a

GAO

United States General Accounting Office

Report to the Chairman, Subcommittee 

on National Security, Emerging Threats, 

and International Relations, Committee 

on Government Reform, House of 

Representatives

June 2004 DEPARTMENT OF 

VETERANS AFFAIRS

Federal Gulf War 

Illnesses Research 

Strategy Needs 

Reassessment

GAO-04-767
www.gao.gov/cgi-bin/getrpt?GAO-04-767.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Janet Heinrich 

at (202) 512-7119. 

Highlights of GAO-04-767, a report to the 

Chairman, Subcommittee on National 

Security, Emerging Threats, and 

International Relations, Committee on 

Government Reform, House of 

Representatives 

June 2004

DEPARTMENT OF VETERANS AFFAIRS

Federal Gulf War Illnesses Research 

Strategy Needs Reassessment 

Most federally funded Gulf War illnesses research projects and 

investigations are complete, but VA—the agency with lead responsibility for 

coordination of Gulf War illnesses issues—has not yet analyzed the latest 

research findings to identify whether there are gaps in current research or to 

identify promising areas for future research. As of September 2003, about 80 

percent of the 240 federally funded medical research projects for Gulf War 

illnesses had been completed. In recent years, VA and DOD funding for this 

research has decreased, federal research priorities have changed, and 

interagency coordination of Gulf War illnesses research has waned. In 

addition, VA has not reassessed the extent to which the collective findings of 

completed Gulf War illnesses research projects have addressed key research 

questions. The only assessment of progress in answering these research 

questions was published in 2001, when findings from only about half of all 

federally funded Gulf War illnesses research were available. Moreover, it did 

not identify whether there were gaps in existing Gulf War illnesses research 

or promising areas for future research. This lack of comprehensive analysis 

leaves VA at greater risk of failing to answer unresolved questions about 

causes, course of development, and treatments for Gulf War illnesses. In a 

separate effort, DOD has conducted 50 investigations since 1996 on potential 

hazardous exposures during the Gulf War. Generally, these investigations 

concluded that there were limited exposures by troops to some hazards and, 

at most, limited short- or long-term adverse effects expected from these 

exposures. As of April 2003, all investigations were complete. 

Federal agencies have funded seven research projects related to cancer 

incidence among Gulf War veterans. However, several limitations exist that 

affect research related to cancer incidence. For example, some cancers may 

take many years to develop and be detected. In addition, some research 

projects studying cancer incidence have not studied enough Gulf War 

veterans to reliably assess cancer incidence. Research may also be 

impeded by incomplete federal data on the health characteristics of Gulf 

War veterans. 

RAC’s efforts to provide advice and make recommendations on Gulf War 

illnesses research to the Secretary of VA may have been hampered by VA 

senior administrators’ incomplete or unclear information sharing and limited 

collaboration on research initiatives and program planning. VA and RAC are 

exploring ways to improve collaboration, including VA’s hiring of a senior 

scientist who would both guide VA’s Gulf War illnesses research and serve 

as the agency’s liaison for routine updates to the advisory committee. 

However, most of these changes had not been finalized at the time of our 

review. 

More than a decade after the 1991 

Persian Gulf War, there is 

continued interest in the federal 

response to the health concerns of 

Gulf War veterans. Gulf War 

veterans’ reports of unexplained 

illnesses and possible exposures to 

various health hazards have 

prompted numerous federal 

research projects on Gulf War 

illnesses. This research has been 

funded primarily by the 

Department of Veterans Affairs 

(VA), the Department of Defense 

(DOD), and the Department of 

Health and Human Services. GAO 

is reporting on (1) the status of 

research and investigations on Gulf 

War illnesses, (2) the efforts that 

have been made by VA and DOD to 

monitor cancer incidence among 

Gulf War veterans, and 

(3) VA’s communication and 

collaboration with the Research 

Advisory Committee on Gulf War 

Veterans’ Illnesses (RAC). 

