the 25th anniversary of the Gulf War, I would like to express my concern and disappointment with the conclusions from the recent volume 

10 Institute of Medicine Gulf War Report and highlight some of the important research that is ongoing in this field. 

Gulf War Illness 

GWI is a constellation of chronic health symptoms including fatigue, pain, headaches, gastrointestinal and cognitive problems. It is a multi-system disorder meaning that it affects not only the central nervous system but also the immune and gastrointestinal systems. It affects about a third of the nearly 700,000 veterans deployed to the war. 

Gulf War Illness as a Functional Disorder 

The IOM report goes to great length to describe GWI as a self-reported symptom 

based disorder for which there are no current objective biomarkers and therefore it 

must be a ‘functional disorder’ meaning it has no physical cause. The report describes it to be similar to other well accepted symptom based disorders including 

post-traumatic stress disorder (PTSD). In fact, this report places PTSD as the only 

disorder that has ‘sufficient evidence of causal association’ to deployment to the Gulf 

War while it places GWI in the second category of ‘sufficient evidence of an association’ to deployment to the Gulf War. 

However, less than 10% of GW veterans have been diagnosed with PTSD and 

more than 30% have been diagnosed with GWI. In addition, it is completely unclear 

why GWI is not also causally-related to deployment to the war when both disorders 

are diagnosed the same way - by self-report of chronic health symptoms. 

The report also stresses that the health conditions associated with Gulf War deployment are primarily mental health disorders and functional medical disorders 

and that these associations emphasize the interconnectedness of the brain and body. 

However, the brain and body are interconnected in GWI not because this is a 

stress-related disorder without a unifying pathobiological cause as the IOM report 

suggests, but rather because they are all part of the brain and immune pathways 

that are activated as part of the neuroinflammatory response to pesticide and nerve 

agent exposures. These chemicals directly target the nervous system and cause inflammation. These pathways start by activating the immune cells in the brain called 

microglia that release chemical messengers called cytokines in the brain and the 

many body systems that are affected in GWI. Activating these inflammatory systems in the brain and throughout the body can result in chronic symptoms such as 

joint and muscle pain, memory problems, fatigue, headaches, and gastrointestinal 

distress-all symptoms found in GWI. Researchers call this type of chronic condition 

a post-inflammatory brain syndrome. 

In fact, a paper by Gulf War researchers from the Centers for Disease Control 

(CDC) recently showed that Gulf War-relevant pesticides and nerve agents produced 

a neuroinflammatory response resulting in hundreds-fold higher cytokine chemical 

signaling in a GWI animal model. Preliminary studies in veterans with GWI suggest 

increased cytokine levels that correlate with GWI symptoms as well. 

Treatment focus for Veterans with GWI 

The IOM report has concluded that research efforts should be realigned to focus 

on the treatment and ‘management’ of Gulf War illness rather than its causes. However, biological targets focused on neuroinflammatory markers described above provide tangible and targeted treatment strategies for GWI. Researchers at Boston University, Nova Southeastern University and VA medical centers in Boston, Bronx and 

Miami are currently assessing the effectiveness of targeted treatment trials using 

intranasal insulin, D-cycloserine and Co-enzyme Q10 to treat the constellation of 

symptoms in GWI including cognitive, fatigue and pain symptoms. Clinical researchers can do better for our veterans than ‘manage’ their symptoms as the IOM 

suggests and the research community is hopeful that these currently funded treatments will provide much needed symptom relief for ill Gulf War veterans. 

Brain Cancer Association with Gulf War Service 

The IOM report also states that the results of two published VA studies reporting 

significantly increased brain cancer mortality rates found in GW veterans who were 

in close proximity to the Khamisiyah weapons depot detonations where large stores 

of sarin/cyclosarin were destroyed cannot be trusted because the exposure plume 

modelling done to determine who was exposed may be inaccurate. However, inacLeonard.horne on VACREP0180 with DISTILLER

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curacies in exposure modeling often make the analysis less sensitive rather than 

more sensitive to finding differences between groups. Therefore, finding a 2 and 3 

fold increase in brain cancer deaths in sarin exposed GW veterans suggests that 

these rates are likely an underestimate of effect rather than an overestimate of the 

effect of sarin exposure on brain cancer mortality in GW veterans. 

Conclusion 

The IOM report has downplayed the importance of continuing to research the remaining questions in GWI including identifying biomarkers of current illness, prior 

neutoxicant exposures and targeted treatment strategies. This work is critically important to Gulf War veterans who suffer from chronic health effects from these toxicant exposures but also for many others including those who are occupationally exposed to pesticides, including farmers and pesticide applicators around the world. 

Gulf War veterans are counting on researchers to identify the cause and 

pathobiology of their debilitating illness, and to identify treatments that will work 

to improve all of their symptoms, not just manage them. 

Most importantly, the end result of this report is that GW veterans suffering from 

brain cancer or family members of those who have already succumbed to brain cancer will not receive VA benefits now or likely ever for their service-related mortality. 

These veterans have been forced to fight for benefits while they are fighting for 

their lives. These veterans should be given the benefit of the doubt in providing 

them with VA service connection for this service-related mortality. 

f 

DAVID K. WINNETT, II 

Thank you, Chairman Coffman, Ranking Member Kuster, and Members of the 

House Veterans’ Affairs Subcommittee on Oversight and Investigations for today’s 

hearing. 

I also wish to thank my fellow brothers- and sisters-in-arms who have joined this 

hearing in person, and to those of my fellow Persian Gulf War veterans who are 

watching these proceedings from afar. The testimony I provide to this distinguished 

Committee is done in honor of the extraordinary sacrifices that my fellow Gulf War 

veterans have made over the course of the past 25 years, first by the historic and 

heroic victory achieved during the 1991 Persian Gulf War, and then by the super 

human sacrifices made in the years since, both individually and collectively, in 

fighting what has turned out to be a much more formidable foe than the enemy soldiers we once routed on the toxic battlefields of the Middle East. 

BACKGROUND 

I am a 20-year veteran of the United States Marine Corps, having enlisted as a 

Private in January 1975 and retiring as Captain in 1995. In total, I wore 11 different ranks as a Marine, from Private (E1) through Staff Sergeant (E6), Warrant 

Officer (W1) through Chief Warrant Officer (W3), then First Lieutenant (earned 

while deployed to the Gulf) to Captain. 

My service as a Marine was, without exception, the most rewarding experience 

of my life. I appear before this honorable body today, exactly 25 years to the day 

that I led a Platoon of the most courageous and capable United States Marines I 

ever had the honor of serving with across the line of departure into Kuwait, along 

with combat elements of the 1st Marine Division, to liberate that beleaguered country and its people from the occupying grip of a vicious dictator. As history now demonstrates, our mission succeeded well beyond what even the most educated military 

scholars had predicted earlier. 

But sadly, I appear here before this Committee in many respects, a physically broken man. Not as a result of the normal aging process, not from the effects of enemy 

bullets or shrapnel, and certainly not from the stress of combat operations that occurred 25 years ago, but because of a physiological demon that managed to find a 

way to penetrate not only the substantial layers of protective clothing and equipment that I wore throughout the ground assault through Kuwait, but into my flesh, 

my internal organs, and through the blood-brain barrier that normally serves to protect the neurological mechanisms that control our cognitive abilities, our autonomic 

nervous system, and just about everything in the brain that regulates normal functioning of the human body. 

In short, I am, and have been a very physically sick man for the past 20-plus 

years. But the fact remains, I am here, I am still a United States Marine, and as 

far as I’m concerned I remain actively engaged in combat, as do hundreds of thousands of my fellow Gulf War veterans. The only thing that has changed over the 

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25 years that have passed since our rapid and resounding defeat of the Iraqi Army 

is that now we face a different foe, a foe much more resourceful and stubborn than 

even the toughest Iraqis that we faced during Operation Desert Storm. It pains me 

to admit that the battle we fight today is against some within the U.S. government 

- the same government that sent us to war in the first place. 

Over the past few weeks I have read numerous media accounts and engaged in 

a number of discussions with my fellow veteran advocates regarding the recent report issued by the Institute of Medicine (IOM) entitled, ‘‘Gulf War and Health, Volume 10: Update of Health Effects of Service in the Gulf War.’’ I cannot find words 

that are of sufficient power to express the disappointment I feel in the conclusions 

and recommendations contained in that report. Given the substantial body of scientific evidence that over the past decade has proven time and time again, beyond 

any doubt whatsoever, that Gulf War Illness is indeed a genuine physiological illness and that effective physiological treatments can likely be found, I simply cannot 

believe that the IOM made a 180-degree turn away from that science to a position 

that Gulf War Illness should now be treated primarily as ‘‘mind-body interconnectedness’’ - as if it were a mental disorder. 

