GULF WAR ILLNESSES

Basic Questions

Unanswered

Statement of Kwai-Cheung Chan, Director, Special Studies and Evaluations,

National Security and International Affairs Division

United States General Accounting Office

GAO Testimony

Before the Subcommittee on National Security, Veterans'

Affairs, and International Relations, Committee on

Government Reform, House of Representatives

For Release on Delivery

Estimated at

10:00 a.m., EST

Wednesday,

February 2, 2000

GAO/T-NSIAD-00-79
Mr. Chairman and Members of the Subcommittee:

We are pleased to be here today to discuss our recently completed report on the research

and investigations conducted on Gulf War veterans’ illnesses.1 Many of the approximately

700,000 Gulf War veterans have complained of illnesses since the war’s end in 1991, and

over 10 percent have completed health examinations through the Department of Veterans’

Affairs (VA) or Department of Defense (DOD). Some are concerned they are suffering

from chronic disabling conditions because of exposures during the war to agents with

known or suspected effects on health. In response to this concern, the government has

funded research, investigation, and information activities through various agencies,

including DOD, VA, and the Department of Health and Human Services (HHS). These

agencies participate in an interagency group, the Persian Gulf Veterans’ Coordinating

Board, which was established in 1994 to coordinate these activities. The Coordinating

Board’s Research Working Group, currently chaired by the Department of Veterans’

Affairs, focuses on research planning, review, and dissemination, but it is not authorized to

manage or distribute the Departments’ research funds. In 1996, DOD established the

Office of the Special Assistant for Gulf War Illnesses to oversee DOD’s efforts regarding

illnesses being experienced by Gulf War veterans.

As requested, today we will discuss the expenditures on these efforts by the Departments

of Defense, Veterans’ Affairs, and Health and Human Services and our work to evaluate

their results. Specifically, we determined

1

Gulf War Illnesses: Management Actions Needed to Answer Basic Research Questions (GAO/NSIAD-00-

32, Jan. 6, 2000).
- the amount of money that these three departments spent in fiscal years 1997 and 1998

on research and investigation into Gulf War veterans’ illnesses and health concerns,

- the results of the research and investigation spending,

- the extent of coordination between the Coordinating Board’s Research Working Group

and DOD’s Office of the Special Assistant for Gulf War Illnesses, and

- the management of contracts supporting DOD’s Office of the Special Assistant.

SUMMARY

I will briefly summarize our four principal findings before providing more detail.

- First, during fiscal 1997 and 1998, the Departments of Veterans’ Affairs, Health and

Human Services, and Defense spent more than $121 million for research and

investigation into Gulf veterans’ illnesses. The Defense Department spent $112 million

of this total, mostly through its Office of the Special Assistant for Gulf War Illnesses.

- Second, results of the research and investigation activities are accruing slowly and

basic questions about the causes, course of development, and treatments of Gulf War

veterans’ illnesses remain unanswered.

- Third, the activities of the Office of the Special Assistant are not effectively coordinated

with those of the Research Working Group.
- Finally, work was improperly awarded to the Office’s support contractors for tasks worth

more than $20 million.

DOD SPENT MOST OF THE RESEARCH AND INVESTIGATION FUNDS

DOD spent most of the $121 million used for Gulf War research and investigation by the

three agencies in fiscal 1997 and 1998. The Department of Health and Human Services

reported it spent less than $2 million, the Department of Veterans’ Affairs $7 million, and

DOD $112 million. These amounts exclude expenses for examinations and clinical care of

ill veterans. Within DOD, the Office of the Special Assistant spent the largest amount, $65

million, while other activities, such as the medical research efforts catalogued by the

Research Working Group, accounted for $47 million.2

Representatives of the Office of the Special Assistant told us that the Office had projected

spending $36 million in fiscal 1999 and $30 million in fiscal 2000. These officials told us in

1998 that they were seeking the guidance of the President’s Special Oversight Board on

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

Office’s investigative work should continue and how it should reduce the role of the Office.

However, funding for the Office is included in DOD’s budget through fiscal 2005.

2 The expenditures for VA’s 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 spending does not include overhead costs for internal studies run by the Department but does for

external ones financed by the Department. In addition, the numbers reported for the Office of the Special

Assistant include overhead costs and some spending on veteran outreach.
BASIC QUESTIONS ABOUT VETERANS’ ILLNESSES REMAIN UNANSWERED

Regarding the results to date of the three Departments’ research and investigations, we

have several observations. First, 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 agenda has satisfied the objectives it identified in 1995.

These objectives include questions about the prevalence of specific health problems and

exposures among the veteran population and the way the prevalence differs between Gulf

War veterans and appropriate control populations. We recommended, and agency

officials agreed, that a date should be established in 2000 for publication of this

assessment.

Also, while findings from research are beginning to accumulate, most of the sponsored

studies are ongoing or in review. By mid-1999, of the 151 research projects monitored by

the Research Working Group, 70 percent were still ongoing, including 19, or about 30

percent of the 62 that were scheduled for completion by then. Group officials attributed the

extended completion dates 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.

In addition, DOD’s Office of the Special Assistant for Gulf War Illnesses had received 19 of

the 20 reports due from its major research contractors. However, only 6 had been publicly
released; the remainder was largely in various stages of interagency review. Fourteen of

these reports had remained in draft or review status for a year or longer.3

While federally sponsored studies have resulted in some descriptive information

concerning veterans’ symptoms, many basic questions remain. Identification of the

potential causes of veterans’ unexplained symptoms has been difficult because

researchers are faced by persistent problems in ascertaining veterans’ specific exposures.

