GAO

United States General Accounting Office

Report to the Chairman, Subcommittee 

on National Security, Veterans’ Affairs 

and International Relations, Committee 

on Governmental Reform, House of 

Representatives

January 2000 GULF WAR 

ILLNESSES

Management Actions 

Needed to Answer 

Basic Research 

Questions

GAO/NSIAD-00-32

Page 1 GAO/NSIAD-00-32 Gulf War Illnesses

Contents

Letter 3

Appendixes Appendix I: Research Objectives Identified by the Research 

Working Group of the Persian Gulf Veterans’ Coordinating 

Board 26

Appendix II: Reports Received and Released by the Office of 

the Special Assistant Under Research Contracts Examined by 

GAO 28

Appendix III: Sample Working Case Definitions Describing 

Symptoms Experienced by Gulf War Veterans 31

Appendix IV: Comments From the Department of Defense 32

Appendix V: Comments From the Department of Veterans’ 

Affairs 46

Appendix VI: Comments From the Centers for Disease Control 

and Prevention 53

Appendix VII: GAO Contacts and Staff Acknowledgments 56

Related GAO Products 58
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United States General Accounting Office

Washington, D.C. 20548

National Security and

International Affairs Division

B-282454 Letr

January 6, 2000

The Honorable Christopher Shays

Chairman, Subcommittee on National Security, 

Veterans’ Affairs, and International Relations

Committee on Government Reform

House of Representatives

Dear Mr. Chairman:

Many of the approximately 700,000 veterans of the Persian Gulf War have 

complained of illnesses since the war’s end in 1991, and over 10 percent 

have sought and completed health examinations through the Department 

of Veterans’ Affairs or Defense. Some fear they are suffering from chronic 

disabling conditions because of wartime exposures to one or more agents 

with known or suspected health effects. In response to these concerns, the 

government has funded research, investigation, and information activities 

through agencies such as the Departments of Veterans’ Affairs, Defense, 

and Health and Human Services, which are represented on the Persian Gulf 

Veterans’ Coordinating Board, the body that coordinates the federal 

response to Gulf War veterans’ illnesses. 

As requested, we identified expenditures on these efforts and evaluated 

their results. Specifically, our objectives were to describe 

• the amount of money that these three departments spent on research 

and investigation of Gulf War veterans’ illnesses and health concerns in 

fiscal years 1997 and 1998, including current and projected spending by 

the Office of the Special Assistant to the Deputy Secretary of Defense 

for Gulf War Illnesses;

• the productivity of this research spending, including the extent to which 

the Coordinating Board has determined that federal research objectives 

have been satisfied, and the extent to which the research has resulted in 

peer-reviewed publications and the identification of the causes or 

successful treatments for Gulf War veterans’ illnesses;

• the extent of coordination between the Research Working Group of the 

Coordinating Board and the Office of the Special Assistant for Gulf War 

Illnesses; and 

• the Office of the Special Assistant for Gulf War Illnesses’ contract 

management. 
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Results in Brief During fiscal years 1997-98, the Departments of Defense, Veterans’ Affairs 

and Health and Human Services spent more than $121 million on research 

and investigation of Gulf War veterans’ illnesses, with DOD spending more 

than $112 million of that total. These funds supported a growing catalog of 

research and investigatory efforts intended to address both veterans’ health 

concerns and their questions about hazards encountered in the conflict. 

The Office of the Special Assistant to the Deputy Secretary of Defense for 

Gulf War Illnesses spent the majority of the federal research and 

investigatory funds we identified, about $65.3 million in fiscal years 1997 

and 1998, with another $65.4 million in spending planned for fiscal years 

1999 and 2000.

Basic questions about the causes, course of development, and treatments 

of Gulf War veterans’ illnesses remain unanswered. As of 

November 30, 1999, the Research Working Group of the Persian Gulf 

Veterans’ Coordinating Board had not published an assessment of the 

extent to which the research program had answered the major questions it 

identified as research objectives in 1995, and no date had been set to 

publish such an assessment. By the end of 1998, among the 151 research 

projects monitored by the Group, 117, or 77 percent, were recorded as 

ongoing, including 29, or 47 percent, of the 62 that were scheduled for 

completion by that time. Among those that were not recorded as complete 

at the end of 1998, about one-third were later completed and the remaining 

two-thirds had their estimated completion dates extended. Group officials 

attributed the extensions either to provisions to collect or incorporate 

additional data or to unanticipated delays, such as difficulty in securing 

approval to collect data or in locating and recruiting veteran participants. 

Augmenting the research monitored by the Group, DOD’s Office of the 

Special Assistant to the Deputy Secretary of Defense for Gulf War Illnesses 

had received 19 of the 20 reports due from its major research contractors 

by late 1999, with 6 publicly released and the remainder largely in various 

stages of interagency review. Fourteen reports had remained in draft or 

review status for a year or longer.

While federally sponsored studies have resulted in some descriptive 

information concerning veterans’ symptoms, many basic questions (such 

as the numbers of veterans with unexplained symptoms and the course of 

their illnesses over time) remain. Answers to more complex questions 

about the potential cause(s) of veterans’ unexplained symptoms have been 

difficult to derive in part because problems in identifying veterans’ specific 

exposures persist. In addition, no working case definition or set of 
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definitions of illnesses affecting veterans has been endorsed by the Group. 

Perhaps because analytic epidemiological research depends heavily upon 

exposure data and/or case definition, completed epidemiological research, 

which comprises a large portion of the research portfolio, has been less 

likely than other types to result in peer-reviewed publications and most of 

these studies have been descriptive. Although the question of causation is 

unresolved, in the interest of assisting ill veterans, the Department of 

Veterans’ Affairs has begun recruiting patients for trials of antibiotic and 

exercise-behavioral treatments for a set of veterans’ unexplained 

symptoms. 

Although the Office of the Special Assistant for Gulf War Illnesses expends 

more than half of the federal funds supporting research and investigation 

into Gulf War veterans’ illnesses, its activities are not effectively 

coordinated with those of the Research Working Group. According to 

officials from both organizations, the Office of the Special Assistant’s 

activities involve investigations, rather than research, and therefore are not 

subject to coordination. However, the Group considered some of the 

Office’s activities to involve research and expressed concern about the lack 

of an external review process. The weak coordination between the Group 

and the Office increases the potential to miss opportunities to leverage 

ongoing and completed work by other agencies, and we found a few 

examples of such problems.

The Office rapidly developed relationships with various contractors to 

support its mission. However, two of the largest task orders were awarded 

improperly, and the Office discouraged competition for another task order 

by specifying a preferred vendor. Because the Office is likely to continue to 

spend a significant part of its budget on support contracts, it needs to 

insure that its contracts fully comply with applicable requirements.

We are making recommendations to improve federal efforts to assess and 

conduct research, coordination between the Office and the Group, and the 

Office’s arrangements with its support contractors. 

Background Several federal agencies and offices have generated and coordinated 

responses to veterans’ complaints of illnesses following the Gulf War. 

These have included the Departments of Defense (DOD), Health and 

Human Services (HHS), Veterans’ Affairs (VA), and Energy, the Central 

Intelligence Agency, the Environmental Protection Agency, the National 

Security Council, and the Office of Management and Budget. 
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The formation of the Persian Gulf Veterans’ Coordinating Board (PGVCB) 

was announced in early 1994 for the purpose of coordinating federal 

research and other activities in response to illnesses reported by Gulf War 

veterans. This body, which is co-chaired by the Secretaries of Defense, 

Veterans’ Affairs, and Health and Human Services, comprises working 

groups on research, clinical issues, and compensation. The PGVCB 

Research Working Group (RWG), which has no budgetary authority, does 

not directly manage or distribute research funds. It describes its 

responsibilities as (1) assessing the state and direction of research and 

identifying gaps in factual knowledge and conceptual understanding, 

(2) identifying testable hypotheses and potential research approaches, 

(3) reviewing research concepts as they are developed, (4) collecting and 

disseminating scientifically peer-reviewed information, and (5) insuring 

that appropriate peer review and oversight are applied to research the 

government has conducted or sponsored.

Within DOD, initial efforts to respond to Gulf War veterans’ complaints 

were managed by the Assistant Secretary of Defense for Health Affairs. In 

November 1996, following worsening public relations, management of 

these efforts was transferred to the newly created Office of the Special 

Assistant for Gulf War Illnesses (OSAGWI), which became responsible for 

oversight of DOD’s efforts regarding illnesses being experienced by Gulf 

War veterans. OSAGWI reported directly to the Deputy Secretary of 

Defense. The Assistant Secretary of Defense for Health Affairs continued to 

be responsible for managing and coordinating related health programs, 

while DOD’s medical research efforts were managed largely by the 

Undersecretary of Defense for Acquisition and Technology and the Army 

Medical Research and Materiel Command. DOD established OSAGWI to 

restore public confidence in DOD’s efforts to deal with Gulf War illnesses 

issues. OSAGWI has focused its efforts on (1) establishing effective 

two-way communications with veterans and veterans’ groups, 

(2) investigating and reporting on incidents of possible chemical warfare 

agent exposures, and (3) applying lessons learned from the Gulf War 

experience to better protect U.S. servicemembers on a contaminated 

battlefield.

The efforts of the various federal agencies have been met with skepticism 

on the part of some veterans. This skepticism was fueled by the delay, until 

1996, in acknowledging potential exposures to low levels of nerve agent at 

a munitions dump in Khamisiyah, Iraq, during postwar demolition 

activities. Additionally, veterans were upset by DOD’s and VA’s initial 

emphasis on stress as a potential explanation for their symptoms. 
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Congressional oversight of DOD’s and VA’s efforts has identified problems 

in the agencies’ clinical monitoring of veterans’ conditions and 

inaccuracies in agency statements about veterans’ potential exposures. 

Spending on Research 

and Investigation of 

Veterans’ Illnesses Is 

Concentrated Within 

DOD

During fiscal years 1997 and 1998, HHS, DOD, and VA reported total 

expenditures of at least $121.3 million on research and/or investigation of 

Gulf War veterans’ illnesses. 1

 These expenditures included $112.4 million 

in DOD funds ($65.3 million for OSAGWI and $47.1 million for 

non-OSAGWI expenditures), $7.2 million for VA, and $1.6 million for HHS.2

These amounts excluded expenditures on examination and clinical care of 

ill veterans during this time period. 

Because OSAGWI managed the majority of DOD’s research and 

investigation expenditures, it was the single largest component of the 

federal research and investigatory effort to respond to veterans’ concerns. 

The remainder of DOD’s spending was attributed to internal and external, 

DOD-sponsored research efforts catalogued by the RWG. 

1

The RWG records funds expended by VA, HHS, and DOD based on the year in which they 

were appropriated. Because these appropriations can be spent over 2 years, RWG data for 

the most recently reported fiscal year (1998) were not necessarily a complete representation 

of final spending for that fiscal year. For this reason, fiscal year expenditures, which were 

provided in December 1998, are likely to have increased during fiscal year 1999. 

2

These figures do not add to $121.3 million because of rounding. The costs for VA studies do 

not include overhead costs because indirect costs are included under VA’s medical care 

appropriation. Similarly, the majority of HHS’ expenditures represent direct costs only. 

DOD’s non-OSAGWI spending does not include overhead costs for intramural studies but 

does for extramural ones. In addition, the numbers reported for OSAGWI include overhead 

costs and some spending on veteran outreach. 
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OSAGWI was established in November 1996, when a staff of 110 and an 

annual budget of $11.4 million were projected. The Office later grew to a 

staff of slightly over 200, spending more than $65 million across fiscal years 

1997 and 1998, and planning expenditures of $35.9 million in fiscal year 

1999 and $29.5 million in fiscal year 2000.3

OSAGWI categorizes its spending as research or support. During fiscal 

years 1997-98, OSAGWI spent $13.3 million, or 20 percent of its 

expenditures, on instruments it characterized as research contracts and 

another $47.1 million, or about 73 percent of its expenditures, on 

instruments it characterized as support contracts. The remaining funds, 

about 7 percent of OSAGWI spending, covered overhead, travel, 

conferences, computer equipment, and miscellaneous other expenses. 