GAO recommends that the 

Secretary of VA conduct a 

reassessment of the federal Gulf 

War illnesses research strategy, 

ensure that a liaison who is 

knowledgeable about Gulf War 

illnesses research is appointed to 

routinely share information with 

RAC, and ensure that VA’s research 

offices collaborate with RAC on 

Gulf War illnesses research 

program development activities. VA

concurred with the report’s 

recommendations and cited several 

actions it has initiated to address 

them. 
Page i GAO-04-767 Gulf War Illnesses Research Strategy 

Letter 1

Results in Brief 2

Background 4

Most Federally Funded Gulf War Illnesses Research Projects and 

Investigations Are Complete, but VA Has Not Collectively 

Analyzed Research Findings to Determine the Status of Key 

Research Questions 11

Some Efforts Are Under Way to Monitor Cancer Incidence among 

Gulf War Veterans, but Research Limitations May Impede 

Reliability of Results 17

RAC’s Efforts to Provide Advice May Be Hindered by VA’s Limited 

Information Sharing and Collaboration, but Several Changes to 

Address These Issues Have Been Proposed 22

Conclusions 27

Recommendations for Executive Action 27

Agency Comments and Our Evaluation 28

Appendix I Scope and Methodology 29 

Appendix II Key Gulf War Illnesses Research Questions 30 

Appendix III Charter for VA’s Research Advisory Committee on 

Gulf War Veterans’ Illnesses 33 

Appendix IV Comments from the Department of Veterans Affairs 36 

Tables 

Table 1: Research Related to Cancer Incidence in Gulf War 

Veterans (GWV) 19

Table 2: Twenty-one Key Gulf War Illnesses Research Questions 31

Contents 
Page ii GAO-04-767 Gulf War Illnesses Research Strategy 

Figures 

Figure 1: Evolution of Interagency Committees That Coordinated 

Federal Gulf War Illnesses Research from 1993 through 

2004 6

Figure 2: DOD Entities Responsible for Gulf War Exposure 

Investigations from 1995 through 2004 9

Figure 3: Cumulative Number of Ongoing and Completed Federal 

Gulf War Illnesses Research Projects by Year 12

Figure 4: Funding Share for Gulf War Illnesses Research by Agency 

and Fiscal Year 13

Figure 5: Funding for Gulf War Research Projects, Fiscal Years 

1994-2003 14

Figure 6: Organizational Relationships between VA and RAC, as of 

April 2004 25
Page iii GAO-04-767 Gulf War Illnesses Research Strategy 

Abbreviations 

CRADO Chief Research and Development Officer 

DHSD Deployment Health Support Directorate 

DHWG Deployment Health Working Group 

DOD Department of Defense 

GWV Gulf War veterans 

HEC VA/DOD Health Executive Council 

HHS Department of Health and Human Services 

MVHCB Military Veterans Health Coordinating Board 

NIH National Institutes of Health 

NSTC National Science and Technology Council 

OSAGWI Office of Special Assistant for Gulf War Illnesses 

OSAGWI-MRMD Office of Special Assistant for Gulf War Illnesses 

 Medical Readiness and Military Deployments 

PGIIT Persian Gulf Illnesses Investigation Team 

PGIRCC Persian Gulf Interagency Research Coordinating 

 Council 

PGVCB Persian Gulf Veterans Coordinating Board 

RAC Research Advisory Committee on Gulf War 

 Veterans’ Illnesses 

RWG Research Working Group 

VA Department of Veterans Affairs 

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Page 1 GAO-04-767 Gulf War Illnesses Research Strategy 

June 1, 2004 

The Honorable Christopher Shays 

Chairman 

Subcommittee on National Security, 

 Emerging Threats, and International Relations, 

Committee on Government Reform 

House of Representatives 

Dear Mr. Chairman: 

More than a decade after the end of the 1991 Persian Gulf War, there is 

continued interest in the federal government’s response to the health 

concerns of Gulf War veterans. While about 700,000 U.S. military 

personnel were deployed during this conflict, casualties were relatively 

light compared with previous major conflicts. However, approximately 

80,000 veterans have reported various symptoms in the years following the 

war, and scientists have agreed that many veterans have unexplained 

illnesses. Gulf War illnesses are characterized by one or more symptoms 

that do not conform to a characteristic diagnosis. Such symptoms 

commonly include fatigue, muscle and joint pains, headaches, memory 

loss, skin rash, diarrhea, and sleep disturbances. In addition to concerns 

about unexplained illnesses, many Gulf War veterans also have elevated 

concerns that possible exposures to chemical or biological warfare agents, 

or environmental contaminants, may be associated with an increased risk 

of developing cancer. Past research projects have found associations 

between some of these substances and different types of cancers. 

Gulf War veterans’ reports of illnesses have prompted numerous federal 

research projects on the nature, extent, and treatment of Gulf War 

illnesses. Federal Gulf War illnesses research projects have been funded 

primarily by the Department of Veterans Affairs (VA), the Department of 

Defense (DOD), and the Department of Health and Human Services (HHS). 

Each agency separately sponsors and funds research projects, though a 

few are conducted jointly. In 1993, the President made the Secretary of VA 

responsible for coordinating research activities undertaken or funded by 

the executive branch of the federal government on the health 

consequences of service in the Gulf War. In 2002, a congressionally 

mandated federal advisory committee—the VA Research Advisory 

Committee on Gulf War Veterans’ Illnesses (RAC)—was established to 

provide advice on federal Gulf War illnesses research needs and priorities 

United States General Accounting Office 

Washington, DC 20548 
Page 2 GAO-04-767 Gulf War Illnesses Research Strategy 

to the Secretary of VA. The committee is made up of members of the 

general public, including non-VA researchers and veterans’ advocates. 