In the interests of providing context to my testimony, I would hope that my military record would serve to support my assertion that when I say that I am physically sick, that I know my own body, and that my health conditions are primarily 

physical and not psychological, that your Committee would take me at my word. As 

many of you know, within the ranks of our military, an officer’s word is his or her 

solemn bond. And when I say that I am convinced beyond any doubt whatsoever 

that, as countless research studies have shown, more than 200,000 of my fellow Gulf 

War veterans are as sick or sicker than myself, that your honorable body will trust 

me on that count as well. 

My military career was, by any measure, a quite successful one. Few United 

States Marines are able to wear 11 different ranks over a period of only 20 years. 

A four-star General has been promoted nine times, usually over a span of 30 or 

more years; I was promoted ten times in 20 years. Three of the five promotions I 

received as a young enlisted Marine were earned ‘‘meritoriously’’. This is not an 

easy accomplishment in the Marine Corps, I assure you. During my assignment to 

the Non-Commissioned Officers (NCO) school at Camp Hansen, Okinawa, I finished 

second out of a class of 39. As a Sergeant (E5) at the Staff NCO Academy at El 

Toro, I finished second out of a class of 59, most of whom were very seasoned Staff 

Sergeants (E6) and Gunnery Sergeants (E7), many of them current or former drill 

instructors. Three years following that I was among just 250 of 2,500 applicants Marine Corps-wide to receive an appointment to the rank of Warrant Officer (W1), and 

I completed the Warrant Officer Basic Course in Quantico in the top 10% of my 

class. Later, while under orders to the Marine Corps Degree Completion Program, 

I completed a Bachelor of Business Degree (BBA) Magna cum Laude. I worked hard 

for every single promotion or personal decoration that I received as a Marine. Not 

once in 20 years did I ever fail to achieve a score of First Class on my quarterly 

Physical Fitness Tests (PFT). I was a competitive shooter as a young Lance Corporal, competing in the 1976 Far East Division Matches. I was good at whatever 

I set my mind to do. 

I’ve listed these career milestones, not as a means of pounding my chest, but to 

convey to your honorable body that in 20 years of service as a United States Marine, 

I was never considered a ‘‘quitter’’ or a ‘‘sick bay commando’’. I was a competitive 

person then, and that competitive spirit still lives in me this very day. In fact, were 

it not for the fighting spirit I learned as a United States Marine, I doubt very much 

that I would be sitting here today. The point I’m making is this: I am appealing 

to the honorable members of this distinguished committee to take this Marine at 

his word. I am not a malingerer. I am not a liar. I am not mentally disturbed. My 

physical pain is real, and it is severe. The profound fatigue that I live with day in 

and day out is not a psychosomatic disorder. More importantly, the more than 

200,000 of my brothers- and sisters-in-arms who live with the same physical pain 

and fatigue and other symptoms that I live with are not imagining their illnesses. 

This preposterous idea that Gulf War Illness should be treated primarily with cognitive behavioral therapy, exercise, and psychiatric drugs as suggested in this new 

DOD/VA Clinical Practice Guideline as if it were a psychosomatic condition is not 

only ridiculous, it is highly offensive to the warriors whose lives have been literally 

destroyed as a result of serving on what was undoubtedly the most toxic battlefield 

American forces have served on in the history of this great country. 

Four years ago my worsening physical condition forced me to walk away from a 

prestigious position as the Fleet Services Manager for the City of Torrance, California, where I managed a $12 million dollar budget, 36 employees, and a fleet of 

over 700 vehicles, and had a salary of over $120,000 per year, not counting benefits. 

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Does anyone believe that a rational individual would walk away from such a lucrative career in order to obtain an annual veteran’s disability payment of $36,000 per 

year? 

I have been a very vocal advocate for veterans suffering from Gulf War Illness 

since 2008. I’ve written a number of op-eds for various news publications around 

the country, participated in radio and television interviews about Gulf War Illness, 

and shared quite a few poems written to honor the sacrifices of my fellow veterans. 

I have been actively involved with the Congressionally Directed Medical Research 

Program (CDMRP) for Gulf War Illness treatment research for the past six years 

as a consumer reviewer at both tiers of the review process, first as a member of 

the Scientific Merit Review panels, and currently as a member of the Programmatic 

Panel. I believe very strongly in the unparalleled work of this treatment development program. 

ONLINE GULF WAR ILLNESSES DISCUSSION GROUP 

In 2009, I created one of the first Facebook pages focused on Gulf War Illness. 

It is a ‘‘closed’’ group that goes by the name of ‘‘Gulf War Illnesses’’. Today this discussion group has an active membership of nearly 10,000 veterans, family members, 

and a few others interested in helping with our cause. As the sole administrator for 

the group, I personally screen each applicant who wishes to join to ensure it remains focused on our core mission - providing a private forum where ill Gulf War 

veterans feel free to share sensitive information about their battles with Gulf War 

Illness and other life challenges that often go hand in hand with chronic illness. 

Members of the Gulf War Illnesses group also post frequent updates regarding ongoing Gulf War Illness research and news articles that are relevant to our cause. 

We have a number of very experienced individuals who offer free VA claims advice 

to other members. But most importantly, we provide a forum where veterans suffering from the debilitating symptoms of Gulf War Illness can find a sense of empathy, camaraderie, and mutual support any time of the day or night. 

SUICIDES. Sadly, and more frequently than I would have expected, we sometimes lose members to suicide. Our group is fiercely loyal and protective of one another. Anytime a veteran posts comments that are indicative of possible suicidal ideations, you can rest assured that there will be an instant and incredible outpouring 

of support aimed at that veteran, including, if necessary, calls to local public safety 

officials asking that they conduct a welfare check on our veteran. Unfortunately, as 

hard as we try, we’ve not always been successful. We’ve lost far too many of our 

members to suicide. The vast majority of them were directly triggered by the sense 

of hopelessness that often follows a veteran’s notification from the VA that his or 

her claim has been denied. These tragedies must stop. Each and every veteran suicide is completely preventable. Only the Department of Veterans Affairs has the 

power to end this epidemic by improving the relevance of the healthcare they provide, reforming their claims processing, and by ensuring that every VA facility 

across this country is operating under the exact same protocols as every other VA 

facility, including healthcare facilities and VA Regional Offices where individual 

claims decisions are adjudicated. 

SURVEY SHOWING VA AND IOM HAVE MISSED THE MARK. Very recently, I conducted an informal survey of sorts on the Gulf War Illnesses group 

about Gulf War veterans’ physical health concerns being dismissed by VA in favor 

of mental health referrals. The response to that question was rapid and voluminous. 

Within the first 24 hours, I had nearly 300 responses, the majority of which verified 

my suspicions that indeed, this problem - that Gulf War veterans with physical 

health issues are sent to VA mental health instead of addressing their physical 

health issues - is widespread and extremely common in just about every region 

within VA’s jurisdiction. In my opinion there is little doubt that this unethical practice is not just a Clinical Practice Guideline document written by DOD and VA officials, it has become standard operating procedure throughout the VA. Below is my 

question and a few of the responses: 

‘‘If you are a Veteran of the 1991 Persian Gulf War and are living with life-altering 

medical problems such as severe muscle or joint pain, profound fatigue, gastrointestinal dysfunction, chronic skin rash, cognitive difficulties, etc.....AND your complaints to VA Physicians have not been taken seriously, I have a question to ask you. 

Who among you, instead of being treated for your physical complaints at the VA have 

instead been referred for psychiatric or psychological treatment?’’ 

fi Veteran from Dallas, Texas - ‘‘Even though I am diagnosed with chronic fatigue (CF), Fibromyalgia, and IBS, just to name a few; The VA still only treats me 

for mental health. And if they do that to me, I can only imagine what they are doing 

to others. My doctors used to think I was just a complainer because I knew too 

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much about GWI, now I am lucky if I ever see a doctor. All they ever give me is 

nurse practitioners, and I don’t know about you guys, but every time an NP checks 

me out, they spend all of their time trying to un-diagnose everything, and trying 

to tell me GWI is all in my head.’’ 

fi Veteran from Taylorsville, Kentucky - ‘‘I was actually told by VA that there 

were no validated reports of illnesses related to the Gulf War.’’ 

fi Veteran from Muskogee, Oklahoma - ‘‘During my last visit to the Muskogee 

VA ER I had a doctor inform me since they could not find anything in the X rays 

or blood test he was submitting a recommendation for mental evaluation and that 

Gulf War Illness was not real. .. If they have physical health conditions the doctors 

will minimize health issues because of the documented psychological problems and 

not do as many tests that may help them on down the road. I had many problems 

at Loma Linda VA. Most consults were denied. Eventually had to go outside VA for 

tests to prove conditions existed. I had to go through director to get MRI. The MRI 

showed severe deterioration condition. Need 2 surgeries. I believe most veterans will 

have real physical issues on down the road and will be managed by the less costly 

meds.’’ 