Many of its support costs are difficult to separate from research and 

investigation expenditures. For example, the objectives of OSAGWI’s 

support contracts ($21 million) with one contractor—BDM International—

include obtaining, documenting, and analyzing information potentially 

related to Gulf War illnesses; documenting the data and analysis in 

databases and other forms of storage; developing questionnaires and 

surveys to collect data; rapidly creating data analysis tools to aid in analysis 

efforts; and developing and producing case studies. 

Basic Questions About 

Causes, Course, and 

Treatment of Veterans’ 

Illnesses Remain 

Unanswered

The RWG has not assessed the extent to which the research agenda has 

satisfied the objectives it identified in 1995. The majority of federal 

research projects remain ongoing or in review. Problems identifying valid 

data on veterans’ exposures persist, and basic questions, such as how many 

veterans have unexplained symptoms and whether those who have 

received care in VA facilities are getting better or worse, remain 

unanswered. 

3

Although OSAGWI officials are seeking the guidance of the Special Oversight Board on 

DOD Investigations of Chemical and Biological Incidents to determine what portion of its 

investigation work should continue and how it should draw down the Office, the Office is 

incorporated in DOD’s budget through fiscal 2005, with twice the number of investigations 

ongoing as have been completed. 
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The Extent to Which 

Research Objectives Have 

Been Met Has Not Been 

Assessed

In April 1999, PGVCB officials told us they had not finished assessing the 

government’s progress in answering the 21 major questions that the RWG 

had identified in 1995. As detailed in appendix I, these research objectives 

include questions about the prevalence of various health problems and 

exposures among the veteran population and the way the prevalence 

differs between Gulf War veterans and “appropriate control populations.” 

With regard to exposure, the research objectives cover Leishmania tropica 

(a type of parasite), petroleum, petroleum combustion products, specific 

occupational/environmental hazards, chemical agent, pyridostigmine 

bromide, and psychophysiological stressors. With regard to veterans’ 

health status, the research objectives cover the prevalence among veterans 

and appropriate control populations of symptoms, symptom complexes, 

illnesses, altered immune function or host defense, birth defects, 

reproductive problems, sexual dysfunction, cancer, pulmonary symptoms, 

neuropsychological or neurological deficits, psychological symptoms or 

diagnoses, and mortality. Questions about exposure to low levels of nerve 

agent were added in 1996, when DOD acknowledged that U.S. troops might 

have experienced such exposures during postwar demolition activities at 

Khamisiyah. 

The research questions incorporate input from HHS, DOD, and VA but do 

not formally constrain the research funded by these agencies. Asked to 

identify which of the 21 research objectives had been satisfied by late 1998, 

RWG officials wrote, “Answers to some of the research questions contained 

in the Working Plan have been achieved to a greater degree of satisfaction 

than others. However, at this time, it is accurate to say that no research 

question has been answered to the extent that additional research would 

not be able to shed more light on the question.” In late 1998, an RWG 

official noted that a draft analysis of research results as they relate to these 

questions was anticipated in late spring or early summer 1999 in 

preparation for publication of a revised working plan for research on Gulf 

War Veterans’ illnesses, but no deadline had been established for publishing 

this analysis and no such analysis had been published as of June 1999. 

While DOD noted that the analysis was in progress, it had not been 

completed or a deadline established for its publication when DOD and VA 

submitted their comments on our draft report in August and September 

1999, respectively.

Return on Research 

Investment Accruing Slowly

Spending on research was spread among various projects catalogued by 

the PGVCB’s Research Working Group and an additional set of projects 
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sponsored by OSAGWI. While findings from this work are beginning to 

accumulate, most of it is ongoing or in review.

Research Catalogued by RWG Although the research portfolio monitored by the RWG includes over 

50 projects that began in 1994 or earlier, only 34 of the 151 projects, or 

23 percent of those cataloged by the RWG, had been reported complete as 

of December 1998. This was 53 percent of the 62 that were scheduled for 

completion by that time. Among the 47 percent of this group that were not 

complete in December 1998, about one-third were later completed and the 

remaining two-thirds had their estimated completion dates revised (with 

extensions varying from a few months to 10 years). RWG officials 

attributed the extensions either to efforts to collect or incorporate 

additional data or to unanticipated delays, such as difficulties in securing 

approval to collect data or problems in locating and recruiting veteran 

participants.4

 The officials identified four instances in which additional 

funds had been provided. For example, the Centers for Disease Control’s 

health assessment of Persian Gulf War Veterans from Iowa was extended to 

2000 to provide for additional follow-up of the survey sample. Similarly, 

DOD has committed to fund two projects for the Army’s Center for Health 

Promotion and Preventive Medicine until 2003 and 2006.5

4 For example, some projects experienced delays in approval of their plans by institutional 

review boards while others experienced difficulty in recruiting subjects. Some survey 

efforts found that it was more difficult than anticipated to track veterans’ whereabouts since 

the war. 

5

Funding is extended through 2006 for the Kuwait Oil Fires Troop Exposure Assessment 

Model, a project responding to P.L. 102-190 by characterizing the potential carcinogenic and 

noncarcinogenic health risks to U.S. military personnel exposed to the environment affected 

by the oil well fires during and after Operation Desert Storm. Funding is extended through 

2003 for the Persian Gulf Veterans Health Tracking System, which is intended to 

characterize exposures (other than airborne contaminants from oil well fires) experienced 

by U.S. military personnel during Desert Storm and to assess the potential health 

risks/consequences of those potential exposures. 
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By June 1999, PGVCB reported only 1 of the 13 primary research areas, 

leishmaniasis, had a majority of projects complete (four of seven).6

 In one 

research area—treatment—no projects had yet been finished. 

Among the 23 percent of federal research projects into Gulf War veterans’ 

illnesses that were completed by December 1998, about two-thirds (22 of 

34) had resulted in at least one article published in a peer-reviewed journal. 

(We focused on this outcome because publication in a peer-reviewed 

journal was suggested as a surrogate marker for research quality in early 

interviews with RWG officials and because publication in this form insures 

more widespread access to research findings.) Some of the other 

completed projects have had findings released in the form of technical 

reports or summarized in an annual report issued by the RWG. Additional 

peer-reviewed publications have been issued from projects that are still 

ongoing.

Research Expenditures Managed 

by OSAGWI

Five key contractors accounted for about 72 percent of the $13.3 million 

that OSAGWI attributed to spending on research contracts in fiscal years 

1997 and 1998. We reviewed the status of deliverables under their contracts 

to determine whether they had been received in a timely manner and had 

been released to the public. We focused on timely provision of deliverables 

as a basic measure of contractor performance and on release of 

deliverables as an indicator of effectiveness, since the contracts were often 

for developing public information and doing so was a major part of 

OSAGWI’s mission. As of December 1999, OSAGWI (or the responsible 

element at DOD) had received 19, or 95 percent, of the 20 products due 

from the 5 research contracts. Among those products received, 6 had been 

released to the public, with the remainder largely in various stages of 

interagency review when we ended our work in December 1999. Fourteen 

products had remained in review or draft status for a year or longer. 

Appendix II contains detailed information on the research contracts we 

examined, including the contractor, the contract amount, the titles or 

topics of deliverables, and the deliverables’ status (i.e., whether they were 

due at the time of our review, had been received, and/or released, what 

6

The RWG cataloged the federal research portfolio by primary research topic in March 1998. 

At that time, there were 121 (instead of the current 151) federally sponsored research 

projects. Because 30 research projects that began after March 1998 were not categorized by 

the RWG into primary research topics, our analysis by primary research topic includes only 

the 121 that had been categorized. See the RWG’s report entitled Annual Report to Congress: 

Federally Sponsored Research on Gulf War Veterans’ Illnesses for 1997, March 1998. 
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form they were in at receipt, what was the date of the earliest known 

receipt, and whether they had been released). 

With respect to other products of OSAGWI’s spending, including 

nonresearch spending, by January 1, 1999, OSAGWI had issued 13 case 

narratives (accounts of particular incidents during the war), 

2 environmental exposure reports, and 4 information papers.7

 Work on an 

additional 26 case investigations was ongoing.8

 As of December 3, 1999, 1 

additional case narrative and 3 additional information papers had been 

issued.

7

Other accomplishments cited by OSAGWI officials in hearings before the Senior Oversight 

Panel on DOD Investigation of Chemical and Biological Incidents (held Nov. 19-20, 1998) 

included visiting five bases, answering 3,000 hotline calls, and responding to 5,000 e-mail 

inquiries. Additional veterans were contacted via the Office’s programs to notify veterans of 

potential exposures or survey veterans on particular topics. 

8

For a review of OSAGWI’s investigatory activities, see Gulf War Illnesses: Procedural and 

Reporting Improvements Are Needed in DOD’s Investigative Processes (GAO/NSIAD-99-59, 

Feb. 26, 1999).
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Problems in Identifying 

Valid Exposure Data Persist

Absence of agreement or valid data on veterans’ wartime exposures has 

presented formidable obstacles to researchers in developing definitive 

information about the causes of veterans’ illnesses. Although the nearly 

half of studies that are epidemiological depend to some extent on the use of 

exposure data, researchers continue to face difficulties in assessing and 

validating veterans’ exposures. These difficulties led us to conclude in our 

1997 report that the many epidemiological studies being sponsored would 

not provide definitive information on the causes of veterans’ illnesses.9

Proceedings of conferences on federally sponsored research also 

document that researchers are experiencing increasingly difficult problems 

in soliciting reliable self-reported data on exposures as time from the 

original events increases. 10 Because of such problems, the likelihood of 

misclassifying persons who received no exposure as having had some or 

significant exposure (or vice versa) will increase, reducing the capacity of 

data analyses to identify associations between exposures and health 

outcomes. Perhaps as a result, completed research projects classified as 

epidemiological had a lower rate of publication in peer reviewed journals 

than other types of federally sponsored research.11

To begin to identify the causes of an unexplained illness, epidemiological 

researchers normally define a set of criteria, known as a case definition, 

that can be used to separate persons who have the condition from those 

who do not. This permits researchers to look into differences in their 

histories to gain insight into what may have caused their illness. However, 

no such working case definition or set of such definitions that might focus 

federal research has been endorsed by the Research Working Group. 

Working case definitions of unexplained illness among veterans that have 

been proposed by individual researchers have been similar to one another 

in emphasizing unexplained fatigue, neurocognitive complaints, and 

9

Gulf War Illnesses: Improved Monitoring of Clinical Progress and Reexamination of 

Research Emphasis Are Needed (GAO/NSIAD-97-163, June 23, 1997). 

10See the RWG, PGVCB, Proceedings: Conference on Federally Sponsored Gulf War 

Veterans’ Illnesses Research, June 17-19, 1998 and June 23-25, 1999. 

11Of the 22 completed research projects classified as epidemiological, 12, or about 

55 percent, had resulted in publication of an article in a peer-reviewed journal. By way of 

comparison, 83 percent (10 of 12) of the completed nonepidemiological projects had results 

published in such journals. (We include projects originally classified by the RWG as clinical 

epidemiology as well as those projects classified as epidemiology in this total; after we 

recommended a shift from epidemiological research in June 1997, the RWG reclassified 

studies formerly designated clinical epidemiology as clinical research projects). 
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musculoskeletal complaints, symptoms reported more commonly by Gulf 

War veterans than by veterans of the same era who were deployed 

elsewhere (see app. III). 