Separately from this research, DOD has conducted investigations on 

specific events that took place during the Gulf War to identify possible 

exposures to potentially hazardous chemical agents, such as sarin, 

mustard, and benzyl bromide. In addition, DOD has conducted 

investigations of potential occupational and environmental hazards, 

including depleted uranium from munitions, smoke from oil well fires, 

pesticides, petroleum, and fuels. DOD has published a number of reports 

that discuss the findings of these Gulf War investigations. 

Because of these concerns, we are reporting on (1) the status of federal 

research and investigations on Gulf War illnesses, (2) the efforts that have 

been made by VA and DOD to monitor cancer incidence among Gulf War 

veterans, and (3) VA’s communication and collaboration with RAC. 

To examine these issues, we interviewed senior officials within VA and 

DOD and senior managers with each agency’s relevant research offices. 

We analyzed pertinent agency documents, including annual reports to 

congressional committees describing research priorities, ongoing and 

completed projects, and agency funding. Additionally, we interviewed RAC 

officials, attended a RAC meeting, and reviewed RAC reports and 

recommendations. We conducted our work from September 2003 through 

May 2004 in accordance with generally accepted government auditing 

standards. (See app. I for further detail.) 

While the federal focus on Gulf War–specific research has diminished, 

VA—the agency with lead responsibility for coordination of Gulf War 

illnesses issues—has not yet analyzed the latest research findings to 

identify whether there are gaps in current research or to identify 

promising areas for future research. As of September 2003, about 80 

percent of the 240 federally funded medical research projects for Gulf War 

illnesses had been completed. In recent years, VA and DOD have 

decreased their expenditures on Gulf War illnesses research and have 

expanded the scope of their medical research programs to incorporate the 

long-term health effects of all hazardous deployments. Interagency 

committees formed by VA to coordinate federal Gulf War illnesses 

research evolved to reflect these changing priorities, but these entities 

have ultimately been dissolved or have become inactive. In addition, VA 

has not reassessed the extent to which the collective findings of 

completed Gulf War illnesses research projects have addressed key 

Results in Brief 
Page 3 GAO-04-767 Gulf War Illnesses Research Strategy 

research questions. The only assessment of progress in answering these 

research questions was published in 2001, when findings from only about 

half of all federally funded Gulf War illnesses research were available. As a 

result, VA has not determined whether previously identified research 

questions have been answered or whether they remain relevant. This lack 

of comprehensive analysis leaves VA at greater risk of failing to answer 

unresolved questions about causes, course of development, and 

treatments for Gulf War illnesses. In a separate effort, DOD has conducted 

50 investigations since 1996 on potential hazardous exposures during the 

Gulf War. Generally, these investigations concluded that there were 

limited exposures by troops to some hazards and, at most, limited short- or 

long-term adverse effects expected from these exposures. As of April 2003, 

all investigations were complete. 

Federal agencies have funded seven research projects related to cancer 

incidence among Gulf War veterans. However, several limitations exist 

that affect research related to cancer incidence. For example, some 

cancers may take many years to develop and be detected. In addition, 

some research projects have not studied enough Gulf War veterans to 

reliably assess cancer incidence. Research may also be impeded by 

incomplete federal data on the health characteristics of Gulf War veterans. 

RAC’s efforts to provide advice and make recommendations on Gulf War 

illnesses research may have been hampered by VA senior administrators’ 

incomplete or unclear information sharing and limited collaboration on 

Gulf War illnesses research initiatives and program planning. For example, 

VA failed to inform RAC about its 2002 major research program 

announcement that included Gulf War illnesses research. Similarly, VA did 

not seek RAC’s review of a draft of the 2002 annual report to congressional 

committees describing current federally funded Gulf War illnesses 

research. VA and RAC are exploring ways to improve information sharing, 

including VA’s hiring of a senior scientist who would both guide VA’s Gulf 

War illnesses research and serve as the agency’s liaison for routine 

updates to RAC. However, most of these changes had not been finalized at 

the time of our review. 

We are making recommendations to the Secretary of VA to improve 

federal efforts to plan and coordinate Gulf War illnesses research. 