fi Veteran from Sturgis, Michigan - ‘‘All my diagnosis [sic] were done [by] my 

private pcp . VA did nothing for me. I have also been on Zoloft since 93 for my depression tried suicide twice so been a long hard road.’’ 

fi Veteran from Tallahassee, Alabama - ‘‘My late husband was referred for 

mental health testing six months or so before he passed in ’99...dismissed all his 

complaints.’’ 

fi Veteran from Springfield, Missouri - ‘‘My primary care provider says that 

my IBS, fatigue, sleep problems, etc. are all just PTSD. My deployment to [the Persian Gulf] was actually easier and more fun than stateside never had any traumatic 

experiences. Also I have never been diagnosed with PTSD, and the psychologist says 

I am not depressed, just frustrated with lack of help for my health problems.’’ 

fi Veteran from Korbel, California - ‘‘I finally went into the VA 3 years ago 

because I could no longer afford an outside physician to treat symptoms of GWI and 

was immediately referred to psych and diagnosed PTSD and given a slew of placating meds. Fortunately I had already failed off of most of them and was persistent 

and finally I am getting them to treat my IBS neuropathy and fibromyalgia.’’ 

fi Veteran from Duncan, Oklahoma - ‘‘Insomnia, chronic fatigue, skin rash, 

sleep apnea. And yes sent to the shrink and tried about 4 different medications each 

one [expletive] me up more than the previous. They said I was depressed within 5 

minutes of appointment. The 2nd doc said I wasn’t depressed just had insomnia, 

prescribed trazadone, which was the very 1st med my primary Dr. Tried. Right back 

to square one. I quit going. And as far as sleep goes, I find listening to an audio 

book is better than any of the meds I was on.’’ 

fi Veteran from Conyers, Georgia - ‘‘My pcp told me she was [not] interested 

in my conspiracy theories, only my current health. X-rays put me in Phys therapy 

for my back. And she referred me to psych, where I was diagnosed with PTSD.’’ 

fi Veteran from Pine Island, Minnesota - ‘‘I was referred to mental health 

after having pulmonary and cardio work-up. When I started this time around (in 

2013) I called to see what I needed to do to be seen for the fatigue and the nurse, 

this was when I actually was able to call the clinic and not triage, was honest 

enough to tell me that I would have to see MH to rule out those possibilities. The 

psychiatrist is the one who actually made the call on CFS. She is also the one who 

told me a year later that she wasn’t sure how I should be treated or what I wanted 

out of continuing seeing her. .. I think many in the VA have no idea what to do 

with undiagnosed, maybe [THEY] should be referred to MH to help them find out 

what is wrong with them that they cannot accept that the medical establishment 

has not been able to definitively establish a diagnosis.’’ 

fi Veteran from Hawthorne, Florida - ‘‘Gainesville VA, mental hygiene is all 

they offer. Make ya think you’re crazy. .. I’ll never walk [through] a VA again willingly.’’ 

fi Veteran from Geneva, Ohio - ‘‘I have but I can say that they put me on anxiety medication . that I have now been on for about 5 years and it has made some 

good changes for sleep for me but . my body still hurts all the time and have joint 

and back pain, . But still living with headaches almost daily as well and skin rashes 

with severe psoriasis and memory loss. Believe it or not as I’m writing this I have 

to stop for a bit to remember names of things that I have known for years, . this 

sucks especially when I have to ask my wife and she looks at me like ‘‘what the 

[expletive] is wrong with you’’ and I’m only 49.’’ 

fi Veteran from Louisville, Kentucky - ‘‘My pcp told me it was because I am 

depressed and had PTSD.’’ 

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fi Veteran from Parkersburg, West Virginia - ‘‘When I first went to the local 

CBOC complaining of these issues I was referred to Psych. Later I was told all my 

problems were from PTSD.’’ 

fi Veteran from Topeka, Kansas - ‘‘I was already seeing psych for PTSD. Every 

visit I would tell her about my CFS, joint pain and migraines. She was the one that 

actually got me the physical appointments I needed.’’ 

fi Veteran from Northampton, Pennsylvania - ‘‘Have all the conditions mentioned, plus additionally shoulder pain from an injury in the service; tinnitus; lack 

of sleep .. Saw the same [VA] PCP for 10 years, who didn’t really take my complaints seriously .. Now seeing new PCP; rheumatology; psychologist; & psychiatrist 

- and NOW they are seeing things that were ignored for years. Never told to ’see 

pysch’ for pain, it was just patently ignored for years. ..’’ 

fi Veteran from Zanesville, Ohio - ‘‘My issue has always been bad headaches 

that started in country in ’91, right around the time the war started. I [go] to the 

Columbus Oh VA hospital and local CBOC. They always circle around and end up 

putting me on mental health meds that do nothing for the headaches and only cause 

negative side effects that are much worse than the headaches alone. After a year 

of being on them I took myself off for this very reason only to be put right back 

on them for the very same reason. They just think they gave me the wrong type! 

I feel like I gotta go thru the motion to prove they are not the solution. I keep telling them that it is my sinuses causing them right now and finally got an allergy 

Doctor to listen enough to put me on a round of antibiotics and within a week it 

helped enough that my headaches are so much better now that I do not have to take 

my pain meds. After dealing w/headaches for 25 years I feel the doctors need to listen to what we feel is causing it and what the solution may be because I feel I know 

my body better than a doctor who is seeing me for the first time.’’ 

fi Veteran from Oak Grove, Kentucky - ‘‘I have been treated, well seen at the 

Nashville VA, since 1995 and have always been told ‘‘It’s all in my head’’ and 

Somatoform disorder. I have all the classic problems, PTSD, Joint pain, back pain, 

pain in all joints except hips. CFS, anxiety, major depression, fibromyalgia, Migraines though the migraines have gotten a lot better in the past few years. .. Have 

also been seen at [several DOD and VA programs], All of which resulted in [VA] 

trying to validate that it was all psychological / Somatoform disorder.’’ 

fi Veteran from Cincinnati, Ohio - ‘‘I was treated condescendingly at the Vet 

Center, got referred for psych help, and prescribed various drugs that only made 

things worse. Finally just quit trying, sucked it up, and just deal with it myself as 

best I can.’’ 

fi Veteran from Neola, Pennsylvania - ‘‘I was almost immediately referred to 

Pysch. It has taken years, and a major decrease in my physical ability, to get anything more than the minimum health care. Fill me up with pills and move on. Pysch 

only set me up with pain management. So on one hand they admit pain but on the 

other they won’t help.’’ 

fi Veteran from Hendersonville, Tennessee - ‘‘Nashville V.A. Primary care 

doc prescribed me gabapentin for my joint pain, especially in my shoulders neck and 

knees. I still have extreme cramps in my legs and calves and some serious muscle 

spasms, not to mention how bad my hands shake. The fatigue, insomnia depression 

and anxiety my doc couldn’t figure out so I was referred to the Shrinks.’’ 

fi Veteran from Cincinnati, Ohio - ‘‘Since I already have a [psych] doc my 

physical problems are ignored.’’ 

fi Veteran from Fort Worth, Texas - ‘‘I had a visit at the Fort Worth Clinic 

where they tried referring me to psych to ‘‘deal’’ with my pain but I basically cussed 

them out and shamed them then left for the Dallas VA only to be questioned as 

to whether I felt safe at home or not. It was a bad ordeal and they even put it in 

my records’’. 

fi Veteran from Hampton, Virginia - ‘‘..My husband asked my PCP if he knew 

anything about the Gulf War Illnesses and he bluntly said NO. Where did they find 

these doctors?’’ 

fi Veteran from Parker, Colorado - ‘‘My pcp is vaguely familiar with it; don’t 

believe any [specialty doctors], GI, [for] example have any clue about GWI or that 

there was even a war fought. Let alone we are sick from it, Honestly I have a hard 

time bringing it up to any of them because of the look most of them give me when 

I have mentioned it to them, can’t help to ask why can’t there be some sort of flag 

like notice in med record that says something like ‘‘Vet is GWI Era possible or Confirmed GWI patient’’ then followed with instructions on how to proceed’’. 

fi Veteran from Havelock, North Carolina - ‘‘My VA pcp is truly a lost cause. 

None of the VA providers here in the VISN–6 region have [any] clue. Since moving 

here to NC from KY I have had 3 VA providers. None of which knew anything about 

the GWS.’’ 

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fi Veteran from Dunnsville, Virginia - ‘‘I have the same thing and they 

thought it was all in my mind at first but I kept complaining. As the time goes by 

the pain gets worse. I hurt and have a heart problem that they continuously ignore’’. 

fi Veteran from London, England - ‘‘this is happening in the UK as well.’’ 

fi Veteran from Denver, Colorado - ‘‘I’m happy with my Denver VA provider. 