Descriptive Information 

Concerning Veterans’ 

Symptoms Exists, but Many 

Basic Questions Remain 

Unanswered 

The government has had some success in cataloging data on the illnesses 

suffered by Gulf War veterans. DOD and VA registries gather such 

information, and studies have been funded to collect data on veterans’ 

symptoms. However, owing to the data collection formats used in the 

registry process and the self-selection of registry participants, the registries 

are not optimal sources of information regarding the prevalence of various 

symptom clusters among veterans, making it difficult to know which of the 

various case definitions or symptom groups deserve closer examination. 

For example, these registries are unlikely to record sufficient data to 

determine whether a veteran meets criteria for multiple chemical 

sensitivity or chronic fatigue syndrome, for which recognized case 

definitions exist, but not standard diagnostic categories, as represented by 

international disease classification codes. Some federally sponsored 

research, notably VA’s National Health Survey, might be able to clarify this 

issue, but descriptive data from the survey remained unpublished at the 

close of our review. 

Although some progress has been made in cataloging veterans’ illnesses, 

the results generally describe only what illnesses a veteran was suffering 

from at a particular point in time. As a result of this and the limitations of 

the DOD and VA registries, several basic descriptive questions remain 

unanswered. For example, the Special Investigative Unit of the Senate 

Veterans’ Affairs Committee and others have identified such open 

questions as the following: 

• How many of those veterans who have been examined have 

unexplained illnesses or symptoms?

• How many of those veterans are also receiving compensation for that 

condition? 

• How many are receiving health care? 

• What treatments have they received? 

• Are those who have received care in VA facilities getting better or 

worse? 

Some data that might be helpful in answering such questions are being 

collected, but an analysis of these data was not available at the close of our 

review. An HHS-sponsored project, which began in 1997, is assessing the 
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persistence and stability of veterans’ symptoms over time. This study is 

planned to end in 2000. In addition, VA and DOD are recruiting patients for 

cooperative trials of antibiotic and exercise-behavioral treatments for a 

broad set of veterans’ unexplained symptoms. However, perhaps because 

there is little understanding of the physical causes underlying veterans’ 

symptoms, VA and DOD officials note that the treatments to be used in 

these trials are expected only to ameliorate symptoms, not to eliminate 

them. 

RWG and OSAGWI 

Activities Not 

Effectively 

Coordinated 

OSAGWI’s activities have not been effectively coordinated with those of the 

RWG in order to maximize the efficient use of resources. We found 

conflicting information about the nature of OSAGWI’s work and whether it 

should be coordinated. Specifically, RWG and OSAGWI officials told us that 

OSAGWI’s activities involve investigations, not research, and therefore are 

not subject to coordination. However, in an August 1997 letter to OSAGWI, 

the RWG raised questions about the methodologies of three OSAGWIsponsored studies and expressed concern over the lack of any external 

review process for these studies and for OSAGWI’s research efforts in 

general. OSAGWI pursued these studies, but it has not published their 

findings. The lack of effective coordination between the RWG and OSAGWI 

increases the potential to miss opportunities to leverage ongoing and 

completed work by other agencies.

Other examples illustrate the need for better coordination. For example, in 

January 1998, the National Academy of Science’s Institute of Medicine 

presented a proposal to VA, which was funded under a congressional 

mandate, to pursue studies at a projected cost of $1.25 million to 

“comprehensively review, evaluate and summarize the available scientific 

and medical information regarding the association between exposures 

during the Persian Gulf War and adverse health effects experienced by 

Persian Gulf War veterans.” However, in 1997, OSAGWI had contracted 

with RAND at a cost of more than $1.5 million for “the preparation of 

literature reviews of key possible causal hypotheses of GWI.”12 The 

Institute’s assessments regarding the links between exposures and health 

outcomes must be based, at least partly, on the review of relevant 

literature, and RAND’s identification of this literature has required, at least, 

some assumptions regarding potential exposure scenarios. Thus, it should 

12OSAGWI eventually authorized RAND work valued at $3.2 million.
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have been possible to use RAND’s ongoing work for the Institute study, and 

better coordination of these two efforts might have saved both time and 

money. When we interviewed Institute staff in June 1998, they were 

generally aware of RAND’s plan to perform literature reviews, but they 

were not familiar with the content of RAND’s work, noting that none of it 

had been released. While RAND did seek approval of a list of scientific peer 

reviewers for its work from Institute officials, in the absence of 

coordination mechanisms, these two efforts were pursued independently. 

Similarly, at least three reviews of the health effects of depleted uranium 

have been commissioned within a few years − one by each agency 

represented on PGVCB. HHS’ Agency for Toxic Substances and Disease 

Registry first released a toxicological profile for uranium in 1989 and issued 

an updated draft toxicological profile on uranium (including depleted 

uranium) on October 17, 1997. This draft, prepared by the Research 

Triangle Institute, incorporated a plain-language public health statement 

and reflected the Agency’s assessment of all relevant toxicological testing 

and information that had been peer-reviewed. In addition, at OSAGWI’s 

request, RAND performed a review of the scientific literature regarding the 

health effects of depleted uranium. Finally, IOM will conduct such a review 

as part of its work for VA. The need for the additional review of depleted 

uranium by RAND, which was submitted in August 1998, after the Agency 

had issued its draft, is questionable.

Contracting for 

OSAGWI Support 

Services Was Flawed

OSAGWI spent more than $47 million in fiscal years 1997 and 1998 on its 

support contracts. We reviewed four support agreements, which made up 

more than 91 percent of OSAGWI’s support spending, and found problems 

with several of the task orders. Specifically, two of the largest task orders 

were awarded improperly, and OSAGWI discouraged competition on 

another by naming a preferred vendor.

Improper Task Orders OSAGWI’s support arrangements consisted largely of task orders under 

multiple-award contracts of other agencies and offices. OSAGWI’s largest 

support arrangement was based on two improper task orders awarded to 

BDM. OSAGWI officials noted that they were directed to establish the 

Office with all possible speed and explained that they anticipated relying 

heavily on contractors for support. As part of addressing this need, an 

initial task order covering a broad range of services was awarded to BDM 

under a National Guard Bureau (NGB) multiple-award task order contract 

for information technology services. 
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Page 17 GAO/NSIAD-00-32 Gulf War Illnesses

The BDM task order describes its objectives as including, but not limited 

to:

“obtaining, documenting, and analyzing information potentially related to Gulf War 

illnesses; documenting the data and analysis in databases and other forms of storage; 

establishing a program to reach-out to veterans; developing questionnaires and surveys to 

collect data; developing maps and other multimedia presentations; plotting and analyzing 

troop movements and locations; rapidly creating data analysis tools to aid in analysis 

efforts; developing and producing case studies; preparing documents for storage on 

GulfLINK; developing recommendations and long range plans; writing papers; and, 

providing testimony.” 

The task order also required BDM to provide facilities, furniture, 

telecommunications, equipment, and services, as needed. 

Orders under multiple-award, task-or-delivery-order contracts are required 

by law to contain a statement of work that “clearly specifies all tasks to be 

performed or property to be delivered under the order.”13 In our opinion, 

this language means that a task order must identify with reasonable 

specificity the task or tasks that a contractor will be expected to perform, 

rather than merely list categories of services. The task order awarded to 

BDM, however, was basically a broad menu of services from which 

OSAGWI could pick and choose as the occasion arose and lacked the 

degree of specificity required. While we appreciate the exigent 

circumstances under which this award was made, we do not believe that 

the award of this broad task order was proper because it did not clearly 

specify the tasks to be performed. The DOD Inspector General also cited 

concerns with OSAGWI’s task orders to BDM.14

When OSAGWI reached its allotted cost ceiling under the NGB contract 

and the NGB did not increase the contract ceiling, OSAGWI continued the 

arrangement with BDM through an order under the General Services 

Administration’s Management, Organizational, Business Improvement 

Services (MOBIS) schedule contract. The MOBIS schedule states that it is 

intended to support business, management, and organizational 

improvement through activities such as quality management, 

benchmarking, reengineering, surveys, strategic planning, and 

development of leadership and management skills. The General Services 

1310 U.S.C. § 2304c(c).

14See DOD Inspector General, DOD Use of Multiple Award Task Order Contracts − Report 

No. 99-116, Apr. 2, 1999. 
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Page 18 GAO/NSIAD-00-32 Gulf War Illnesses

Administration’s summary of MOBIS services states that such contracts are 

not intended for independent management or technical studies. 

The task order to BDM was outside the scope of the MOBIS contract. The 

work identified in the task order supports OSAGWI’s operational functions 

and activities and does not fit properly within the scope of the contract. 

Specifically, the objective of the task order is to support OSAGWI’s 

research and investigation into potential causes of Gulf War veterans’ 

illnesses, rather than, as OSAGWI contends, to support efforts to improve 

managerial or organizational processes of the type intended for the MOBIS 

contract. In this regard, the MOBIS scope of work states that the 

“performance of operational activities” and database planning are not 

appropriate for purchase under MOBIS. Given the substantial disparity 

between the purposes of this contract and the BDM task order, we believe 

that the task order is outside the scope of the MOBIS contract and should 

not have been awarded under that contract. OSAGWI officials have 

informed us that this task order will expire in January 2000, but that the 

need for the type of support services that BDM is providing will continue 

for an indefinite period. 

Competition for Task Order 

Discouraged

Under multiple award task order contracts, all of the multiple award 

contractors are to be given a fair opportunity to be considered for the 

award of any particular task order, typically by submitting proposals in 

response to agency announcements. Competition is one of the means by 

which agencies insure they obtain the best value from their contractors. 

OSAGWI’s solicitation for one task order opportunity, however, 

discouraged competition among the multiple award contractors by naming 

Systems Research and Applications Corporation (SRA) as the preferred 

contractor.
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We have testified and reported that naming preferred contractors in task 

order announcements discourages competition, frequently resulting in just 

one proposal being received.15 SRA was the only multiple award contractor 

that responded to the announcement.16 OSAGWI has not argued that SRA 

was uniquely qualified to perform the required work.

Conclusions During fiscal years 1997-98, the government expended considerable funds 

on research and investigation into Gulf War veterans’ illnesses—about 

$121 million. More than half of this total was spent by the Office of the 

Special Assistant for Gulf War Illnesses. 

Even though significant funding has been spent on research and 

investigation of Gulf War veterans’ illnesses, most of the research is 

ongoing and the Research Working Group has not completed an 

assessment of the extent to which federal research objectives identified in 

1995 have been satisfied. While about two-thirds of the 34 completed 

projects had resulted in peer-reviewed publications, researchers face 

increasingly difficult problems in identifying valid data on veterans’ 

exposures. Moreover, little is known about how veterans’ conditions have 

changed over time, no working case definitions have been endorsed in 

order to focus research efforts, and research on treatments has begun only 

recently. As a result, little knowledge exists concerning the causes, 

courses, or successful treatments for Gulf War veterans’ illnesses. In 

addition, although the Office of the Special Assistant for Gulf War Illnesses 

has received most of the material requested of its research contractors, the 

review process established by the Office can be slow.

Coordination of planned efforts is key to maximizing the government’s 

investment into research on Gulf War veterans’ illnesses. However, 

15Defense Acquisition: Improved Program Outcomes Are Possible (GAO/T-NSIAD-98-123, 

Mar. 18, 1998), and Acquisition Reform: Multiple Award Contracting at Six Federal 

Organizations, (GAO/NSIAD-98-215, Sept. 30, 1998). In response to our testimony, the Office 

of Management and Budget directed that the Federal Acquisition Regulation be revised to 

prohibit the naming of preferred contractors in task order announcements. The federal 

acquisitions regulation was revised to prohibit the designation of preferred awardees 

effective August 16, 1999.

16After the initial award was made to the preferred vendor identified in the announcement, 

succeeding awards were directed to the same vendor under an exception to the fair 

opportunity requirement for work that is a “logical follow-on” from prior work. Thus, the 

anticompetitive effect of directing the initial award was magnified in subsequent awards.
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Page 20 GAO/NSIAD-00-32 Gulf War Illnesses

disagreement regarding which activities should be subject to coordination 

exists. As a result, the Office of the Special Assistant for Gulf War Illnesses, 

which spends more than half of the federal funds supporting research and 

investigation, has not effectively coordinated its activities with the 

Research Working Group. 