Specifically, we recommend that VA conduct a reassessment of the federal 

Gulf War illnesses research strategy to ensure its continued validity and to 

identify promising areas for future research. We also recommend that VA 

improve its sharing of research information and its collaboration with 

RAC. 
Page 4 GAO-04-767 Gulf War Illnesses Research Strategy 

In commenting on a draft of this report, VA concurred with the report’s 

recommendations and said that it has begun a preliminary assessment of 

the federal Gulf War illnesses research strategy, including an evaluation of 

the 21 key research questions. The agency also noted that it has 

undertaken various steps, such as coordinating its most recent request for 

Gulf War research applications with RAC, in order to better collaborate 

with the advisory committee. 

Following Iraq’s invasion of Kuwait in August 1990, the United States and 

other allied nations sent troops to the Persian Gulf region in Operation 

Desert Shield. In the winter of 1991, the allied forces attacked Iraq in an air 

campaign and subsequent invasion by ground forces (Operation Desert 

Storm). Despite the harsh environment, illness, injury, and death rates 

among approximately 700,000 U.S. military personnel were significantly 

lower than in previous major conflicts. Yet, shortly after the war, some 

veterans began reporting health problems that they believed might be due 

to their participation in the war. VA, DOD, HHS, and other federal agencies 

initiated research and investigations into these health concerns and the 

consequences of possible hazardous exposures. 

In 1993, the President designated VA as the lead coordinator of research 

activities on the health consequences of service in the Gulf War. 

Subsequently, in 1998, the Congress expanded VA’s coordination to 

include all Gulf War health-related activities. These activities include 

ensuring that the findings of all federal Gulf War illnesses research are 

made available to the public and that federal agencies coordinate outreach 

to Gulf War veterans in order to provide information on potential health 

risks from service in the Gulf War and corresponding services or benefits. 

The Secretary of VA is required to submit an annual report on the results, 

status, and priorities of federal research activities related to the health 

consequences of military service in the Gulf War to the Senate and House 

Veterans’ Affairs Committees. VA has provided these reports to 

congressional committees since 1995. In May 2004, VA issued its annual 

report for 2002.1

 VA has carried out its coordinating role through the 

auspices of interagency committees, which have changed over time in 

concert with federal research priorities and needs. The mission of these 

 1

See Deployment Health Working Group Research Subcommittee, U.S. Department of 

Veterans Affairs, Annual Report to Congress: Federally Sponsored Research on Gulf War 

Veterans’ Illnesses for 2002 (Washington, D.C.: 2004). 

Background 
Page 5 GAO-04-767 Gulf War Illnesses Research Strategy 

interagency committees has evolved to include coordination for research 

on all hazardous deployments, including but not limited to the Gulf War. 

(See fig. 1.) 
Page 6 GAO-04-767 Gulf War Illnesses Research Strategy 

Figure 1: Evolution of Interagency Committees That Coordinated Federal Gulf War Illnesses Research from 1993 through 

2004 

Note: GAO analysis of VA data, public laws, and presidential directives.

a

Federal agencies are VA, DOD, and HHS. 

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

PGVCB

Presidential 

Memorandum

Federal agenciesa

PGIRCC

Research Working Group 

Research Working Group

DHWG

Research Subcommittee

Indicates length of time

Indicates overlap of major committees or councils

Source: VA.

1993 On August 31, 1993, pursuant to Public Law 102-585, President William J. Clinton named the 

Secretary of Veterans Affairs (VA) to coordinate research on the health consequences of 

service in the Gulf War. VA initially carried out its coordinating role through the auspices of the 

Persian Gulf Interagency Research Coordinating Council (PGIRCC).

1994 On January 21, 1994, the Secretaries of DOD, HHS, and VA announced the establishment of 

the Persian Gulf Veterans Coordinating Board (PGVCB) to coordinate efforts to resolve the 

health concerns of Gulf War veterans. PGVCB developed three mission objectives, and 

assigned each to a separate working group: the Clinical Working Group, the Research Working 

Group, and the Disability and Benefits Working Group. The Research Working Group (RWG) 

subsumed PGIRCC responsibilities.

1999 In December 1999, MVHCB was officially established to oversee the interagency plan to 

improve the federal response to the health needs of military veterans and their families as it 

relates to all deployments. MVHCB included three working groups: Deployment Health, Health 

Risk Communications, and Research. These groups were established based 

on the recommendations of NSTC's plan.

2000 The PGVCB was subsumed within MVHCB, thereby including activities related to Gulf War 

Illnesses in the mission of MVHCB. The RWG of PGVCB became the RWG of MVHCB.

2002 In October 2002, within the VA/DOD Health Executive Council (HEC), the Deployment Health 

Work Group (DHWG) was established to provide recommendations and coordination for all 

matters that related to the health of all troops in military deployments. For the sake of efficiency, 

DOD thought that it would be best to have one channel for VA/DOD coordination, so the 

decision was made to disband MVHCB and subsume its activities under the HEC, more 

specifically under the broader mission of the DHWG. 