Treats the symptoms as best as he can and makes credible suggestions. Knowledgeable on GWI and doesn’t sum it up as mental.’’ -Veteran from southern Arizona - 

‘‘You got lucky!′′ 

CLAIMS ALSO AFFECTED. Not only are VA clinicians summarily dismissing 

the complaints of veterans suffering from extremely debilitating muscle pain, profound fatigue, chronic unexplained skin rashes, etc., VA seems to be following that 

exact same model for claims. For the veterans in this discussion group, it appears 

that if the veteran agrees to be seen by mental health professionals at the VA, it 

then seems like his or her chances of getting a disability claim approved are almost 

assured, whereas those who reject treatment by VA psychiatrists or psychologists 

seem more likely to have their claim denied. The following is a sampling of comments related to claims that various members of the Gulf War Illnesses Facebook 

page posted after I had asked the aforementioned question: 

fi Veteran from Muskogee, Oklahoma - ‘‘.. VA claims are easier for those 

claiming psychological (PTSD) issues but think it is bad for the veteran. If they have 

physical health conditions the doctors will minimize health issues because of the 

documented psychological problems and not do as many tests that may help them 

on down the road. ..’’ 

fi Veteran from Muscle Shoals, Alabama - ‘‘When I received my letter denying 

my claim for stomach cancer the nurse that did the evaluation said my cancer was 

caused by SAD. Severe Anxiety Disorder. I have never been diagnosed by any Psychiatrist or psychologist???’’ 

fi Veteran from Neosho, Missouri - ‘‘I’m rated 90 percent with IU, but all my 

complaints and gulf war illnesses were denied individually and all was put under 

PTSD, filed claim at mount Vernon, Missouri and regional office St Louis, so yeah 

they did it wrong, but not going to rock the boat when I got total and permanent.’’ 

fi Veteran from Coatesville, Pennsylvania - ‘‘Been seen for all and VA comes 

back and says not service related.’’ 

fi Veteran from Las Vegas, Nevada - ‘‘Tomah VA treated both mental health 

and primary care until the OIG Investigation had them on Administrative Leave. 

Then nobody treated me until I filed a Congressional Complaint and spoke to Carolyn Clancy...Nothing got done still with referrals after their negligence. A few 

months later the PCP agreed to PTSD inpatient, but again stone-walled by their 

staff so it would look like my denial was my fault. I have all of the diagnosis and 

claim is still pending while now being referred in Las Vegas for numerous medical 

treatments. They don’t acknowledge GWI here...then again they don’t anywhere.’’ 

fi Veteran from Allegan, Michigan - ‘‘In 1993 went to Los Angeles VA they 

pushed me through said nothing was wrong. In 2003 went to Phoenix VA same 

thing. In 2008 went to Sacramento VA was told I wasn’t eligible for benefits. 2011 

I was diagnosed by civilian Dr. with ulcerative colitis. 2013 had BCIR surgery by 

civilian Dr. 2014 registered at the Chicago VA never made an appointment because 

people are just plain mean there. In 2015 went to Wyoming Michigan VA. They 

have yet to do anything about my headaches, fatigue and joint pain, went through 

the shrink thing made them stop. 9 months later and I received 100% disability just 

for ulcerative colitis, 50% PTSD.’’ 

fi Veteran from Topeka, Kansas - ‘‘I filed for undiagnosed illnesses of chronic 

fatigue and joint pain in 95. Denied for both but my VSO had added PTSD. (I was 

diagnosed with chronic fatigue and PTSD only at that time. ) I have now managed 

to get a listing dx of CFS.’’ 

fi Veteran from Oak Grove, Kentucky - ‘‘Only reason I kept going was because 

my claim was pending and if I didn’t, they would say, I ‘‘refused treatment’’. Don’t 

think any of my ratings are considered service connected or not. Afraid to mess with 

it as I’m getting .. [100% Individual Unemployability] so I’m leaving it alone for 

now.’’ 

fi Veteran from Eads, Tennessee - ‘‘As soon as the VA read the words ‘‘stress’’ 

in my application for C& P for numerous ailments with unknown etiology from 

Desert Shield/Desert Storm I was sent to a psychologist at Memphis VA hospital 

for evaluation....you don’t need to hear what he wrote....I felt betrayed and haven’t 

been back since.’’ 

CONCLUSIONS 

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Gulf War Illness is a physiological illness, period. That’s not just the opinion of 

this very ill veterans’ advocate and multi-year CDMRP participant, it is the opinion 

of hundreds of Ph.D’s and M.D.s who have studied Gulf War Illness over the past 

decade. These are highly skilled experts in the fields of science and medicine. 

It’s long past the time when the self-serving interests of political operatives and 

defense contractors trump the medical and financial needs of the more than 200,000 

of America’s 1991 Persian Gulf War veterans whose good health and ability to support their families is nothing more than a distant memory. This American tragedy 

must be brought to end, once and for all. History is watching, and everyone involved 

will be judged according to his or her actions, or inaction. Which side of history will 

you be on? 

Very Respectfully Submitted, 

David Keith Winnett, Jr. 

Captain, United States Marine Corps (Retired) 

Representing: Veterans for Common Sense 

Home address: New Braunfels, Texas 

f 

LEA STEELE, PH.D. 

Yudofsky Chair in Behavioral Neuroscience, Professor of Neuropsychiatry 

Baylor College of Medicine 

My name is Dr. Lea Steele. I am a neuroepidemiologist and have conducted research on the health of Gulf War veterans since the late 1990s. Our initial efforts 

were sponsored by the State of Kansas, where we worked with state officials to establish a research and outreach program for Persian Gulf War veterans in Kansas, 

collaborating with Kansas State University. Since those early years I have continued clinical and population research on Gulf War health issues and have served on 

multiple federal Gulf War research panels, including 5 years as Scientific Director 

of the Congressionally-mandated Research Advisory Committee on Gulf War Veterans’ Illnesses. I am currently a professor at Baylor College of Medicine in Houston, where our veterans’ health research continues. 

I am submitting this statement to offer my perspective, as an experienced Gulf 

War scientist, on where things stand with federal efforts to address health outcomes 

in 1991 Gulf War veterans, 25 years after Desert Storm. With respect to Gulf War 

illness (GWI), the signature health problem of the 1991 Gulf War, we have seen significant progress in understanding its nature and its causes, and the magnitude of 

the problem. We can diagnose GWI by its consistent profile of symptoms that have 

now persisted, for many veterans, for 25 years. Symptoms include chronic headaches, widespread pain, debilitating fatigue, cognitive difficulties and other concurrent problems. We know GWI affects a substantial proportion of the nearly 700,000 

veterans who served in Desert Storm-roughly 25–30%. We know GWI is not a psychiatric disorder and was not caused by combat or stress-PTSD rates are relatively 

low in Gulf War veterans, as expected from the four day ground war in which most 

personnel did not see combat. Rather, research has most consistently pointed to 

chemical exposures widely encountered by veterans during deployment-toxicants 

that, individually and in combination, have long-term adverse effects on the brain 

and other systems. 

I want to emphasize just how consequential this scientific progress has been, and 

the promise it offers for understanding GWI, for avoiding this problem in future deployments, and for near-term identification of diagnostic tests and treatments for 

veterans who have suffered for so long. 

Gulf War illness is a complex disorder that was long denied or minimized by federal agencies charged with addressing it. The fact that we have learned so much 

about the nature and causes of GWI, especially in the last 10 years, is the result 

of several important factors: the persistence and dedication of Gulf War veterans 

who have continued to push federal agencies to find answers and treatments, the 

persistence of Congress in directing that government agencies provide the needed 

research, healthcare, and benefits, and the diligent work of dedicated scientists. 

Still, despite impressive progress, the most essential work remains. That work is 

to ensure that the large number of veterans who still suffer from the long term medical consequences of service in the 1991 Gulf War are diagnosed and effectively 

treated. This effort is underway, and scientists working in this arena are now seeing 

returns in the push to better understand the biology of GWI and identify treatments 

that significantly improve the health of Gulf War veterans. This is exemplified by 

the rapid expansion of treatment studies-both in ill Gulf War veterans and animal 

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models of Gulf War illness-sponsored in recent years by the DOD’s Office of Congressionally Directed Medical Research Programs (CDMRP). 

While the DOD, researchers, and veterans have made important strides in understanding and addressing this serious problem, VA has lagged behind in providing 

an effective response to Gulf War health issues. The poor response was more understandable in the early years after the Gulf War, when little was understood about 

this problem. But it continues today, reflected day in day out in the difficulties Gulf 

War veterans face in obtaining effective care at VA. These pervasive problems are 

also evident in the Clinical Practice Guidelines issued in 2014 to inform VA 

healthcare providers about treatment options for veterans with Gulf War illness. 

They are evident in the lack of the fundamental VA research necessary to inform 

IOM panels and the Secretary of Veterans Affairs concerning benefits decisions. And 

they are evident in ill-informed findings resulting from a piecemeal approach to the 

evidence considered in a recent IOM report commissioned and charged by VA. 