DOD established the Office of the Special Assistant for Gulf War Illnesses 

to restore public confidence in DOD’s efforts to deal with Gulf War illnesses 

issues. While officials of the Office of the Special Assistant for Gulf War 

Illnesses noted that they intended to seek advice on drawing down the 

office, they planned expenditures of $65.4 million across fiscal years 1999 

and 2000, and the Office remains in DOD’s budget through fiscal year 2005. 

Because the Office spends a high percentage of its budget on support 

contracts, it is important that its contracting procedures comply fully with 

applicable laws and regulations. 

Recommendations With respect to the health research efforts coordinated by the Research 

Working Group of the Persian Gulf Veterans’ Coordinating Board, we 

recommend that the Secretaries of Veterans’ Affairs, Defense, and Health 

and Human Services direct the executive director of the Research Working 

Group to

• establish and achieve a target date within fiscal 2000 for publishing its 

assessment of progress toward addressing the research objectives it 

identified in 1995;

• compile data on the number of Gulf War veterans with unexplained 

illnesses, the progression of their illnesses, the treatments they are 

receiving, and the success of these treatments (recognizing that 

application of some working case definitions or categorization scheme 

may be useful for purposes of such an accounting); and 

• effectively coordinate the efforts of the Office of the Special Assistant 

for Gulf War Illnesses with related activities of DOD, VA, and HHS to 

prevent duplication and improve the efficiency of resource use. 

We also recommend that the Secretary of Defense direct the Office of the 

Special Assistant for Gulf War Illnesses to replace the task order issued 

under the MOBIS contract with a proper contracting arrangement as soon 

as practicable. In addition, the Secretary should direct the Office of the 

Special Assistant for Gulf War Illnesses that all future support contracts 

should comply fully with applicable laws and regulations. 
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Page 21 GAO/NSIAD-00-32 Gulf War Illnesses

Agency Comments and 

Our Evaluation

In written comments on a draft of our report, DOD and VA agreed with 

some of our findings and recommendations but disagreed with others, and 

CDC generally concurred with our findings and recommendations. DOD 

provided additional technical comments, which we incorporated as 

appropriate. Also, CDC requested that we incorporate additional 

information on two of its sponsored studies, which we did. (App. IV, V, and 

VI contain the written comments of DOD, VA, and CDC, respectively, and 

our evaluation of them.)

DOD commented that our report paints a pessimistic picture of the 

research on Gulf War veterans’ health. The Department cited studies that 

compared the hospitalization in military facilities, the birth outcomes in 

military facilities, and the mortality of active duty Gulf War veterans to 

large groups of nondeployed veterans as support for a more optimistic 

perspective on veterans’ health. However, DOD did not cite the most 

consistent finding of the health research to date; that is, Gulf War veterans 

seem to exhibit more of some symptoms, such as fatigue, difficulty 

concentrating, and muscle and joint pain, than do nondeployed veterans.17

DOD believes that the failure to identify a “unique syndrome” is an 

optimistic sign of veterans’ health overall. We disagree. Even if the 

symptoms reported more often by Gulf War veterans are not confined to 

those veterans, DOD needs to explain why Gulf War veterans report these 

symptoms more frequently. Furthermore, none of the studies DOD cited 

examined the possible existence of significant differences in the health of 

Gulf War veterans based on specific exposures to hazardous materials 

during military service.18

17 Institute of Medicine, Gulf War Veterans: Measuring Health (Washington, D.C.: National 

Academy Press, 1999), p. 2; Iowa Persian Gulf Study Group, “Self-Reported Illness and 

Health Status Among Gulf War Veterans: A Population-Based Study,” Journal of the 

American Medical Association, 227 (3), (1997), pp. 238-245; and K. Fukuda, et al., “Chronic 

Multisymptom Illness Affecting Air Force Veterans of the Gulf War,” Journal of the American 

Medical Association, 380 (11), (1998), pp. 981-88.

18 One study argued that the Gulf War veterans may have been more fit than those not 

deployed; thus, the finding of no difference between the two groups might suggest a 

significant decline in the post-war health of the Gulf War veterans. R. Haley, “Point: Bias 

From the ‘Health Warrior Effect’ and Unequal Follow-up in Three Government Studies of 

Health Effects of the Gulf War,” American Journal of Epidemiology, 148 (4), (1998), 

pp. 315-23.
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Page 22 GAO/NSIAD-00-32 Gulf War Illnesses

DOD also said that we were incorrect in stating that little is known about 

how veterans’ conditions have changed over time. However, our report is 

consistent with a September 1999 report of the Institute of Medicine. The 

report notes that there has been no systematic evaluation of whether or 

how veterans’ health status is changing.19 Also, in a 1998 report to 

Congress, the Research Working Group stated that no government research 

is specifically directed toward understanding the progress of Gulf War 

veterans’ illnesses over time and that research should determine the longterm health of these veterans.20

DOD further stated that the effectiveness of government research has been 

demonstrated in a variety of ways. We agree that the research to date has 

added to what was known about Gulf War veterans’ health shortly after the 

war. Nevertheless, little information is available on the extent or course of 

the development of veterans’ undiagnosed illnesses, basic information on 

the prevalence of veterans’ symptoms is unavailable, and no research on 

the treatment of such illnesses has been completed. Although joint 

commands have revised joint policy on record-keeping, and operational 

changes have been made to improve environmental monitoring, these 

changes do not serve as proof of research effectiveness. Rather, they 

address problems that have challenged Gulf War researchers in interpreting 

data on veterans’ illnesses because they lack accurate and precise 

information (i.e., duration and doses) on veterans’ exposures to hazardous 

materials.

Both DOD and VA concurred with our recommendation that the Research 

Working Group set a date in fiscal year 2000 for reporting its progress in 

addressing the research objectives it identified in 1995. DOD confirmed, as 

we noted in our draft report, that this report is in progress, but neither 

agency provided a specific date for its publication. 

Regarding our recommendation that steps be completed to compile data on 

the number of Gulf War veterans with unexplained illnesses, the treatments 

they were receiving, and the success of these treatments, DOD partially 

concurred and VA did not concur. Neither agency opposed the collection of 

information on the number and health status of Gulf War veterans with 

19 Institute of Medicine, Gulf War Veterans: Measuring Health (Washington, D.C.: National 

Academy Press, Sept. 1999), p. 3, 35.

20 Persian Gulf Veterans’ Coordinating Board − Research Working Group, Annual Report to 

Congress − 1998 (Washington, D.C.: PGVCB RWG, June 1999), p. 53.
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Page 23 GAO/NSIAD-00-32 Gulf War Illnesses

unexplained illnesses. However, VA stated that it could not implement the 

recommendation as worded without specific case definitions (that is, 

criteria to identify distinct illnesses). We agree that some categorization 

scheme or set of working case definitions would be useful in counting the 

numbers of veterans that have unexplained illnesses of some type, and we 

revised our recommendation accordingly.

Although DOD concurred with our recommendation that the Research 

Working Group coordinate with the Office of the Special Assistant for Gulf 

War Illnesses on activities related to Gulf War veterans’ illnesses, DOD 

disagreed that its current coordination was weak. It stated that 

coordination was already occurring and that coordination on Officesponsored reviews of scientific literature was unnecessary because the 

reviews were not research. VA did not concur with the recommendation 

because most of the work of the Office of the Special Assistant involves 

investigations of specific wartime incidents rather than research. 

Regardless of whether the work of the Office is considered research or not, 

it describes the extent and nature of veterans’ possible exposures to 

hazardous materials. These descriptions are important to researchers 

trying to identify the health consequences of such exposure. Moreover, the 

law does not limit the Working Group’s coordination efforts to activities 

that constitute research, however defined. Accordingly, we are now 

recommending that the Research Work Group effectively coordinate the 

activities of the Office of the Special Assistant with related activities of 

DOD, VA, and the Department of Health and Human Services to prevent 

duplication of effort and optimize the use of resources. We are making this 

recommendation to prompt these organizations to work more closely on 

behalf of ill veterans. We believe that greater cooperation, exchange of 

information, and coordination will help expedite the process and help find 

solutions the veterans need. 

Finally, DOD did not concur with our recommendation to replace an 

improperly awarded task order as soon as practicable and to comply fully 

with applicable laws and regulations in future contracting activities. DOD 

noted that because its Gulf War illnesses office does not have contracting 

officers, it relies on the professional judgment of contracting professionals 

outside that office, who did not object to the office’s contract actions. DOD 

contends that the office complied with all legal requirements in effect at the 

time.
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Page 24 GAO/NSIAD-00-32 Gulf War Illnesses

We note that DOD did not disagree with our conclusion that the task order 

was improperly awarded. The task order was for support of office 

operations in developing information related to Gulf War illnesses, even 

though the underlying contract prohibited its use for the performance of 

operational activities. The task order was therefore improper and should 

be terminated, if practicable, as we recommended.

We recognize that the Office of the Special Assistant relies on contracting 

professionals outside that office to execute its support contracts. 

Nevertheless, the office is, at a minimum, responsible for determining its 

requirements for support, a process that in one instance resulted in naming 

a preferred vendor and in another led to an overly broad statement of work. 

The effect of these practices is to discourage competition. It is important, 

therefore, that both requiring agencies, such as the Gulf War illnesses 

office, as well as agencies that execute contracts, adhere to the statutes 

and regulations designed to maximize competition.

Scope and 

Methodology

To determine how much DOD, HHS, and VA have spent on research and 

investigation of Gulf War veterans’ illnesses and health concerns in fiscal 

years 1997 and 1998, we reviewed budget documents, contracts, and other 

relevant documents. We also interviewed RWG members, as well as DOD, 

HHS, and VA officials managing the respective agencies’ budgeting for 

research, investigation, and clinical care. During our interviews, we 

inquired about spending levels and the distribution of funds across 

activities.

The expenditure estimates included in this report are limited to DOD, VA, 

and HHS. Because we targeted key entities within these agencies on the 

basis of the public profile of their research and investigatory efforts, the 

expenditures we identified may exclude related spending by entities that 

have not been prominently identified with the federal effort. We did not 

independently assess the estimates provided us by the various agencies and 

offices apart from determining that they were basically consistent with the 

contract documents examined. 

To determine the status of research efforts and identify research products, 

we reviewed research and investigatory objectives, reports to Congress, 

agency documents, and articles appearing in peer-reviewed journals. In 

addition, we interviewed researchers, PGVCB officials, and officials at the 

sponsoring agencies. We did not independently assess the appropriateness 
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Page 25 GAO/NSIAD-00-32 Gulf War Illnesses

of federal research objectives, nor did we determine how well federally 

sponsored research had addressed them. 

To investigate the extent of coordination between OSAGWI and the RWG, 

we interviewed members of OSAGWI; the RWG; representatives from DOD, 

HHS, and VA; and researchers about the process. We reviewed agency 

documents and the minutes of PGVCB and other meetings and examined 

research protocols, contracts, and documentation of reviews conducted by 

sponsoring agencies into research and investigatory activities. 

To determine the expenditures and resources OSAGWI had directed 

toward veterans’ health concerns and the way it managed its contracts, we 

interviewed OSAGWI officials and contracting officers and reviewed 

contracts, task orders, statements of work, copies of deliverables, and 

requested any assessments of contractor performance. For efficiency, we 

limited the review to four support and five research contracts, which 

accounted for 91 percent and 72 percent of OSAGWI’s expenditures in the 

respective areas. 

Our work was conducted from May 1998 through December 1999 in 

accordance with generally accepted government auditing standards. 