2003 DHWG established the Research Subcommittee to provide coordination of the interagency 

research strategy related to the health of troops in all military deployments, for active duty 

military personnel and veterans.

1997 On April 21, 1997, President Clinton issued Presidential Directive 5 (PRD-5), which called for a 

report by the National Science and Technology Council (NSTC) based on an interagency review 

to establish a plan to improve the federal response to the health needs of veterans and their 

families related to the adverse effects of deployment.

MVHCB

Pub. L. 105-368 

issued

Public Law 105-368 expanded VA's coordination to include all health- related activities for Gulf 

War veterans.

On November 11, 1998, President Clinton issued a memorandum directing the Secretaries of 

DOD, HHS, and VA to establish the Military Veterans Health Coordinating Board (MVHCB) to 

oversee the implementation of NSTC's plan.

1998

Pub. L. 102-585

PRD-5

 Focus on all deployment health Focus on Gulf War illnesses
Page 7 GAO-04-767 Gulf War Illnesses Research Strategy 

Federal research efforts for Gulf War illnesses have been guided by 

questions established by the interagency Research Working Group (RWG), 

which was initially established under the Persian Gulf Veterans 

Coordinating Board (PGVCB) to coordinate federal research efforts. From 

1995 through 1996, RWG identified 19 major research questions related to 

illnesses in Gulf War veterans. In 1996, the group added 2 more questions 

regarding cancer risk and mortality rates to create a set of 21 key research 

questions that serves as an overarching strategy in guiding federal 

research for Gulf War illnesses. (See app. II for the list of key questions.) 

The 21 research questions cover the extent of various health problems, 

exposures among the veteran population, and the difference in health 

problems between Gulf War veterans and control populations. In 1998, 

RWG expanded federal Gulf War illnesses research priorities to include 

treatment, longitudinal follow-up of illnesses, disease prevention, and 

improved hazard assessment; however, RWG did not add any new 

research questions. With regard to veterans’ health status, the research 

questions cover the prevalence among veterans and 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. 

With regard to exposure, the research questions cover 

• Leishmania tropica (a type of parasite), 

• petroleum, 

• petroleum combustion products, 

• specific occupational/environmental hazards (such as vaccines and 

depleted uranium), 

• chemical agents, 

• pyridostigmine bromide (given to troops as a defense against nerve 

agents), and 

• psychophysiological stressors (such as exposure to extremes of human 

suffering). 
Page 8 GAO-04-767 Gulf War Illnesses Research Strategy 

Separately from these research efforts, DOD is responsible for 

investigating and reporting incidents of possible chemical and biological 

agent exposures and other potential occupational and environmental 

hazards. Within DOD, the entities responsible for overseeing Gulf War 

exposure investigations have also evolved over time. (See fig. 2.) 
Page 9 GAO-04-767 Gulf War Illnesses Research Strategy 

Figure 2: DOD Entities Responsible for Gulf War Exposure Investigations from 1995 through 2004 

Note: GAO analysis of DOD data. 

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

OSAGWI

Department of Defense

PGIIT

OSAGWI-MRMD

Deployment Health 

Support Directorate

1995 Deputy Secretary of Defense John Deutch established a Senior Oversight 

Panel and created the Persian Gulf Illnesses Investigation Team (PGIIT) within 

the Office of the Assistant Secretary of Defense for Health Affairs.

1996 The United Nations Special Commission on Iraq Weapons Inspection Team 

confirmed the presence of chemicals at Khamisyah, Iraq. PGIIT 12-person staff 

was overwhelmed by the public reaction from the Khamsiyah disclosure.

PGIIT was disbanded, and Office of the Special Assistant for Gulf War Illnesses 

(OSAGWI) was established with broad authority to coordinate all aspects of the 

department's programs, excluding medical research and direct patient care.

2000 The Secretary of Defense created the Office of Special Assistant for Gulf War 

Illnesses, Medical Readiness, and Military Deployments (OSAGWI-MRMD) in an 

effort to ensure that lessons learned from OSAGWI's Gulf War investigations 

would be applied to situations in current and future deployments. 

2002 DOD dissolved OSAGWI-MRMD and delegated its responsibilities to the 

Deployment Health Support Directorate, which is charged with assisting DOD to 

address the health and medical needs of troops before, during, 

and after deployments.