With regard to the recent treatment guidelines and IOM report, a long list of specific examples could be provided that illustrate the limitations, misassumptions, and 

errors contained in these documents. For those experienced in conducting research 

and caring for ill Gulf War veterans, these reports are the latest in a long line of 

clinical and research missteps from VA. In many ways, they harken back to the 

1990s, before the now extensive evidence was available to inform our understanding 

of GWI, and guide the steps required to effectively address it. 

For example, the recent IOM report states that Gulf War illness studies have 

largely excluded psychological problems and recommends that future efforts incorporate mind-body approaches to this problem. In fact, the opposite is true. Gulf War 

studies have always included psychological issues and, until recent years, focused 

more heavily on psychological factors than any other single area. Research consistently found no association between combat stress and GWI, and studies found little 

effect of behavioral therapies in improving veterans’ symptoms. Today, stress is no 

longer the central focus of GWI research. But studies continue to evaluate psychological symptoms and psychiatric comorbidities in Gulf War veterans, and treatment 

studies are testing mind-body therapeutic interventions to alleviate veterans’ symptoms. To suggest an increased emphasis on psychological factors and interventions 

is baffling and misrepresents widely available evidence. 

Similarly, the 2014 Clinical Practice Guidelines for VA healthcare providers emphasize the use of psychiatric medications and behavioral interventions, despite 

there being no evidence that these treatments provide meaningful benefit for veterans with GWI. Studies, again, have demonstrated just the opposite, that behavioral interventions provide little benefit for veterans with GWI. Proceeding in the 

direction suggested by just these two examples would misdirect precious resources 

and, more importantly, further delay the appropriate medical care needed by veterans. 

From my perspective as a scientist, there are two common threads that have undermined the effectiveness of VA programs to effectively address GWI. (1) VA’s ongoing failure to affirmatively engage GWI as a medical condition that affects veterans as a result of their deployment to the Kuwaiti Theater of Operations in 1990– 

1991. The most fundamental essentials are lacking. VA still does not refer to this 

condition by an identifiable name and VA clinicians have few resources and little 

training in how best to assist veterans with this condition. (2) VA’s failure to bring 

in experts to develop and steer healthcare and research programs that effectively 

address Gulf War health issues. Gulf War illness is a complex and unfamiliar medical condition, and effective VA programs require scientific and clinical expertise 

specific to this problem. In contrast to VA, the scientific progress brought about by 

DOD’s effective Gulf War Illness Research Program in recent years can be traced 

directly to DOD’s developing this program in partnership with scientific experts who 

are most experienced in Gulf War research and Gulf War veterans who are most 

affected by this problem. 

It goes without saying that Gulf War veterans deserve clear answers, effective 

healthcare, and informed research to improve their health. It is a travesty that, 25 

years after the brief war and heroic victory achieved by the military in Operation 

Desert Storm, veterans who served in that war continue to have to fight for recognition, care, and benefits for the long-term health problems they still suffer as a consequence of their service. 

f 

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Questions For The Record 

Questions from Chairman Mike Coffman for the Department of Veterans 

Affairs: 

Question 1: According to the 2013 report of the Institute of Medicine 

(IOM), studies referenced were from 2008 and earlier and provided a disclaimer that drug manufacturers may have influenced several clinical 

trials or employed researchers. VA used those same studies in writing its 

guidelines. Was VA aware of the potential that its guidelines are based on 

questionable material? 

VA Response: Yes, VA was aware of such concerns. VA and the Department of 

Defense (DoD) have a rigorous process for assessing and rating the quality of published studies used in the development of our joint Clinical Practice Guidelines 

(CPGs). More specifically, this process was used in the development of the DoD/VA 

Chronic Multi-Symptom Illness Clinical Practice Guideline. 

Question 2: That same IOM report noted a high risk of bias for a number 

of studies that are also referenced as sources for VA’s treatment of Gulf 

War Veterans. Was VA aware of this when it used them to create the guidelines? 

VA Response: Yes, as mentioned above, VA was aware of such concerns and addressed them in the process of development of DoD/VA CPGs through a process of 

rating the strength and quality of various studies being considered. 

Questions 3: Since VA wrote the contract that employed IOM for the 

study, why didn’t VA exclude questionable or high risk material in the 

study or do so in the results the department continued to tout? 

VA Response: Because scientific and clinical evidence exists on a spectrum of 

strength and quality, VA, IOM, DoD and similar organizations, as well as scientific 

researchers evaluate the ‘‘strengths and limitations’’ of studies and research based 

evidence. That is the approach used in the interpretation of IOM reports as well 

as in the development of DoD/VA CPGs. 

Question 4: VA’s guidelines state ‘‘an internal working document’’ of VHA 

and DOD was used in developing the guidelines. Please provide that document in its entirety. 

VA RESPONSE: The ‘‘internal working document’’ identified in the request is the 

‘‘Guideline for Guidelines’’ which can be accessed directly at http:// 

www.healthquality.va.gov/documents/ 

cpgGuidelinesForGuidelinesFinalRevisions051214.docx. 

This document outlines the process from start to finish for the development of VA/ 

DoD CPGs. It covers such areas as: identifying and requesting a VA/DoD CPG be 

developed, identifying subject matter experts from both VA and DoD agencies, methodology for key question development and evidence review, evidence grading, potential conflict of interest, adapting/adopting/new CPG development, internal/external 

review and approval process. 

QUESTION 5: IT HAS BEEN FORTY YEARS SINCE THE VIETNAM WAR ENDED AND VETERANS HAD TO FIGHT FOR CARE RELATED TO AGENT ORANGE. IT HAS BEEN TWENTYFIVE YEARS SINCE THE PERSIAN GULF WAR, AND VETERANS ARE STILL FIGHTING FOR

THEIR CARE. NOW, VETERANS ARE ALSO DEALING WITH BURN PITS AND OTHER TOXIC

RELATED ISSUES. IS VA GETTING THE OCCUPATIONAL AND ENVIRONMENTAL HEALTH

SURVEILLANCE DATA THAT IT NEEDS FROM DOD IN ORDER TO CARE FOR VETERANS

PROPERLY? IF NOT, WHAT ADDITIONAL DATA WOULD BE HELPFUL AND WHY?

VA RESPONSE: Unfortunately, for many Veterans, particularly those of the Vietnam and the Persian Gulf Wars, it appears that reliable occupational and environmental health surveillance data just do not exist. To the extent that such data are 

available, DoD shares them with VA as needed. DoD has much better surveillance 

data available for more recent conflicts and events. 

Building on the lessons learned from the Persian Gulf War, Operation Enduring 

Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND), 

VA and DoD work collaboratively to identify and measure military related exposures, to identify those potentially exposed, and to generate risk estimates for any 

known or potential acute and long term health effects. 

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The evolution of the Agent Orange benefits program is an excellent example of 

the progress VA has made in terms of support for individuals with deployment related environmental exposures. It is an extremely ‘‘worker friendly policy’’ for those 

whose health may have been negatively impacted by dioxin exposure in the places 

and time periods designated. The Airborne Hazards and Open Burn Pit Registry is 

also a measure of how much more proactively we are approaching the documentation, assessment, and monitoring of deployment related exposure concerns. http:// 

www.va.gov/HEALTH/NewsFeatures/2016/March/Were-you-exposed-to-burn-pitswhile-deployed.asp. 

The Tomodachi Registry of about 75,000 DoD-affiliated individuals (Service members, family members, veterans, contractors) in the vicinity of Japanese Dai-ichi reactor meltdown was created and populated immediately after the disaster and includes individual- and geolocation-sampling readings of ionizing radiation exposure 

levels. This registry could prove very useful in the future, as needs arise for potential future follow-up in the overall health of this Veteran population. 

A major emphasis of the DoD/VA Deployment Health Work Group (DHWG) is on 

Service members returning from OEF, OIF, or OND. The DHWG also coordinates 

initiatives related to Veterans of all eras. Joint efforts continue to increase sharing 

of health surveillance information and review of relevant literature on hazardous 

environmental exposures, so that risky situations in theater are identified, and the 

Department’s responses are appropriately coordinated. The DHWG analyzed complex clinical medicine, toxicology, and policy aspects to develop synchronized DoD 

and VA actions. The DHWG organized twelve meetings in FY15 to coordinate DoD 

and VA responses to five major environmental exposures in Iraq, Afghanistan, and 

the US, as described below: 

• potential health effects of exposure to burn pit smoke in OEF/OIF/OND 

• potential health effects of high ambient concentrations of particulate matter in 

OEF/OIF/OND 

• potential health effects of chemical warfare agent exposure in OIF 

• potential health effects of historical exposure to contaminated drinking water 

at Marine Corps Base Camp Lejeune, NC 

• potential health effects of exposure to Agent Orange during and after the Vietnam War 

The DHWG provides ongoing oversight of the development of the Individual Longitudinal Exposure Record (ILER) project, including briefings every two months. 