As agreed with your office, unless you publicly announce its contents 

earlier, we plan no further distribution of this report until 30 days from its 

issue date. At that time, we will send copies of this report to other 

interested congressional committees and members.

If you have any questions or would like additional information, please 

contact those listed in appendix VII.

Sincerely yours,

Kwai-Cheung Chan

Director, Special Studies and Evaluations
Page 26 GAO/NSIAD-00-32 Gulf War Illnesses

Appendix I

Research Objectives Identified by the Apendxies

Research Working Group of the Persian Gulf 

Veterans’ Coordinating Board ApendxIi

1. What is the prevalence of symptoms/illnesses in the Persian Gulf veteran 

population? How does this prevalence compare to that in an appropriate 

control group?

2. What was the overall exposure risk of troops to Leishmania tropica?

3. What were the exposure concentrations to various petroleum products, 

and their combustion products, in typical usage during the Persian Gulf 

conflict?

4. What was the extent of exposure to specific occupational/environmental 

hazards known to be common in the Persian Gulf veteran’s experience? 

Was this exposure different from that of an appropriate control group?

5. What were the potential exposures of troops to organophosphate nerve 

agent and/or sulfur mustard as a result of allied bombing at Muhammadiyat 

and Al Muthanna, or the demolition of a weapons bunker at Khamisiyah?

6. What was the extent of exposure to chemical agent, other than at 

Khamisiyah, Iraq, in the Persian Gulf as a function of space and time?

7. What was the prevalence of PB use among Persian Gulf troops?

8. What was the prevalence of various psychophysiological stressors 

among Persian Gulf veterans? Is the prevalence different from that of an 

appropriate comparison population?

9. Are Persian Gulf veterans more likely than an appropriate comparison 

group to experience non-specific symptoms and symptom complexes?

10. Do Persian Gulf veterans have a greater prevalence of altered immune 

function or host defense when compared with an appropriate control 

group?

11. Is there a greater prevalence of birth defects in the offspring of Persian 

Gulf veterans than in an appropriate control population?

12. Have Persian Gulf veterans experienced lower reproductive success 

than an appropriate control population?

13. Is the prevalence of sexual dysfunction greater among Persian Gulf 

veterans than among an appropriate comparison population?
Appendix I

Research Objectives Identified by the 

Research Working Group of the Persian Gulf 

Veterans’ Coordinating Board

Page 27 GAO/NSIAD-00-32 Gulf War Illnesses

14. Do Persian Gulf veterans report more pulmonary symptoms or 

diagnoses than persons in appropriate control populations?

15. Do Persian Gulf veterans have a smaller baseline lung function in 

comparison to an appropriate control group? Do Persian Gulf veterans 

have a greater degree of non-specific airway reactivity in comparison to an 

appropriate control group?

16. Is there a greater prevalence of organic neuropsychological and 

neurological deficits in Persian Gulf veterans compared to appropriate 

control populations?

17. Can short-term, low-level exposures to pyridostigmine bromide, the 

insect repellant DEET, and the insecticide permethrin, alone or in 

combination, cause short-term and/or long-term neurological effects?

18. Do Persian Gulf veterans have a significantly higher prevalence of 

psychological symptoms and/or diagnoses than do members of an 

appropriate control group?

19. What is the prevalence of leishmaniasis or other infectious diseases in 

the Persian Gulf veteran population?

20. Do Persian Gulf veterans have a greater risk of developing cancers of 

any type when compared with an appropriate control population?

21. Are Persian Gulf veterans experiencing a mortality rate that is greater 

than that of an appropriate control population? Are specific causes of death 

related to service in the Persian Gulf?
Page 28 GAO/NSIAD-00-32 Gulf War Illnesses

Appendix II

Reports Received and Released by the Office 

of the Special Assistant Under Research 

Contracts Examined by GAO ApendxiI

Contractor

Contract 

amount Topics/titles Due Received

Form and date of 

earliest known 

receipt

Released 

(as of 

12/15/99)

Mitre 

Corporationa

$3,185,000 Iraqi Chemical Warfare Study Yes Yes Classified draft 

report (4/4/97)b

Partial 

(9/5/97)c

RAND $3,200,000 Oil Fires: A Review of the Scientific 

Literature as It Pertains to 

Illnesses of Gulf War Veterans

Yesd Yes Partial draft (12/97). 

Draft for agency 

review (4/16/98).

Yese (11/5/98)

A Review of Scientific Literature as 

It Pertains to Gulf War Illnesses, 

Volume V: Depleted Uranium

Yesd Yes Draft for agency 

review (8/4/98).

Yes (4/16/99)

A Review of the Scientific 

Literature as It Pertains to Gulf 

War Illnesses, Volume VI: 

Chemical and Biological Warfare 

Agents

Yesd Yes Draft for agency 

review (9/1/98).

No

A Review of the Scientific 

Literature as It Pertains to Gulf 

War Illnesses: Volume III: 

Pyridostigmine Bromide

Yesd Yes Draft for agency 

review (6/10/98).

Yes 

(10/19/99)

Stress: A Review of the Scientific 

Literature as It Pertains to Health 

Problems of Gulf War Veterans

Yesd Yes Draft for agency 

review (4/23/98).

Yes (5/19/99)

Infectious Disease Yesd Yesf Draft for agency 

review (2/11/98).

No

Immunizations Yesd Yes Draft for agency 

review (4/22/99).

No

Military Uses of Drugs Not Yet 

Approved by FDA for BW/CW 

Defense: Lessons from the Gulf 

War

Yesd Yes Draft for agency 

review (4/24/98).

Yes (4/16/99)

Assessing the Health Effects of 

Military Deployments: DOD’s 

Activities Following the Gulf War

Yesd Yes Draft for agency 

review (9/15/98).

No

Notes on the history of stress Yesd No Not received as of 

12/20/99.

No

Pesticides Yesd Yes Draft for agency 

review (11/3/98).

No

Institute for 

Defense 

Analyses

$389,000 Full Dimensional Protection: 

Military Records and Reports 

Dimension

Yes Yes Draft for agency 

review (12/10/97) 

Revised draft 

(7/28/98).

Nof

(Continued )
Appendix II

Reports Received and Released by the Office 

of the Special Assistant Under Research 

Contracts Examined by GAO

Page 29 GAO/NSIAD-00-32 Gulf War Illnesses

Safe and Timely Disposal in 

Wartime of Large Quantities of 

Captured Chemical and Biological 

Munitions

Yes Yes Draft for agency 

review (11/8/97).

Nog

Protecting Against the Uncertain 

Risks of Exposure to Very Low 

Concentrations of Chemical 

Warfare Nerve Agents

Yes Yes Draft received 9/99. No

[A paper describing planned and 

possible alternative approaches 

for improving DOD capabilities to 

detect chemical agents on the 

battlefield and archive such data]

Yes Yes Report delivered 

6/16/97.

No

National 

Academy of 

Sciences

$2,703,809h Force Protection: Lessons 

Learned from the Gulf War

Noi Noj No final report due 

before 3/31/00.

Birch & Davis 

Associates 

$176,500k Birth Defects Among Children of 

Gulf War Veterans and Potential 

Nerve Agent Exposure

Yes Yes Draft for agency 

review (8/21/98).

Nol

Comprehensive Clinical Evaluation 

Program Gulf War Studies and 

Analyses: Report on Findings from 

a Telephone Survey of Persian 

Gulf War Veterans Assigned to 

Demolition Units

Yes Yes Draft for agency 

review (12/1/97).

No

Toxicity Assessment and Risk 

Evaluation for Exposure of U.S. 

Troops to Chemical Agents at 

Khamisiyah

Yes Yes Draft for agency 

review (5/22/98).

No

Admissions to Field Hospitals 

During the Gulf War and Potential 

Nerve Agent Exposures

Yes Yes Draft for agency 

review (7/16/98).

No

Total $9,654,309 20 19 6

Contractor

Contract 

amount Topics/titles Due Received

Form and date of 

earliest known 

receipt

Released 

(as of 

12/15/99)

(Continued from Previous Page)
Appendix II

Reports Received and Released by the Office 

of the Special Assistant Under Research 

Contracts Examined by GAO

Page 30 GAO/NSIAD-00-32 Gulf War Illnesses

a

Mitre contracted with the Assistant to the Secretary of Defense for Intelligence Oversight, but the 

Office of the Special Assistant for Gulf War Illnesses (OSAGWI) was directed to provide $3,185,000 to 

support Mitre’s work on the study. Although OSAGWI does not have direct oversight of the effort, the 

status of the study is shown here in the interest of tracking the products associated with funds provided 

to OSAGWI. 

b

The Office of the Assistant Secretary of Defense for Intelligence Oversight reported that no final report 

was available as of July 27, 1998.

c

A declassified version of chapter 11 of this report was released by OSAGWI on September 5, 1997, in 

response to a request from the Presidential Advisory Committee on Gulf War Veterans’ Illnesses. An 

official of the Office of the Assistant Secretary of Defense for Intelligence Oversight indicated on 

December 15, 1999 that he expected the report to be transmitted to the Secretary on or before 

December 25, 1999 accompanied by a recommendation for release of a substantial portion in 

unclassified form.

d

Products of the RAND contract were originally due in September 1997. A December 1997 

modification to RAND’s agreement with the Department of Defense (DOD) reestablished due dates 

between December 1997 and January 1998. 

e

In many instances, the deadlines on these products were extended or the Office was slow to provide 

the official comment necessary for the contractor to issue a final product. OSAGWI also instituted a 

review process that incorporated comments from various government agencies. This process has 

required months to apply, and some deliverables spent a year or longer in unreleased or draft form. 

OSAGWI officials indicated that they initiated the external review process at the urging of the Research 

Working Group (RWG), but Group officials said that they encouraged an external, university-based 

review process, not the extensive interagency review OSAGWI adopted.

f

OSAGWI officials told us that this document was finalized in August 1999 and distributed to the Office 

of the Secretary in October 1999, but has not been publicly released.

g

OSAGWI officials told us that this document was finalized in October 1999 and distributed to the 

Office of the Secretary in November 1999, but has not been publicly released.

h

The total cost of this contract over the anticipated period of performance, including option years, is 

expected to be $5,922,305.

i

None of the report deliverables for this contract, apart from progress and status reports, was due 

before March 29, 1999, when a draft panel report was expected. A final interim report is due on March 

29, 2000, and a final consensus report on September 29, 2000. 

j

Subsidiary products from this contract have been provided and released. The National Academy 

Press has released the following documents in 1999 as part of a series on Strategies to Protect the 

Health of Deployed U.S. Forces: (1) Medical Surveillance, Record Keeping and Risk Reduction; 

(2) Analytical Framework for Assessing Risks (and Workshop Proceedings: Strategies to Protect the 

Health of Deployed U.S. Forces: Assessing Health Risks to Deployed U.S. Forces ); and (3) Strategies 

to Protect Deployed U.S. Forces: Force Protection and Contamination.

k

The total amount of funds OSAGWI reported as supporting its research contract with Birch & Davis in 

fiscal years 1997 and 1998. The total cost of delivery order 46 for contract number DASW01-95-D0026 was $1,684,773, but this order also covered substantial work for DOD/Health Affairs and its 

Deployment Surveillance Team to validate and analyze data from the Comprehensive Clinical 

Evaluation Program and other surveillance activities. Cost information is not available by product.

l

An April 9, 1997, request by Birch & Davis Associates for approval to disseminate and/or publish 

articles based on analyses conducted under delivery order 46 was formally rescinded by an April 15, 

1997, letter that cited a conversation on the subject that led the contractor to understand “that any 

request to disseminate and/or publish articles under the referenced contract must be done on a ‘case 

by case’ basis and must be accompanied by a definite publication plan.” In explanation of non-release 

of one or more of this contractor’s products, OSAGWI staff cited dissatisfaction with the deliverables as 

presented by the contractor in July 1998. However, they provided no written performance reviews for 

the contractor, explaining that the products were developed under a task order that was part of a 

contract with the Office of the Assistant Secretary of Defense for Health Affairs, which was presumably 

responsible for evaluating the contractor’s performance.
Page 31 GAO/NSIAD-00-32 Gulf War Illnesses

Appendix III

Sample Working Case Definitions Describing 

Symptoms Experienced by Gulf War Veterans ApendxIi

a

Memorandum from Jay P. Sanford, M.D. to MG Ronald Blanck, MC USA, re: Gulf War Syndrome: 

Proposed Provisional Case Definition, Jan. 27, 1994.

b

Robert W. Haley et al., “Is There a Gulf War Syndrome? Searching for Syndromes by Factor Analysis 

of Symptoms,” Journal of the American Medical Association, vol. 277 (Jan. 15, 1997), pp. 215-222.

c

Keiji Fukuda et al., “Chronic Multisymptom Illness Affecting Air Force Veterans of the Gulf War,” 

Journal of the American Medical Association, vol. 280 (Sep. 16, 1998), pp. 981-988.

d

National Health Survey Research Team, “Unique Cluster of Symptoms Among Gulf Veterans,” In The 

Research Working Group [of the] Persian Gulf Veterans Coordinating Board, Conference on Federally 

Sponsored Gulf War Veterans’ Illnesses Research: Program and Abstract Book, 1999, p. 99.