Indicates length of time

Source: DOD. Focus on all deployment health Focus on Gulf War illnesses
Page 10 GAO-04-767 Gulf War Illnesses Research Strategy 

In 2002, VA established RAC to provide advice to the Secretary of VA on 

proposed research relating to the health consequences of military service 

in the Gulf War.2

 RAC, which is composed of members of the general 

public, including non-VA researchers and veterans’ advocates, was tasked 

with assisting VA in its research planning by exploring the entire body of 

Gulf War illnesses research, identifying gaps in the research, and 

proposing potential areas of future research. VA provides an annual 

budget of about $400,000 for RAC, which provides salaries for two fulltime employees and one part-time employee and supports committee 

operating costs. RAC’s employees include a scientific director and support 

staff who review published scientific literature and federal research 

updates and collect information from scientists conducting relevant 

research.3

 RAC’s staff provide research summaries for discussion and 

analysis to the advisory committee through monthly written reports and at 

regularly scheduled meetings. RAC holds public meetings several times a 

year at which scientists present published and unpublished findings from 

Gulf War illnesses research. In 2002, RAC published a report with 

recommendations to the Secretary of VA. It expects to publish another 

report soon. 

 2

VA was required to establish RAC by the Veterans Programs Enhancement Act of 1998, 

Pub. L. No. 105-368, § 104, 112 Stat. 3315, 3323. 

3

RAC’s scientific director, a research associate professor, is also an appointed member of 

RAC. 
Page 11 GAO-04-767 Gulf War Illnesses Research Strategy 

More than 80 percent of the 240 federally funded Gulf War illnesses 

research projects have been completed. In recent years, funding for this 

research has decreased, federal research priorities have expanded to 

incorporate the long-term health effects of all hazardous deployments, and 

interagency coordination of Gulf War illnesses research has waned. In 

addition, with respect to the federal research strategy, VA has not 

reassessed the research findings to determine whether the 21 key research 

questions have been answered or to identify the future direction of federal 

research in this area. In a separate but related effort, as of April 2003, all of 

DOD’s Gulf War investigations were complete. 

Since 1991, 240 federally funded research projects have been initiated by 

VA, DOD, and HHS to address the health concerns of individuals who 

served in the Gulf War. As of September 2003, 194 of the 240 federal Gulf 

War illnesses research projects (81 percent) had been completed; another 

46 projects (19 percent) were ongoing. 4

 (See fig. 3.) 

 4

Annual reports to congressional committees submitted by VA on federally sponsored 

research on Gulf War veterans’ illnesses identify projects as completed when total project 

funding has concluded. 

Most Federally 

Funded Gulf War 

Illnesses Research 

Projects and 

Investigations Are 

Complete, but VA Has 

Not Collectively 

Analyzed Research 

Findings to Determine 

the Status of Key 

Research Questions 

Most Federally Funded 

Gulf War Illnesses 

Research Projects Are 

Complete, and Funding Is 

Decreasing as Research 

Priorities Broaden 
Page 12 GAO-04-767 Gulf War Illnesses Research Strategy 

Figure 3: Cumulative Number of Ongoing and Completed Federal Gulf War Illnesses 

Research Projects by Year 

Note: GAO analysis of VA data. 

a

This total includes ongoing projects from 1991through 1994. 

From 1994 through 2003, VA, DOD, and HHS collectively spent a total of 

$247 million on Gulf War illnesses research. DOD has provided the most 

funding for Gulf War illnesses research, funding about 74 percent of all 

federal Gulf War illnesses research within this time frame. Figure 4 shows 

the comparative percentage of funding by these agencies for each fiscal 

year since 1994. 

0

50

100

150

200

250

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Year

Completed Gulf War research projects 

Ongoing Gulf War research projects

Number of projects

Source: VA.

62

3

11

83 15

99

135

25

40

152

56

182

98

196

123 152 194

213

232

240

25

75

125

175

225

a

59 72 84 110 112 126 98 90 80 46
Page 13 GAO-04-767 Gulf War Illnesses Research Strategy 

Figure 4: Funding Share for Gulf War Illnesses Research by Agency and Fiscal Year 

Notes: GAO analysis of VA data. Percentages may not add to 100 percent because of rounding. 

After fiscal year 2000, overall funding for Gulf War illnesses research 

decreased. (See fig. 5.) Fiscal year 2003 research funding was about $20 

million less than funding provided in fiscal year 2000. 

0

20

40

60

80

100

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Fiscal year

HHS 

VA

DOD

Percentage

Source: VA.

16

84

15

70

16

22

68

9 9

91

24

68

8

26

69

5

31

65

4

71 84 70

26

14

25

3 3 5
Page 14 GAO-04-767 Gulf War Illnesses Research Strategy 

Figure 5: Funding for Gulf War Research Projects, Fiscal Years 1994-2003 

Note: GAO analysis of VA data. Only direct costs for each agency are included. Direct costs cover the 

actual research activities and materials and have not been adjusted for inflation. 