The goal of ILER is to create a complete record of every Service member’s occupational and environmental exposures over the course of their career. ILER is a $19.1 

million jointly funded pilot project and the goals are: to demonstrate the feasibility 

of producing ILER; and to develop a prototype that provides an initial operating capacity (IOC). At IOC, DoD and VA will decide whether to proceed to Full Operating 

Capability, which would require considerable sustainment funding from both Departments in future years. 

The ILER will mine several existing DoD data systems that contain in-garrison 

and deployment exposure-related information. It will link career location and year 

with exposure data and will be available to DoD and VA health care providers to 

help inform diagnosis and treatment, and to VBA claims adjudicators to help establish service connection. This will assist Veterans in establishing their individual exposures. 

Question 6: In 2015, GAO reported that DOD provided VA with access to 

unclassified summaries of historical environmental health surveillance 

monitoring efforts through a website. The summaries are referred to as 

POEMS (or Periodic Occupational and Environmental Monitoring Summaries). However, VA officials were uncertain about how often these summaries were being used. Is VA using these summaries, and if so, how often 

and to what extent? 

VA Response: Clinicians at the War Related Illness and Injury Study Centers 

(WRIISCs) perform specialty consultations about the environmental and occupational health and exposure concerns of Veterans referred for evaluation. They use 

their expertise to regularly incorporate information from the POEMs and the online 

information request services available from the Army Public Health Center, as well 

as personal contacts at the Army Public Health Center and the Navy and Marine 

Corps Public Health Center to complete their assessments and recommendations. 

The services of Army Public Health Center are available to any clinician or patient 

according to their website, but are perhaps most suitable to specialty evaluations. 

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1Sim, M., D. Clarke, B. Forbes, D. Glass, S. Gwini, J. Ikin, H. Kelsall, D. McKenzie, B. 

Wright, A. McFarlane, M. Creamer, and K. Horsley. 2015. Australian Gulf War Veterans’ follow 

up health study: Technical report 2015. Canberra, Australia: Department of Veterans’ Affairs. 2 Young, H. A., J. D. Maillard, P. H. Levine, S. J. Simmens, C. M. Mahan, and H. K. Kang. 

2010. Investigating the risk of cancer in 1990–1991 U.S. Gulf War Veterans with the use of 

state cancer registry data. Annals of Epidemiology 20(4):265–272. 

Here is the website for the Army Public Health Center. More detail is available 

here under the ‘‘topics and services’’ and ‘‘request services’’ tabs. https:// 

phc.amedd.army.mil/Pages/default.aspx. 

Question 7: How does VA use DOD’s occupational and environmental 

health surveillance data? Does it play a role in how VA treats patients with 

Gulf War Illnesses? If so, please explain in detail. 

VA Response: DoD’s occupational and environmental health surveillance data 

are used in accordance with its completeness, accuracy, and relevance to help address the health concerns reported by Veterans. The DoD has provided tremendous 

support in the development of an Airborne Hazards and Open Burn Pit Registry by 

providing data for pre-population of deployment dates and locations using information from existing DoD databases. Earlier efforts to construct a model of the plume 

of low-dose chemical warfare agent dispersion from the Kamisiyah demolition have 

been subject to criticism by GAO and IOM, but used the best data and methodologies available at the time to understand the exposure. Treatment decisions are handled based on clinical presentation of the individual patient, including the Veteran’s 

self-reported history of exposures and the scientific soundness and safety of available therapy options. 

In the routine care of Veterans, clinicians are encouraged to ask Veterans about 

their military experience, and in the case of specialized assessments, utilize principles of occupational medicine and knowledge about known hazards to reconstruct 

a self-reported exposure assessment. This can then be used by clinicians to estimate 

the extent of their patients’ possible exposure to such hazards and to develop a 

crude probability of any known or possible long term health effects related to these 

exposure(s). The treating providers then continue to monitor these patients for any 

possible associated condition(s) that may clinically manifest as a result of their inservice exposure to such hazards. It is important to recognize that clinicians will 

also treat patients with known or suspected exposures in a holistic and caring matter. 

Question 8: IOM Volume 8 noted a fifteen percent excess of lung cancer 

for Gulf War Veterans and recommended further follow up because ‘‘cancer 

incidence in the past 10 years has not been reported.’’ Yet, IOM Volume 10 

mentions a lack of sufficient evidence between deployment to the Gulf War 

and any form of cancer. Please provide the updated disease specific incidence and mortality data accounting for this change. 

VA Response: The IOM Volume 10 does not have readily available disease specific cancer mortality that would compare deployed and non-deployed populations. 

The IOM however used several studies to study cancer incidence. A recent study of 

Australian Veterans showed no definitive difference in deployed versus non-deployed Veterans for any cancer except for a statistically significant increase in thyroid cancer based on five events. (Sim et al., 2015) 1 A large scale second study 

looked at Veterans diagnosed with cancer using data from the Defense Manpower 

Data Center, which was linked to central cancer registries in 28 states and to the 

VA Central Cancer Registry. Using statistical methods that included regression 

analyses, lung cancer was the only site-specific cancer found to have a significantly 

higher proportion among deployed Veterans compared with non-deployed era Veterans (PIR = 1.15, 95 percent CI 1.03–1.29). [Note: this appears to be the 15 percent 

increase cited above and is found in Volume 10] However, the risk was not increased over the general population. An important caveat is that smoking history, 

the known primary cause of lung cancer, was not controlled for in the study. Other 

cancers did not show an elevation of risk. Overall, after controlling for age, race, 

and sex, there was no significant association between Gulf status and the proportion 

of Veterans with a cancer (odds ratio, 0.99; 95 percent CI, 0.96–1.02) identified from 

a state registry. (Young et al., 2010). 2

It is important to recognize, however, as the IOM Volume 10 states: the length 

of follow-up was, at most, 15 years, which may not be enough time for certain cancers such as lung cancer to develop if there were a Gulf War exposure factor. A 

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3Dursa, E. K., S. K. Barth, A. I. Schneiderman, and R. M. Bossarte. 2016. Physical and mental health status of Gulf War and Gulf era Veterans. Journal of Occupational and Environmental Medicine 58(1):41–46. 

study led by VA (Dursa et. al., 2016) 3 used survey data of thousands of Veterans 

and demonstrated no statistical increase in cancers, but brain cancer was slightly 

elevated at 1.02 OR. Finally, VA provided a health care use report for Gulf War era 

deployed and non-deployed Veterans who sought care in VA facilities from October 

2001 to December 2013. These VA health care users represent 46 percent of all deployed Gulf War Veterans and 36 percent of all non-deployed era Veterans. This 

data also has deployed Veterans with a slightly lower percentage of lung or trachea 

cancers (6.0 percent versus. 6.3 percent) out of all cancers diagnoses than non-deployed Veterans. Importantly, an ongoing VA technical workgroup, which includes 

VA, will look closely at all available data/cited publications on all cancers, and especially, review the results for lung cancer for its upcoming technical workgroup report and recommendations to the Secretary. 

Question 9: Given the O&I hearing in June 2015, where videos of VA employees acknowledged that the department is making drug addicts out of 

Veterans and the CDC and American Medical Association’s concerns related to overmedication were highlighted, why is VA prescribing these serious drugs for Gulf War Illness? 

VA Response: Some of the drug categories of concern due to their potential to 

cause addiction and/or unintentional overdose (or other adverse outcomes) are opioid 

medications, benzodiazepines (medications for sleep and anxiety), stimulants, 

immunotherapies, antibiotics and corticosteroids. These are specifically mentioned 

as medications to avoid as treatments for Gulf War Illness (GWI) related CMI in 

Veterans unless clinically indicated for co-occurring conditions With respect to 

opioids in particular, the guideline states ‘‘Avoid the long-term use of opioid medications’’ unless clinically indicated. In general, the CPG suggests that treatment 

teams ‘‘Maximize the use of non-pharmacologic therapies’’. 

Question 10: In its 2011 report, the IOM recommended that additional 

studies of health effects in Veterans deployed to Iraq and Afghanistan were 

needed to help determine whether certain long-term health effects were 

likely to result from exposure to burn pits during deployments. Please describe the research VA conducted in response to this recommendation. 

VA Response: VA and DoD research on respiratory illness among Veterans deployed to Iraq and Afghanistan is focused on: (1) determining the prevalence and 

severity of lung disease associated with deployment to South West Asia, (SWA) and, 

(2) identifying the geographical, behavioral, medical, and causative factors related 

to deployment associated lung disease. 