Origin Date Inclusion criteria Exclusion criteria

Sanforda 1994 (1) In theater of operations between 8/8/90 and late July 1991

(2) New onset of a symptom complex with the occurrence of at least 

five of eight minor criteria: fatigue, arthralgia, headache, diarrhea, 

neuropsychiatric complaints, difficulty sleeping, low-grade fever, 

and/or weight loss.

Other clinical conditions with similar 

symptomologies based on thorough 

evaluation, including history, physical 

exam and appropriate lab studies.

Haleyb 1997 The three primary syndromes are impaired cognition (symptoms 

include distractibility, difficulty remembering, depression, middle 

and terminal insomnia, fatigue, slurring of speech, confused thought 

process, and migraine-like headaches); confusion-ataxia (symptoms 

include problems with thinking and reasoning processes, getting 

confused, getting disoriented, problems keeping their balance, 

posttraumatic stress disorder, depression, liver disease, and sexual 

impotence); and arthro-myo-neuropathy (symptoms include 

generalized joint and muscle pains, increased difficulty lifting 

heavy objects, muscle exhaustion after exertion, and tingling or 

numbness of the hands, arms, feet, and legs).

CDCc 1998 One or more chronic symptoms (present for more than 6 months) 

from at least two of the following three categories: fatigue, mood and 

cognition (feeling depressed, difficulty remembering or concentrating, 

feeling moody, feeling anxious, trouble finding words or difficulty 

sleeping), and/or musculoskeletal (joint pain, stiffness, or muscle pain).

Other clinical conditions with similar 

symptomologies based on thorough 

evaluation, including history, physical 

exam and appropriate lab studies.

National 

Health 

Survey 

Teamd

1999 Combination of blurred vision, loss of balance/dizziness, 

tremors/shaking, and speech difficulty (reported by 277, or 2.4 percent, 

of surveyed Gulf-deployed veterans in contrast to 43 or 0.5 percent of 

surveyed nondeployed veterans).
Page 32 GAO/NSIAD-00-32 Gulf War Illnesses

Appendix IV

Comments From the Department of Defense ApendxIVi

Note: GAO comments 

supplementing those in the 

report text appear at the 

end of this appendix.

See comment 1.

See comment 2.

See comment 3.

See comment 4.

See comment 5.

See comment 6.

See comment 7.

See comment 8.

See comment 9.
Appendix IV

Comments From the Department of Defense

Page 33 GAO/NSIAD-00-32 Gulf War Illnesses

See comment 9.

See comment 10.

See comment 11.
Appendix IV

Comments From the Department of Defense

Page 34 GAO/NSIAD-00-32 Gulf War Illnesses

See comment 12.
Appendix IV

Comments From the Department of Defense

Page 35 GAO/NSIAD-00-32 Gulf War Illnesses

See comment 10.

See comment 11.
Appendix IV

Comments From the Department of Defense

Page 36 GAO/NSIAD-00-32 Gulf War Illnesses

See comment 11.

See comment 9.

See comment 12.
Appendix IV

Comments From the Department of Defense

Page 37 GAO/NSIAD-00-32 Gulf War Illnesses

GAO Comments The following is GAO’s response to the Department of Defense’s (DOD) 

comments dated August 19, 1999.

1. With respect to the refinement of future research direction, it is 

important to note that a National Institutes of Health working group 

assembled in 1994 noted the desirability of identifying one or more case 

definitions or an evolving case definition to focus research efforts. Our 

report notes that the Research Working Group had not endorsed one or 

more case definitions that might focus future research efforts on veterans’ 

unexplained illnesses and that problems with exposure data persist.

2. Our report notes that 8 years after the war, the Department of Veterans’ 

Affairs has just begun to recruit subjects for clinical trials and no treatment 

research has yet been completed. We have not evaluated the quality of 

these trials or the selection of treatments to be evaluated. 

3. Longitudinal follow-up of mortality, cancer rates, and health status will 

require many years. However, without accurate and precise exposure data 

(i.e., duration and dose), the interpretation of morbidity and mortality data 

from these studies will remain challenging.
Appendix IV

Comments From the Department of Defense

Page 38 GAO/NSIAD-00-32 Gulf War Illnesses

4. The facts and observations in this report are consistent with those of the 

Institute of Medicine (IOM). The Institute noted in a report issued in midSeptember 1999, the month after DOD provided its formal comments, that 

no one has systematically evaluated whether the health of Gulf War 

veterans is changing and, if so, how. Similarly, it noted that no one had 

determined the number of veterans who have symptoms of illnesses that 

they attribute to service in the Gulf War, or whether the health of these 

veterans is better than, worse than, or the same as that of veterans who 

were not deployed to the Gulf War, although some studies have found 

higher levels of reported symptoms among Gulf War veterans.1

 In addition, 

RWG, in its annual report to Congress for 1998 stated that, “although 

several individual research projects...have longitudinal components built 

into them, no research is specifically directed toward understanding the 

progress of Gulf War veterans’ illnesses over time. The RWG has concluded 

that to the extent feasible, research approaches need to be applied to 

determine the long-term health of Gulf War veterans in contrast to the 

several cross-sectional epidemiological research projects recently 

completed or still ongoing.”2

1

Institute of Medicine, Gulf War Veterans: Measuring Health.

2

Persian Gulf Veterans’ Coordinating Board − Research Working Group, Annual Report to 

Congress − 1998.
Appendix IV

Comments From the Department of Defense

Page 39 GAO/NSIAD-00-32 Gulf War Illnesses

5. It has been difficult for researchers to progress from descriptive to 

analytical epidemiology due partly to the absence of accurate and precise 

data on the factors to which veterans were exposed. None of the research 

DOD cited compared veterans on the basis of their specific exposure 

history. Instead, results generally describe the experience of persons who 

were on active duty in the Gulf War theater (that is, the Persian Gulf, 

Kuwait, Iraq, Saudi Arabia, the Red Sea, the Gulf of Oman, the Gulf of Aden, 

the northern portion of the Arabian Sea, Oman, Bahrain, Qatar, or the 

United Arab Emirates) between August 2, 1990, and June 13, 1991, as 

compared to those who were on active duty elsewhere during this time 

frame. As we noted in 1997, one might not find differences between these 

large and diverse groups even if some veterans have illnesses that are 

significantly related to specific military exposures. Nonetheless, 

researchers have documented that these two groups differ in their 

frequency of reporting various symptoms and, even with poorly defined 

exposures, some investigators have reported associations between certain 

exposures and indicators of veterans’ post-war health.3

3

See, for example, S. P. Proctor et al., “Health Status of Persian Gulf War Veterans: 

Self-reported Symptoms, Environmental Exposures, and the Effect of Stress,” International 

Journal of Epidemiology, 27 (6), 1000-10. Unwin, C. et al. (1999.) Health of U.K. Servicemen 

Who Served in Persian Gulf War. Lancet, 353, 169-178. Haley, R. W., & Kurt, T. L. (1997). Is 

There a Gulf War Syndrome? Journal of the American Medical Association, 277 (3), 215-22 

and related articles at 223-37.
Appendix IV

Comments From the Department of Defense

Page 40 GAO/NSIAD-00-32 Gulf War Illnesses

6. DOD’s comments do not embrace the most consistent finding of the 

health research to date. As IOM concluded, “There does seem to be a higher 

prevalence of some symptoms among veterans who served in the Gulf War 

as compared to nondeployed veterans. The primary symptoms include 

fatigue, difficulty concentrating, memory loss, skin rash, headache, and 

muscle and joint pain.”4

 Several studies support this conclusion. For 

example, a study funded by the Centers for Disease Control conducted 

telephone interviews of a stratified random sample of 3,695 of 29,000 Gulf 

War-era military personnel listing Iowa as their home of record and found 

that those deployed to the Gulf War were more likely than those who 

served elsewhere during the war to report symptoms suggestive of 

cognitive dysfunction, depression, chronic fatigue, post-traumatic stress 

disorder, and respiratory illness (asthma and bronchitis).5

 These symptoms 

appeared to affect the functional activity and daily lives of the Gulf War 

veterans. Similarly, a CDC study of Air Force personnel found that a 

multisymptom case definition developed after clinical examination of 

158 veterans was, in its severe form, reported several times more frequently 

by sampled Gulf War veterans than by nondeployed personnel.6

Mild-to-moderate cases, while more evenly spread, were still well over 

twice as common in the Gulf War group. Gulf War veterans classified as 

having mild-to-moderate and severe illness had a significant decrease in 

functioning and well-being compared with Gulf War veterans who did not 

fit the criteria for the multisymptom illness. Similar findings were reported 

in a study of 3000 veterans from New England, a study of 525 women 

veterans, and a study of 8,000 veterans from the United Kingdom.7

Moreover, a survey of Canadian veterans found significantly higher rates of 

self-reported chronic conditions and symptoms of a variety of conditions 

among Gulf-deployed veterans compared to those serving elsewhere during 

the Gulf conflict.8

 The conditions reported more frequently by Gulf War 

4 Institute of Medicine (1999). Gulf War Veterans: Measuring Health, Washington, D.C.: 

National Academy Press, p. 2.

5

Iowa Persian Gulf Study Group. (1997). Self-reported Illness and Health Status Among Gulf 

War Veterans: A Population-Based Study. Journal of the American Medical Association,

277 (3), 238-245.

6

See Fukuda, K. et al. (1998.) Chronic Multisymptom Illness Affecting Air Force Veterans of 

the Gulf War. Journal of the American Medical Association, 280, 981-88. They report that 

6.0% of 1155 Gulf War veterans they surveyed reported symptoms that fit their working 

definition of a severe case of multisymptom illness, while only 0.7% of the 2520 surveyed 

non-deployed personnel did so. The investigators reported that the univariate association 

between Gulf War veteran status and fitting the severe case criteria was statistically 

significant (odds ratio =12.7 with 95% confidence limits between 7.5 and 21.5).
Appendix IV

Comments From the Department of Defense

Page 41 GAO/NSIAD-00-32 Gulf War Illnesses

veterans included problems with bones and joints, allergies, and limitations 

in activity due to health.

It is common throughout the epidemiological literature to accept a 

statistically significant difference in the risk of an illness as evidence of 

association. Even if the symptoms disproportionately reported by Gulf War 

veterans are not confined to these veterans, their increased frequency 

among Gulf War veterans needs to be explained. IOM has similarly 

concluded that, “It appears that veterans who served in the Gulf are more 

likely than their nondeployed comrades or civilians to experience a set of 

symptoms that include cognitive, musculoskeletal and energy/fatigue 

elements. In some cases, the symptoms are severe enough to be totally 

debilitating. Not all veterans experience the same cluster of symptoms; 

therefore, assuming a single underlying pathology or single cause for the 

complaints would not be appropriate.”9

7

Wolfe, J. et al. (1998.) Health Symptoms Reported by Persian Gulf War Veterans Two Years 

After Return. American Journal of Industrial Medicine, 33, 104-113. Unwin, C. et al. (1999.) 