This overall decrease in federal funding was paralleled by a shift in federal 

research priorities, which expanded to include all hazardous deployments 

and shifted away from a specific focus on Gulf War illnesses. VA officials 

said that although Gulf War illnesses research continues, the agency is 

expanding the scope of its research to include the potential long-term 

health effects in troops who served in hazardous deployments other than 

the Gulf War. In October 2002, VA announced plans to commit up to $20 

million for research into Gulf War illnesses and the health effects of other 

military deployments. Also in October 2002, VA issued a program 

announcement for research on the long-term health effects in veterans 

who served in the Gulf War or in other hazardous deployments, such as 

Afghanistan and Bosnia/Kosovo.5

 As of April 2004, one new Gulf War 

illnesses research project was funded for $450,000 under this program 

announcement. 

 5

The October 2002 research program announcement on deployment health research 

remains open for researchers to submit proposals. 

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Fiscal year

Dollars in millions

Source: VA.

0

5

10

15

20

25

30

35

40
Page 15 GAO-04-767 Gulf War Illnesses Research Strategy 

Although DOD has historically provided the majority of funding for Gulf 

War illnesses research, DOD officials stated that their agency currently has 

no plans to fund new Gulf War illnesses research projects. 

Correspondingly, DOD has not funded any new Gulf War illnesses 

research in fiscal year 2004, except as reflected in modest supplements to 

complete existing projects and a new award pending for research using 

funding from a specific appropriation. DOD also did not include Gulf War 

illnesses research funding in its budget proposals for fiscal years 2005 and 

2006. DOD officials stated that because the agency is primarily focused on 

the needs of the active duty soldier, its interest in funding Gulf War 

illnesses research was highest when a large number of Gulf War veterans 

remained on active duty after the war—some of whom might develop 

unexplained symptoms and syndromes that could affect their active duty 

status.6

 Since 2000, DOD’s focus has shifted from research solely on Gulf 

War illnesses to research on medical issues of active duty troops in current 

or future military deployments.7

 For example, in 2000 VA and DOD 

collaborated to develop the Millennium Cohort study, which is a 

prospective study evaluating the health of both deployed and nondeployed 

military personnel throughout their military careers and after leaving 

military service. The study began in October 2000 and was awarded $5.25 

million through fiscal year 2002, with another $3 million in funding 

estimated for fiscal year 2003. 

VA’s coordination of federal Gulf War illnesses research has gradually 

lapsed. Starting in 1993, VA carried out its responsibility for coordinating 

all Gulf War health-related activities, including research, through 

interagency committees, which evolved over time to reflect changing 

needs and priorities. (See fig. 1.) In 2000, interagency coordination of Gulf 

War illnesses research was subsumed under the broader effort of 

coordination for research on all hazardous deployments. Consequently, 

Gulf War illnesses research was no longer a primary focus. The most 

recent interagency research subcommittee, which is under the 

 6

DOD officials also told us that there are about 100,000 Gulf War veterans currently on 

active military duty but these veterans generally are in good health. 

7

DOD refers to medical research related to current or future military deployments as its 

Force Health Protection Research Program. This program focuses on prevention of illness, 

reduction of injuries or the severity of injury, faster evacuation of casualties, and 

enhancements to general medical capabilities. 

VA’s Coordination of 

Federal Gulf War Illnesses 

Research Has Lapsed, and 

VA Has Not Determined 

Whether Key Research 

Questions Have Been 

Answered 
Page 16 GAO-04-767 Gulf War Illnesses Research Strategy 

Deployment Health Working Group (DHWG), has not met since August 

2003, and as of April 2004, no additional meetings had been planned. 

Additionally, VA has not reassessed the extent to which the collective 

findings of completed Gulf War illnesses research projects have addressed 

the 21 key research questions developed by the RWG. (See app. II.) The 

only assessment of progress in answering these research questions was 

published in 2001, when findings from only about half of all funded Gulf 

War illnesses research were available. Moreover, the summary did not 

identify whether there were gaps in existing Gulf War illnesses research or 

promising areas for future research. No reassessment of these research 

questions has been undertaken to determine whether they remain valid, 

even though about 80 percent of federally funded Gulf War illnesses 

research projects now have been completed. In 2000, we reported that 

without such an assessment, many underlying questions about causes, 

course of development, and treatments for Gulf War illnesses may remain 

unanswered.8

As of April 2003, DOD had completed all of its Gulf War health-related 

investigations, which are separate from Gulf War illnesses research. DOD 

began conducting investigations on Gulf War operations and their 

implications for service members’ and veterans’ health in 1996. Generally, 

DOD instituted an investigation after it received a report of a possible 

exposure to a chemical or biological agent or some other environmental, 

chemical, or biological hazard. From 1996 to 2003, DOD conducted 50 

investigations at a cost of about $68 million. 