In addition, the Research Working Group has not endorsed any case definition or set of

such definitions that might focus federal research. 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.4 In particular, difficulty in

accurately classifying veterans by the levels of their exposure to specific agents makes it

hard to detect associations between exposures and health outcomes.

Other basic questions remain unanswered 9 years after the veterans returned home. As

early as 1994, a National Institutes of Health Work Group that met to consider research

needs on Gulf War veterans’ illnesses, observed that better estimates of the prevalence of

symptoms were desirable. In 1997, we noted -- as did the Special Investigative Unit of the

Senate Veterans’ Affairs Committee -- that open questions included how many of the

veterans who had been examined had unexplained illnesses or symptoms. However, a

3

For a review of the Office’s investigatory activities, see Gulf War Illnesses: Improved Monitoring of Clinical

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

4 Epidemiology is the study of the distribution of illness. Epidemiological studies generally first describe

patterns of illness, environmental factors, and exposures. Researchers then form hypotheses based on

patterns seen in such descriptive data and conduct analytic epidemiological studies to test these hypotheses,

often by comparing the exposures of persons who fit specific illness criteria to those who do not or by

comparing rates of illness among persons with different levels of specific exposures.
September 1999 report of the Institute of Medicine noted that no systematic evaluation has

been done to determine whether or how veterans’ health status is changing.5 Also, in its

1998 report to Congress, the Research Working Group acknowledged that no government

research is specifically directed toward understanding the progress of Gulf War veterans’

illnesses over time and that research should assess the long-term health of these

veterans.6

Some data that might be helpful in answering such questions are being collected as part of

a national health survey of Gulf War veterans being conducted by VA, but an analysis of

these data was not available at the close of our review. In addition, an HHS-sponsored

project, which began in 1997, is assessing the persistence and stability of veterans’

symptoms over time. This study is planned to end in 2000.

We recommended 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 with this recommendation and VA did not

concur. Neither agency opposed the collection of information on the number and health

status of Gulf War veterans with 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). DOD objected that veterans’ illnesses were not

amenable to a single, unifying case definition. Although consensus on a single definition

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

Sept. 1999), p. 3, 35.

6 Persian Gulf Veterans’ Coordinating Board – Research Working Group, Annual Report to Congress – 1998

(Washington, D.C.: PGVCB RWG, June 1999), p. 53.
would simplify this task, it is not essential. Nonetheless, we agree that some categorization

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

veterans that have unexplained illnesses of some type and we revised our

recommendation to reflect this. In September 1999, the Institute of Medicine issued a

report to VA which recommended a methodology for measuring veterans’ health status.

This approach is consistent with our recommendation that VA and DOD select a strategy

for answering this question and compile the appropriate data.

ACTIVITIES ARE NOT EFFECTIVELY COORDINATED

The Office of the Special Assistant’s activities have not been effectively coordinated with

those of the Research Working Group to maximize the efficient use of resources. Group

and Office representatives stated that the Office’s activities involve investigations, not

research, and were therefore not subject to coordination. However, in a 1997 letter to the

Office of the Special Assistant, the Research Working Group clearly regarded some of the

Office’s activities as 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. Characterizing veterans’ exposures is the focus of several of the

research objectives the Group established in 1995, and the Office’s investigations of

potential exposures should be germane to researchers trying to identify the consequences

of such exposure.

The lack of effective coordination between the Group and the Office also increases the

potential to miss opportunities to take advantage of ongoing and completed work by other
agencies. For example, in January 1998, the 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 review, evaluate and summarize the available scientific and medical

information regarding the association between Gulf War veterans’ exposures and the

adverse health effects they had experienced. However, in 1997, the Office of the Special

Assistant contracted with RAND at a cost of more than $1.5 million to conduct a similar

review.7 In addition, the three Departments separately funded reviews of the health effects

of depleted uranium. Better coordination of these efforts might have saved both time and

money.

To prompt these offices to work more closely on behalf of all veterans, we have

recommended that the three Department secretaries direct the Executive Director of the

Research Working Group to 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 believe that greater

cooperation, exchange of information, and coordination will help expedite the process and

help find solutions the veterans need.

CONTRACTING FOR THE OFFICE’S SUPPORT SERVICES WAS FLAWED

With regard to the management of contracts supporting the Office, we reviewed four

support agreements, which accounted for more than 91 percent of the $47 million the

Office spent for support services. We found that two task orders worth over $20 million

were awarded improperly, and the Office discouraged competition for another task order by

7 The Office eventually authorized RAND work valued at $3.2 million.
specifying a preferred vendor. Because the Office is likely to continue to spend a

significant part of its budget on support contracts, the Office needs to ensure that its

contracts fully comply with applicable requirements.

We recommended that the Secretary of Defense direct the Office of the Special Assistant

to replace an improperly awarded task order with a proper contracting arrangement as

soon as practicable. Finally, we recommended that the Secretary direct the Office that all

future support contracts should comply fully with applicable laws and regulations. DOD did

not concur with these recommendations, stating that the Office of the Special Assistant

does not have its own contracting officers and relied on the judgment of contracting

professionals outside the office, who did not object to the Office’s contract actions. We

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

outside the 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 that both requiring agencies, such as the Office, as well as agencies that execute

contracts, adhere to the statutes and regulations designed to maximize competition.

---------------

Mr. Chairman, this concludes my statement. I would be happy to answer any questions

you may have.
Contacts and Acknowledgments

For future questions regarding this testimony, please contact Kwai-Cheung Chan at (202)

512-3652. Individuals making key contributions to this testimony included Dr. Sushil K.

Sharma and Dr. Betty Ward-Zukerman.

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