Health of U.K. Servicemen Who Served in Persian Gulf War. Lancet, 353, 169-178. Pierce, P. 

(1997.) Physical and Emotional Health of Gulf War Veteran Women. Aviation, Space and 

Environmental Medicine, 68, 317-21.

8

Goss Gilroy, Inc. (1998.) Health Study of Canadian Forces Personnel Involved in the 1991 

Conflict in the Persian Gulf, vol. 1. Ottawa: Goss Gilroy.

9

Institute of Medicine (1999). Gulf War Veterans: Measuring Health, Washington, D.C.: 

National Academy Press, p. 33.
Appendix IV

Comments From the Department of Defense

Page 42 GAO/NSIAD-00-32 Gulf War Illnesses

7. Veterans of the Gulf War differ from the general civilian population with 

respect to fitness profile and other factors, so it is not surprising that their 

mortality rate would also differ from the rate for the general civilian 

population. Research found the mortality rate of Gulf War veterans through 

September 1993 to be slightly higher than that of veterans of the same era 

who served elsewhere, with the difference explained largely by greater 

mortality in motor vehicle accidents.10 In the published report of the 

mortality study, the authors speculate that increased mortality in 

automobile accidents might be attributed to increased risk-taking among 

war veterans in general, but they note that the reasons for the excess of 

deaths due to external causes among war veterans are not well understood. 

The finding was replicated in a follow-up study extending the observation 

period through December 1997.11

10The odds ratio for this difference was 1.09 with 95% confidence limits between 1.01 and 

1.16. See Kang, H.K. & Bullman, T. A. (1996.) Mortality Among U.S. Veterans of the Gulf War. 

New England Journal of Medicine, 335, 1498-1504. See also Haley, R. W., (1998.) 

“Commentaries: Point: Bias from the ‘Healthy Warrior Effect’ and Unequal Follow-up in 

Three Government Studies of Health Effects of the Gulf War.” American Journal of 

Epidemiology, 148 (4), pp. 315-338.

11The follow-up study found that the excess in deaths attributable to motor vehicle accidents 

persisted among Gulf War veterans observed through December 1997 (crude rate ratio = 

1.32; confidence interval 1.23-1.41), while the risk of disease related deaths did not increase 

or decrease over time. See Kang, H.A. & Bullman, T. A. (1999). Mortality Among U.S. 

Veterans of the Gulf War: Update Through December 1997. Conference on Federally 

Sponsored Gulf War Veterans’ Illnesses Research: Program and Abstract Book, (June 23-25, 

1999). Washington, D.C.: The Research Working Group of the Persian Gulf Veterans’ 

Coordinating Board, p. 28.
Appendix IV

Comments From the Department of Defense

Page 43 GAO/NSIAD-00-32 Gulf War Illnesses

8. DOD does not note the methodological limitations of these studies as 

their authors do in the respective published reports. As noted by IOM, the 

studies of hospitalization (Gray et al., 1996; Knoke and Gray, 1998) and 

adverse birth outcomes (Araneta et al., 1997; Cowen et al., 1997) have been 

limited to personnel remaining on active duty and to events occurring in 

military hospitals. Conceivably, those suffering from Gulf War-related 

symptoms might leave active duty voluntarily or take a medical discharge. 

Hospitalizations for that group would appear in VA or private sector 

databases but not in the DOD database. The health or characteristics of 

active duty personnel could differ from those of personnel who have left 

active duty or who have been treated in nonmilitary hospitals. Moreover, 

economic and other non-health-related factors are likely to affect use of 

nonmilitary hospitals and health care services.12 However, through 1993, 

studies did not observe an increase in hospitalization among deployed 

versus nondeployed veterans in the active duty military. Knoke and Gray, 

analyzing the same database, observed slightly more admissions for 

symptoms, signs and ill-defined conditions among Gulf-deployed veterans 

than among veterans deployed elsewhere during the same timeframe. They 

attributed the difference to admissions for evaluation purposes under the 

Comprehensive Clinical Evaluation Program, which offered examination 

and diagnostic services to Gulf War veterans.

9. Whether OSAGWI performs medical research is not relevant to 

determining whether the Research Working Group should coordinate its 

activities. We see nothing in the law that would limit the Group’s 

coordinating efforts to activities that constitute research, however defined.

DOD also contends that OSAGWI does not need to coordinate with RWG 

and that it has coordination mechanisms. However, DOD’s assertion that 

close coordination is already occurring is difficult to reconcile with our 

finding that duplication has occurred. Federal agencies have commissioned 

at least three reviews of the health effects of depleted uranium in the last 

few years, one each by the agencies represented on RWG. In addition, two 

major efforts to review the health effects of Gulf War veterans’ exposures 

have been pursued more or less independently − one by RAND, under 

contract to DOD, and another by the National Academy of Sciences, under 

contract to VA.

12Institute of Medicine (1999). Gulf War Veterans: Measuring Health, Washington, D.C.: 

National Academy Press, p. 36.
Appendix IV

Comments From the Department of Defense

Page 44 GAO/NSIAD-00-32 Gulf War Illnesses

Minutes of RWG meetings from April 1997 forward indicate that they have 

been attended by a succession of OSAGWI professional staff, as 

participants or observers, and we have revised the report to reflect this. 

Nonetheless, the working relationship between these organizations 

appears far from seamless. For example, RWG felt it necessary to write to 

OSAGWI to request a briefing on the literature reviews the office had 

tasked RAND to conduct. Similarly, in a letter to OSAGWI in April 1997, a 

VA RWG official expressed concerns about the lack of external review for 

several of OSAGWI’s proposed research efforts.

We understand that OSAGWI is not responsible for DOD’s medical research 

programs. As noted in our report, we deliberately adopted a broad scope, 

to include both research and investigation of exposure scenarios, to 

comprehensively examine relevant efforts. In any event, some of OSAGWI’s 

projects (listed in app. II) constitute research not only by the dictionary 

definition that DOD cites but also by DOD’s more restrictive criteria. 

Whether these undertakings are regarded as research or some other type of 

endeavor, our interest was in assessing their productivity. Thus, the key 

point is that most of the contracted projects are completed, but only a 

handful had been released.

10. While DOD and others have published various assessments of the 

research program, none of them have directly addressed the status of the 

research objectives identified in 1995. We requested this information from 

RWG officials, orally and in writing, and did not receive it. DOD contends 

that the effectiveness of these research efforts is not yet fully measureable. 

However, what is needed is not a final judgment but a simple accounting of 

where federal efforts stand with respect to answering the basic questions 

identified in 1995.

11. We have not called for an identification of a single unifying case 

definition or a summary judgment of treatment efficacy for heterogeneous 

conditions. However, it would seem reasonable to expect an accounting of 

the status of veterans’ health over time and a description of the types of 

treatments they have received. DOD suggests that it would be 

unreasonably difficult to provide such information. We note in the text that 

some basic questions about veterans’ health may be addressed by VA’s 

national health survey. However, at this writing, data from the survey have 

not yet been published. In mid-September 1999, the National Academy of 

Sciences Institute of Medicine Committee that VA commissioned to study 

methodological problems issued a report that describes a method of health 
Appendix IV

Comments From the Department of Defense

Page 45 GAO/NSIAD-00-32 Gulf War Illnesses

assessment. The law requires that VA continue this process by reviewing 

the methods suggested by IOM and pursuing, to the extent feasible, the 

collection of appropriate data.

12. With respect to the task order issued under the Management, 

Organizational, Business Improvement Schedule (MOBIS) contract, 

OSAGWI does not take issue with our conclusion that the order is outside 

the scope of the contract. For the reasons stated in the report, we continue 

to believe that the task order was improper. Therefore, the order should be 

terminated, if practicable, as we recommended and the office should 

ensure that any subsequent support contract is properly awarded. 

We recognize that OSAGWI relies on contracting professionals outside that 

office to execute its support contracts. However, that does not absolve the 

office of all responsibility concerning how its contract support is acquired. 

At a minimum, OSAGWI is responsible for determining and articulating its 

requirements, a process that in one instance resulted in the naming of a 

preferred vendor and in another instance led to an overly broad statement 

of work. The effect of these practices was to discourage competition for 

over $20 million in awards and therefore to risk inefficient use of funds. It 

is important that both entities that initiate requests for goods and services 

(for example, OSAGWI) as well as agencies that execute contracts for 

these goods and services ensure adherence to the statutes and regulations 

designed to maximize competition.
Page 46 GAO/NSIAD-00-32 Gulf War Illnesses

Appendix V

Comments From the Department of Veterans’ 

Affairs ApendxVi

Note: GAO comments 

supplementing those in the 

report text appear at the end 

of this appendix.

See comment 1.

See comment 2.
Appendix V

Comments From the Department of Veterans’ 

Affairs

Page 47 GAO/NSIAD-00-32 Gulf War Illnesses

See comment 2.

See comment 3.

See comments 4-6.

See comment 5.

See comment 6.

See comment 7.

See comment 8.

See comment 4.

See comments 7-9.
Appendix V

Comments From the Department of Veterans’ 

Affairs

Page 48 GAO/NSIAD-00-32 Gulf War Illnesses

See comment 8.

See comment 9.

See comment 10.

See comment 11.

See comment 12.
Appendix V

Comments From the Department of Veterans’ 

Affairs

Page 49 GAO/NSIAD-00-32 Gulf War Illnesses

GAO Comments The following is GAO’s response to the Department of Veterans’ Affairs 

comments dated September 9, 1999.

1. VA acknowledges that complete answers remain unavailable to the basic 

questions we identified in this report and in an earlier report (for example, 

how many veterans have unexplained illnesses and whether ill veterans 

examined by VA and DOD are better or worse than when they were first 

seen).1

 A basically satisfactory answer to the question of whether those ill 

veterans who have registered with VA or DOD are in better or worse health 

than when first examined involves only a periodic reassessment of their 

health, which is part of routine medical care.2

 As we stated when we first 

made such a recommendation 2 years ago, augmenting the data on the 

progress of ill Gulf War veterans with comparative data would add valuable 

information. However, at a minimum, it seems desirable to collect 

descriptive information on how Gulf War veterans’ conditions have 

improved or worsened. In mid-September 1999, IOM issued its report, 

which recommended a methodology to VA for measuring veterans’ health 

status (a longitudinal follow-up of a cluster sample of Gulf War veterans 

with several comparison groups). This approach is consistent with our 

recommendation that VA and DOD select a strategy for answering this 

question and compile the appropriate data.

2. Many of the efforts VA cites appear worthwhile, but VA does not assert 

that any of these have answered or would answer the basic questions we 

have identified about the prevalence of diagnosed and undiagnosed 

conditions in Gulf War veterans, the treatments they have received, and the 

course of any unexplained illnesses. The Veterans’ Health Administration’s 

(VHA) intention to collect longitudinal data on these veterans’ satisfaction 

with VHA services may provide a useful monitor of veterans’ perceptions. 

Early findings from this work suggest that Gulf War veterans, as a group, 

1

See Gulf War Illnesses: Improved Monitoring of Clinical Progress and Reexamination of 

Research Emphasis Are Needed (GAO/NSIAD-97-163), June 23, 1997.

2

For example, such an effort has been pursued by one of the VA’s Integrated Service 

Networks. Using a standardized assessment of health-related functioning, the SF-36 from 

the RAND medical outcomes study, researchers found that the presenting Gulf War veterans 

scored lower than U.S. norms on all dimensions of health status and that baseline scores 

were significantly different from 6 month follow-up. See Powell-Cope, G. M. & Roswell, R. 