In 2013, VA’s East Orange, New Jersey WRIISC launched the Airborne Hazards 

Center of Excellence to provide comprehensive medical evaluations focused on the 

respiratory health in deployed Veterans. Their clinical research has addressed several important gaps in the diagnostic evaluation of symptomatic Veterans, in addition to addressing Veterans’ health concerns through direct patient care. Their research efforts have resulted in 12 peer-reviewed publications, eight conference abstracts, and a book chapter. East Orange WRIISC researchers reviewed data published from 2001 to 2014 pertaining to respiratory health in military personnel deployed to Iraq and/or Afghanistan and found 19 unique studies. In summary, published data based on case reports and retrospective cohort studies suggest a higher 

prevalence of respiratory symptoms and respiratory illness in Veterans deployed to 

Iraq and/or Afghanistan. However, the association between chronic lung disease and 

airborne hazards exposure requires further longitudinal research studies with objective pulmonary assessments. 

VA’s Office of Research and Development (ORD) funds research projects that address respiratory health issues in Veterans deployed to Iraq and Afghanistan. ORD’s 

Request for Applications under the ‘‘Merit Review Award for Deployment Health Research OEF/OIF/OND’’ lists the health effects of burn pits as a specific area of emphasis. 

ORD funded research projects completed in 2015: 

• Effects of Deployment Exposures on Cardiopulmonary and Autonomic Function; 

Investigator: Michael Falvo, PhD; East Orange, New Jersey 

• Nanoparticle Coupled Antioxidants for Respiratory Illness in Veterans; Investigator: Rodney Schlosser, MD; Charleston, Sout Carolina 

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Ongoing ORD funded research: 

• Mechanisms of Cigarette Smoke-Induced Acute Lung Injury; Investigator: Sharon Rounds, MD; Providence, Rhode Island (7/1/2015–6/30/2019) 

• Carbon Black Induced Activation of Lung Antigen-Presenting Cells (APCs); Investigator: David B. Corry, MD; Houston, Texas (7/1/2013–6/30/2017) 

• Targeting HSC-derived Circulating Fibroblast Precursors in Pulmonary Fibrosis; Investigator: Amanda C. LaRue, PhD; Charleston, South Carolina 

(10/1/2013–9/30/2017). 

VA continues to make use of longitudinal research studies to evaluate the respiratory health of deployed Veterans. VA and DoD have developed an Interagency 

Agreement to support the joint examination of data collected by the Millennium Cohort Study. The aim of this collaboration is to evaluate the impact of military service on health and disease over time. 

The VA-led National Health Study of a New Generation of US Veterans sampled 

60,000 OEF/OIF deployed Service members and non-deployed Veterans in 2008, and 

administered a survey that included self-reported measures of exposure and disease. 

The New Generation study has resulted in one publication analyzing prevalence of 

respiratory diseases, and additional analyses are underway. 

In addition, VA conducts ongoing surveillance of VA health care utilization 

through systematic reviews and investigation of diseases treated. This surveillance 

drives in-depth investigation of areas of special concern, such as respiratory diseases. These studies enable VA to identify potential adverse health effects associated with deployment, including respiratory disease, and follow them over time. 

Question 11: On February 11th, VA issued its final report on Gulf War Illness, which had similar findings to IOM’s previous report. IOM concluded 

that future research efforts need to focus on the interconnectedness of the 

brain and the rest of the body’s organ systems when seeking to improve 

treatment of Veterans for Gulf War Illness. What actions, if any, does VA 

plan to take in response to this report? 

VA Response: VA has implemented a technical workgroup (see VA Response for 

Question 16 for details) to review all the recommendations in this report and to provide recommendations in response to the report to the Secretary of Veterans Affairs. 

This will include a review of this important recommendation. VA also plans to have 

listening sessions in the near future with Veterans to get their input into this and 

other IOM recommendations, as well as getting that of the Research Advisory Committee on Gulf War Veterans’ Illnesses. The VA takes seriously the idea that ongoing research will need to focus on the holistic treatment of Veterans; as such, VA 

research will aim to find solutions that take into account the inter-connectedness 

of the brain with other organ systems. 

One area where VA is increasing its focus is Integrative Health Care (IHC). Still, 

we caution that positive research findings related to use of IHC do not automatically 

translate into available clinical services, because VA may only provide care that is 

in accord with generally accepted standards of medical practice and is needed to 

promote, preserve, or restore health as provided in 38 Code of Federal Regulations 

17.38(b). To this end, VA is conducting a randomized control trial, entitled ‘‘Complementary and Alternative Medicine (CAM) for Sleep, Health Functioning, and 

Quality of Life in Veterans with Gulf War (GW) Veterans’ Illnesses’’,’’ also referred 

to as the GW–CAM Study. This study examines Gulf War Veterans Illness by assessing the hallmark conditions of pain, fatigue, sleep and cognitive difficulty, and 

the efficacy of a CAM intervention on these conditions. To further expand our understanding of Gulf War Veterans Illness and the efficacy of a CAM treatment intervention, the GW–CAM Study has also partnered with the Department of Defense 

to develop a brain imaging protocol that will be incorporated into the GW–CAM 

Study. 

Question 12: Dr. Hunt’s testimony was that psychiatric medications 

should not be given for Gulf War Illness and yet the clinical guidelines created and promulgated by VA (including Dr. Hunt) recommending numerous 

pharmacologic agents for Gulf War Illness. Please explain this discrepancy 

in detail. 

VA Response: The Chronic Multi-Symptom Illness (CMI) CPG is based upon current evidence-based approaches to CMI. The specific symptoms experienced by Gulf 

War Veterans vary from one Veteran to another. Given that treatment for CMI/Gulf 

War Illness is primarily aimed at symptom management, the treatment approaches 

are personalized and will vary from Veteran to Veteran, depending upon whether 

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an individual has fatigue, pain, cognitive disturbances, gastrointestinal disorders or 

other symptoms as their predominant manifestation of CMI. 

Certain medications that are also used for depression, such as selective serotonin 

reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors (SNRI’s) have 

also been found to be helpful in symptom reduction in individuals with pain-predominant CMI, fatigue predominant CMI or global symptoms CMI. These medications, when clinically appropriate and used in the care of Gulf War Veterans are 

not being used as ‘‘psychiatric medications’’. They are being used to offer relief from 

specific symptoms or combinations of symptoms. In general, the CPG advocates 

treatment teams to ‘‘Maximize the use of non-pharmacologic therapies’’ as clinically 

appropriate; again, our providers must abide by the applicable standards of care and 

these may involve the use of certain drugs in a particular patient case, especially 

where the use of non-pharmacologic therapies has not been effective. 

Question 13: Dr. Hunt’s presentation titled ’’A Model for Providing Services for Returning Combat Veterans,’’ implies that he and others in VA believe Gulf War Illness is a ‘‘mental disorder.’’ This is further substantiated 

in Dr. Hunt’s Community of Practice call conducted Friday, March 11th. 

During this call, VA discussed issues related to our subcommittee’s hearing 

held on February 23rd. The call included more than fifty participants, and 

it discussed how to improve care for Veterans suffering from Gulf War Illness. Unfortunately, the majority of the attention was given to a presentation by Dr. David Kearney regarding chronic pain, with what seemed to 

be an emphasis on PTSD - and the use of mindfulness as a method of treatment for Gulf War Illness. Please explain in detail the discrepancy in Dr. 

Hunt’s public statements and his internal VA discussions and presentations. 

VA Response: Dr. Hunt’s presentation, ’’A Model for Providing Services for Returning Combat Veterans,’’ was not intended to imply that he and others in VA believe Gulf War Illness is a ‘‘mental disorder.’’ The presentation focuses on the importance of understanding and responding effectively to the complex experience of combat. Environmental exposures are one aspect of that experience, and a particularly 

important aspect in our Gulf War Veterans as is pointed out in slides 25 - 32 presented to the Committee. This is important whether considering entitlement to benefits administered by VHA or VBA. The importance of assisting Veterans in accessing benefits is mentioned in several slides that were presented. 

Question 14: Does Dr. Hunt believe Gulf War Illness is specifically a mental, psychiatric, psychologic, or psychosomatic issue? Please do not convolute the answer by discussing the obvious mind-body connection associated with how the brain works in relation to body mechanics. 

VA Response: No. As Dr. Hunt stated in his testimony, he does not believe that 

Gulf War illness is specifically a mental, psychiatric, psychological, or psychosomatic 

issue. Dr. Hunt’s board certification is in Occupational and Environmental medicine, 

the medical specialty that focuses on toxic exposures in the home, workplace, and 

other external environments. He is a Clinical Associate Professor in this program 

at the University of Washington. From the beginning, his work with Gulf War Veterans has been oriented primarily towards ensuring that they receive the care that 

will most effectively support them. 