(1999). Health Status of Gulf War Veterans in VISN 8. The Research Working Group, Persian 

Gulf Veterans Coordinating Board, Conference on Federally Sponsored Gulf War Veterans’ 

Illnesses Research, Washington, D.C.: PGVCB/RWG, p. 32.
Appendix V

Comments From the Department of Veterans’ 

Affairs

Page 50 GAO/NSIAD-00-32 Gulf War Illnesses

were somewhat less satisfied with VHA services than other veteran groups. 

VHA’s efforts to clarify the reasons for this through the use of focus groups 

are also appropriate. Similarly, the health services research efforts that VA 

identifies may help improve service delivery but do not appear suited to 

developing much longitudinal information because the projects are funded 

for only 2 years.

3. Among the conclusions the NIH Working Group reached in 1994 was 

that, “It is important that a more accurate estimate of the symptom 

prevalence be established.” In support of our finding that basic information 

on the prevalence of various symptom clusters remains unavailable, we 

note that VA and DOD registries of examined Gulf War veterans also do not 

provide sufficient data for determining which of various symptom clusters 

deserve the closest attention. We agree that the registries may be valuable 

for other purposes and that there are additional reasons that they might be 

imperfect research tools. While the VA’s national health survey has 

collected much of the symptom data sought by the NIH group, its results 

remained unpublished at the close of our review.

4. In support of its objection to our criticism of the coordination between 

the PGVCB RWG and the Office of the Special Assistant, VA notes that the 

role of the PGVCB is one of communication and coordination of its 

member agencies’ activities; it does not control these activities. For this 

reason, our draft report noted that PGVCB has no budgetary authority. 

Nonetheless, part of the function of communication and coordination is to 

reach agreement on a plan of action to optimize resources while meeting 

sometimes varied needs for information. We observed that some projects 

sponsored by agency members of the RWG are duplicative (see our 

comment 9 in app. IV.)

5. In support of its objection to our criticism of the coordination between 

the PGVCB’s RWG and the Office of the Special Assistant, VA notes that 

OSAGWI is represented on the RWG’s parent organization, the 

Coordinating Board, along with other DOD elements. We have revised the 

report to reflect that professional staff from OSAGWI did attend RWG 

meetings, as participants or observers, beginning in April 1997. We have not 

asserted that a coordination mechanism is missing; our criticism is related 

to the effectiveness of this mechanism in eliminating duplicative 

expenditures and ensuring uniformly high confidence across agencies in 

the research activities undertaken.
Appendix V

Comments From the Department of Veterans’ 

Affairs

Page 51 GAO/NSIAD-00-32 Gulf War Illnesses

6. While most of OSAGWI’s expenditures appear to be focused on the 

investigation of specific incidents for the potential exposures that might 

have resulted, which would be germane to epidemiological researchers, 

OSAGWI officials identified $13.3 million, a substantial amount of the 

office’s expenditures, as being devoted to research. It is worth noting that 

this amount, while it represents a minority of OSAGWI’s budget, exceeds 

the total of VA and CDC Gulf War research expenditures over the period we 

examined. 

7. First, appendix II of the draft report noted that only four of the nine 

RAND reports submitted for interagency review had actually reached 

publication by mid-1999 and that publication had, in some instances, 

occurred over a year following submission. After receiving DOD’s 

comments on our report, RAND’s report on pyridostigmine bromide was 

released 16 months after its submission to interagency review in June 1998. 

Similarly, RAND’s report on stress was published approximately a year 

after submission for review, and its report on chemical and biological 

warfare agents was submitted for interagency review 15 months ago. Thus, 

delaying the release of these documents to IOM until publication occurs 

does not seem an effective means of coordinating two such closely linked 

tasks. 

Second, it is important to note that the Agency for Toxic Substances and 

Disease Registry’s report on uranium (including depleted uranium) was 

made available for public comment on October 17, 1997 (the public 

comment period ended on Feb. 17, 1998, and revision was begun based on 

comments received). Thus, the need for an additional review of depleted 

uranium by RAND in 1997 was questionable. The RAND review was not 

submitted until August of 1998, after the Agency review had been issued in 

draft form.3

 We have added a discussion of this matter to our report.

8. VA asserts that the goals and methods of these two studies are different 

but does not explain how they are different. Because IOM will not be 

conducting original research to make its determinations, it will also rely on 

existing literature. Material distributed by IOM in connection with a recent 

meeting of its Committee on Health Effects Associated with Exposures 

During the Gulf War indicates that, “The purpose of this project would be to 

conduct a review of the scientific and medical literature regarding adverse 

3

See Agency for Toxic Substances and Disease Registry (Sept. 1997). Draft Toxicological 

Profile for Uranium. Atlanta, GA:U.S. Dept. of Health and Human Services, PHS/ATSDR.
Appendix V

Comments From the Department of Veterans’ 

Affairs

Page 52 GAO/NSIAD-00-32 Gulf War Illnesses

health effects associated with exposures experienced during the Persian 

Gulf War.” Similarly, the preface to one of RAND’s literature reviews notes, 

“The reviews are intended principally to summarize the scientific literature 

on the known health effects of given exposures to these risk factors.” 

Accordingly, we find little distinction between these two activities in terms 

of purpose or basic methodology.

9. The issue we are raising is not whether IOM’s work ought to have been 

initiated but that its work has not benefited from coordination with RAND’s 

to save time and money in accomplishing a goal that is widely regarded as 

important. Similarly, RAND’s work was not coordinated with that of CDC’s 

Agency for Toxic Substances and Disease Registry. 

10. Even if the symptoms reported by Gulf War veterans are not confined 

to these veterans, their increased frequency among Gulf War veterans 

needs to be explained. Our report does not suggest that a single case 

definition is appropriate; we note simply that RWG has not endorsed one or 

more case definitions that might focus research on veterans’ undiagnosed 

symptoms.

11. This recommendation has been reworded to refer to “the number of 

Gulf War veterans with unexplained illnesses.” We understand that, in 

implementing the recommendation, it may be appropriate to characterize 

unexplained illnesses using some groupings or working case definitions for 

the purposes of counting.

12. We made this recommendation to prompt organizations to work more 

closely on behalf of veterans suffering from these illnesses. We believe that 

greater cooperation, exchange of information, and coordination will help 

expedite the process and help find solutions the veterans need. While VA 

indicates that RWG has provided sufficient information on the scope of 

activities it continues to coordinate among DOD, VA, and HHS, we found 

substantially similar activities that fell outside this scope. In addition, we 

find nothing in the law that would limit the Group’s coordinating efforts to 

this scope of activities.
Page 53 GAO/NSIAD-00-32 Gulf War Illnesses

Appendix VI

Comments From the Centers for Disease 

Control and Prevention ApendxViI

Note: GAO comments 

supplementing those in the 

report text appear at the end 

of this appendix.

See comment 1.
Appendix VI

Comments From the Centers for Disease 

Control and Prevention

Page 54 GAO/NSIAD-00-32 Gulf War Illnesses

See comment 2.
Appendix VI

Comments From the Centers for Disease 

Control and Prevention

Page 55 GAO/NSIAD-00-32 Gulf War Illnesses

GAO Comments The following is GAO’s response to the Centers for Disease Control and 

Prevention’s comments dated August 20, 1999.

1. CDC’s Air Force study was cited in appendix III of our draft report along 

with the case definition it developed as one of a set of overlapping working 

case definitions that have been advanced since 1994. We have added 

information about these studies and their findings to the final report and 

have discussed them more fully in our response to agency comments and 

also in our more detailed response to DOD’s comments (see comment 6 in 

app. IV). 

2. Our draft report noted that the extensions discussed were partially 

attributed to efforts to incorporate additional data. We have added the 

word “additional” before “follow-up” to specifically clarify that the 

extension of the Iowa project was to provide for work not initially 

anticipated, not to allow additional time for work already planned.
Page 56 GAO/NSIAD-00-32 Gulf War Illnesses

Appendix VII

GAO Contacts and Staff Acknowledgments ApendxViI

GAO Contacts Sushil K. Sharma (202) 512-3460

Betty Ward-Zukerman (202) 512-2732

Acknowledgments In addition to those named above, Margaret Best, John Carter, 

Howard Deshong, and William Woods made key contributions to this 

report.
Page 57 GAO/NSIAD-00-32 Gulf War Illnesses
Page 58 GAO/NSIAD-00-32 Gulf War Illnesses

Related GAO Products

Gulf War Illnesses: Procedural and Reporting Improvements Are Needed 

in DOD’s Investigative Processes (GAO/NSIAD-99-59, Feb. 26, 1999).

Acquisition Reform: Multiple-Award Contracting at Six Federal 

Organizations (GAO/NSIAD-98-215, Sept. 30, 1998).

VA Health Care: Better Integration of Services Could Improve Gulf War 

Veterans’ Care (GAO/HEHS-98-197, Aug. 19, 1998).

Role of the Persian Gulf Veterans’ Coordinating Board in Scientific 

Evaluation of Research Proposals and the Funding Recommendations 

Made by Its Research Working Group (GAO/NSIAD-98-170R, Aug. 10, 

1998).

Gulf War Veterans: Limitations of Available Data for Accurately 

Determining the Incidence of Tumors (GAO/T-NSIAD-98-186, May 14, 

1998).

VA Health Care: Persian Gulf Dependents’ Medical Exam Program 

Ineffectively Carried Out (GAO/HEHS-98-108, Mar. 31, 1998).

Gulf War Veterans: Incidence of Tumors Cannot Be Reliably Determined 

From Available Data (GAO/NSIAD-98-89, Mar. 3, 1998).

Gulf War Illnesses: Federal Research Strategy Needs Reexamination

(GAO/T-NSIAD-98-104, Feb. 24, 1998).

Gulf War Illnesses: Research, Clinical Monitoring, and Medical 

Surveillance (GAO/T-NSIAD-98-88, Feb. 5, 1998).

Veterans’ Benefits: Improvements Made to Persian Gulf Claims 

Processing (GAO/T-HEHS-98-89, Feb. 5, 1998).

Gulf War Illnesses: Public and Private Efforts Relating to Exposures of 

U.S. Personnel to Chemical Agents (GAO/NSIAD-98-27, Oct. 15, 1997).

Gulf War Illnesses: Reexamination of Research Emphasis and Improved 

Monitoring of Clinical Progress Needed (GAO/T-NSIAD-97-191, June 25, 

1997).

Gulf War Illnesses: Enhanced Monitoring of Clinical Progress and of 

Research Priorities Needed (GAO/T-NSIAD-97-190, June 24, 1997).
Related GAO Products

Page 59 GAO/NSIAD-00-32 Gulf War Illnesses

Gulf War Illnesses: Improved Monitoring of Clinical Progress and 

Reexamination of Research Emphasis Are Needed (GAO/NSIAD-97-163, 

June 23, 1997).

VA Health Care: Observations on Medical Care Provided to Persian Gulf 

Veterans (GAO/T-HEHS-97-158, June 19, 1997).

Chemical and Biological Defense: Protection of Critical Overseas Ports 

and Airfields Remains Largely Unaddressed (GAO/NSIAD-97-9, 

June 13, 1997).

Operation Desert Storm: Evaluation of the Air Campaign (GAO/NSIAD97-134, June 12, 1997).

Defense Health Care: Medical Surveillance Has Improved Since the Gulf 

War, but Results in Bosnia Are Mixed (GAO/NSIAD-97-136, May 13, 1997).

Veterans’ Compensation: Evidence Considered in Persian Gulf War 

Undiagnosed Illness Claims (HEHS-96-112, May 28, 1996).

Chemical and Biological Defense: Emphasis Remains Insufficient to 

Resolve Continuing Problems (GAO/NSIAD-96-103, Mar. 29, 1996).

(713038) Letr
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