He has admittedly been very concerned that at times the debate over ‘‘what 

causes Gulf War Illness’’ (a challenging, but nonetheless extremely important, question that still has not been answered after 25 years of research) has distracted both 

the clinical and research communities from offering effective support for these Veterans. He does not question the fact that environmental exposures have contributed 

to the health concerns of GW Veterans and consistently promotes two important 

parallel courses of action: 

1.Ongoing research to identify specific causal relationships between specific exposures (or combinations of exposures) and health conditions in GW Veterans so that 

specific targeted treatments can be established (such as CoQ10 which he mentioned 

in his testimony); and, 

2.Until such relationships and targeted treatments are clearly established, clinicians must provide effective condition-specific treatment. General and specialist 

health care is available under VA’s medical benefits package to enrolled Veterans 

to ensure they do well. VA’s treatment authority for GW Veterans is broadly worded 

and permits VA to treat them at no cost for conditions that may be associated with 

their service in the Gulf War; not withstanding the current lack of evidence that 

such a condition (s) is associated with such service. Only those conditions that can 

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be ruled out by the USH as not being associated with such service are excluded and 

those are few in number. 

Quesiton 15: Many Veterans have complained that VA’s questionnaires to 

Veterans suffering from Gulf War Illness (GWI) are worded in such a way 

to reach a preconceived finding that GWI is a mental issue or a PTSD issue. 

Please submit all such questionnaires provided to Veterans and all responses from the recipients of the questionnaire. 

VA Response: VA has conducted a number of research studies on the health concerns of Gulf War Veterans. The largest study has followed the same panel of 30,000 

Gulf War Era Veterans with three surveys since 1995; half of the Veterans selected 

for the study deployed to the Gulf and the other half served elsewhere. The goal 

of this study was to assess the health of Gulf War and Gulf War Era Veterans. Each 

of three surveys administered over this period has asked a core set of questions important for assessing major domains of well-being, illness, and health determinants, 

or risk factors. Health has many domains: physical, mental, reproductive, functional, and social. This study completed its most recent follow up assessment in 

2012 was a comprehensive assessment of multiple domains of health among Gulf 

War and Gulf War Era Veterans. While certain health conditions may be more prevalent among Gulf War Veterans, the purpose of this study is not to focus on one 

particular domain or health condition, but to present a population level assessment 

of the health of Gulf War and Gulf War Era Veterans. 

This will help VA better understand any possible associations between their service and the clinical symptoms, and so better serve this population of Veterans. The 

questionnaire included standard validated scales and screening tools that are used 

widely both in clinical practice and in research. The inclusion of questions that 

measure symptoms of PTSD and other mental health conditions is based on evidence from the peer-reviewed literature that demonstrates these conditions are 

prevalent among Veterans (regardless of era or deployment status) and are associated with poor health outcomes overall. The principles of good questionnaire design 

dictate the selection of validated scales, construction of clear questions, and layout 

choices that elicits information in an unbiased fashion; the questionnaires used to 

study this panel of Gulf War Era Veterans have not been worded in such a way 

as to reach a preconceived result regarding the etiology of GWI or any association 

it may have with mental health symptoms or PTSD. This study has consistently 

provided evidence that Gulf War Veterans who deployed are sicker than their nondeployed peers. Notably, this study provided early evidence to support the understanding of Gulf War Illnesses as a multisystem illness state. 

Copies of the IRB and OMB-approved surveys that were sent to Veteran participants of this study in 1995, 2005, and 2012 are attached. VA cannot provide all responses from the recipients of the questionnaires; as the research participants did 

not consent to have their individual data shared. 

Question 16: Given VA’s public acknowledgement that Gulf War Illness is 

a biological disorder, please explain why VA’s clinical treatment protocols 

treat it as a psychological disorder. 

VA Response: The DoD/VA CMI CPG does not treat GWI as a psychological disorder. It can be found on the web page of the DoD/VA Clinical Practice Guidelines 

in the section of ‘‘Military Related.’’ It is not included in the section of the website 

where DoD/VA’s related CPGs to mental health are found. http:// 

www.healthquality.va.gov/. This underscores that it is considered to be a deployment health matter. The CPG is meant to offer guidance in how to provide effective 

care for Veterans with CMI. It begins by advocating that each Veteran be assigned 

a basic medical team ‘‘including a behavioral health specialist in Primary Care.’’ 

This is standard for all Veterans enrolled in VA’s health care system, particularly 

those who have been deployed to combat theaters. ‘‘Deployment related exposures’’ 

are one of a number of ‘‘critical domains’’ for knowledge on these teams. The standard of care in VA is to have behavioral health available for any Veteran who needs 

it through their expanded Patient Aligned Care Team. 

Question 17: What is VA’s opinion of IOM’s conclusions in its most recent 

report given the similarities with its last report? Is VA satisfied that sufficient progress is being made to identify and better understand the causes 

of Gulf War Illness? 

VA Response: A technical workgroup (TWG) of VA subject matter experts has 

been assembled to review IOM’s report, Gulf War and Health: Volume 10: Update 

of Health Effects of Serving in the Gulf War, 2016. This TWG is working to determine how the findings and recommendations might help to identify possible adverse 

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health effects related to such service in order to make a recommendation to the VA 

Secretary as to whether to establish a presumption of service-connection for a certain condition(s). This review will also include all other information and peer-reviewed literature which have become recently available. The TWG will draft a formal VA response document with recommended courses of action which will then be 

carefully staffed through senior leadership. Ultimately, the recommendations will go 

to the Secretary of Veterans Affairs for decision. This process is expected to take 

3 - 4 months. VA would be happy to discuss our ongoing process in this regard, but 

feel that it is presently premature to discuss our impressions or views. 

Question 18: What is VA’s opinion of IOM’s decision not to consider the 

results of animal research in its conclusions? 

VA Response: The IOM committee conducted an extensive review of animal research related to Gulf War Veterans’ symptoms. VA will be discussing in its technical workgroup (see above) the results of the animal studies and the ways in which 

these studies were evaluated and used by the IOM committee in drawing their conclusions. The IOM recommendations about possible future research concerning the 

validity of animal models will also be considered by the TWG, but it would be premature to make comments about specific IOM conclusions and recommendations before the work of VA’s TWG is complete. 

Question 19: What is VA’s opinion of the Research Advisory Committee 

(RAC) on Gulf War Veterans’ Illnesses (RAC)’s 2008 report, which used animal studies to conclude that pyridostigmine bromide pills and pesticide are 

associated with War Illness? 

VA Response: In its 2008 report (http://www.va.gov/RAC- GWVI/docs/Committee—Documents/GWIandHealthofGWVeterans—RAC- GWVIReport—2008.pdf), 

the RAC on Gulf War Veterans’ Illnesses concluded that there was ‘‘strong support 

for both PB [pyridostigmine bromide] and pesticides as causal factors in Gulf War 

illness.’’ (p. 185). 

In its report, Gulf War and Health: Volume 8 (2010), (http://www.nap.edu/catalog/ 

12835/gulf-war-and-health-volume-8-update-of-health-effects), IOM reviewed the 

publications cited by the RAC and determined that there was ‘‘insufficient support 

for the conclusion’’ reached by the RAC (p. 279). The IOM indicated that there was 

a lack of association in agricultural workers who used pesticides regularly, a lack 

of persistent effects on the central nervous systems in animals, and a lack of consistent results in studies of Gulf War Veterans. 

VA’s position, based on IOM’s earlier reports (excluding Volume 10 published in 

2016) is that the cause of Gulf War illness is not yet known with certainty, even 

though groups of qualified scientists and physicians have reviewed the same data, 

including animal studies. 

Question 20: Please explain the reasons for the turnover in leadership 

and membership of the RAC that has occurred since 2013. As part of your 

response, please provide the background and qualifications for each of the 

current committee members. 

VA Response: This committee, required by section 104(b) of Public Law 105–368 

(1998), is, in addition to relevant VA policy, subject to the Federal Advisory Committee Act (FACA), codified at 5 U.S.C. App., and regulations administered by the 

General Services Administration. 

As a committee governed by the FACA, the RAC is required to follow FACA 

guidelines and VA policy. The charter (http://www.va.gov/RAC–GWVI/docs/Committee—Documents/CharterRACGWVI2015May.pdf) for the RAC specifies that the 

Chair can be appointed for an initial 2— year term and may be reappointed for an 

additional 1 or 2-year term. Similarly, the remaining members can be appointed for 

a 2 or 3 - year term and may be reappointed for an additional 1 or 2 - year term. 

As of 2013, six members had served since the committee was formed in 2002, three 

had served since 2005, and one each had served since 2006, 2007, and 2008. To become compliant with FACA and VA policy, approximately one-third of the committee 

members were to be replaced in each of the next three years. Membership rotations 

will continue each year into the future to ensure that multiple viewpoints from scientists, physicians, and Veterans are brought to VA. Nominations for membership 

are solicited in the Federal Registry. Brief biographies of current members are available on the RAC webpage (http://www.va.gov/RAC–GWVI/Members—and—Consultants.asp). 

Æ 

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