DOD published the 50 investigations in the form of 20 case narratives,9

 10 

information papers,10 5 closeout reports,11 and 5 environmental exposure 

 8

U.S. General Accounting Office, Gulf War Illnesses: Management Actions Needed to 

Answer Basic Research Questions, GAO/NSIAD-00-32 (Washington D.C.: Jan. 6, 2000). 

9

Case narratives are interim reports of specific events that took place during the Gulf War 

and were updated pending further investigative efforts. 

10Information papers are reports of what is known about military procedures and 

equipment used during the Gulf War. 

11A closeout report is used to close an investigation. The report is issued after an 

investigation has been reviewed and recommendations have been made to terminate the 

investigation. 

DOD’s Gulf War 

Investigations Are 

Complete 
Page 17 GAO-04-767 Gulf War Illnesses Research Strategy 

reports.12 Additionally, the RAND Corporation was contracted by the 

Office of Special Assistant for Gulf War Illnesses (OSAGWI) to publish 10 

reports reviewing the medical and scientific literature on the known health 

effects of substances to which Gulf War veterans may have been exposed. 

Some investigations focused on examining possible exposures to chemical 

warfare agents or the presence of chemical weapons at specific sites. 

Other investigations studied the possible linkage between environmental 

hazards (such as contaminated water, equipment used during the Gulf 

War, oil well fires, and particulate matter) and illnesses or health effects. 

OSAGWI published four annual reports summarizing the results of 

investigations. Generally, these reports concluded that there were limited 

exposures by troops to some hazards and limited or no short- or long-term 

adverse effects expected from these exposures. The last annual report was 

published in December 2000. 

As of April 2004, federal agencies had funded seven research projects 

related to cancer incidence among Gulf War veterans, four of which have 

been completed. Published results from the completed and ongoing 

studies generally show that rates of cancer among Gulf War veterans were 

similar to or lower than the rates among nondeployed veterans or the 

general population. However, results of these studies may not be reliable 

due to limitations in research related to cancer incidence in Gulf War 

veterans. Future research efforts may also be hindered by inadequate 

federal data on the health characteristics of Gulf War veterans. 

 12Environmental exposure reports are those that focus on exposure to potential 

environmental hazards. 

Some Efforts Are 

Under Way to Monitor 

Cancer Incidence 

among Gulf War 

Veterans, but 

Research Limitations 

May Impede 

Reliability of Results 
Page 18 GAO-04-767 Gulf War Illnesses Research Strategy 

Of the 240 federally funded research projects on Gulf War illnesses, VA 

officials stated that only 7 were related to cancer incidence in Gulf War 

veterans—accounting for about 3 percent of the entire research portfolio.13

Four of the seven research projects have been completed; the other three 

are ongoing. Only two of the seven research projects specifically studied 

cancer incidence. The remaining five research projects did not focus on 

cancer incidence, but instead included cancer as a component of a 

broader analysis of mortality, hospitalization, or general health status of 

Gulf War veterans. (See table 1 for more details on these studies.) 

 13Our review focused only on research related to cancer incidence among Gulf War 

veterans; therefore, Gulf War illnesses research projects studying other aspects of cancer, 

such as treatments for or causes of specific cancers, were not reviewed. 

Few Research Projects 

Related to Cancer 

Incidence in Gulf War 

Veterans Have Been 

Funded 
Page 19 GAO-04-767 Gulf War Illnesses Research Strategy 

Table 1: Research Related to Cancer Incidence in Gulf War Veterans (GWV) 

 Description Topic Status Published Selected limitations 

1 Postwar Hospitalization Experience 

of U.S. Veterans of the Persian 

Gulf War 

Hospitalization Complete Yesa Sample was limited to hospitalized GWV 

in VA, DOD, and some California 

hospitals. All other GWV were not 

included. 

2 Combined Analysis of the VA and 

DOD Gulf War Clinical Registries 

General health Complete Yesb Sample was limited to GWV who selfenrolled in DOD and VA Gulf War clinical 

evaluation programs. All other GWV were 

not included. 

3 National Health Survey of Persian 

Gulf Veterans 

General health Complete Yes (interim)c GWV self-reported data may be subject 

to overreporting of poor health status. 

Results were not supported by objective 

data or documentation. 

4 Gulf War and Vietnam Veterans 

Cancer Incidence Surveillance 

Cancer incidence Complete No Due to the long latency period of cancer,e

it may have been too early to study 

cancer incidence in GWV. 

5 Deployment to the Gulf War and 

the Subsequent Development of 

Cancer 

Cancer incidence Ongoing No Due to the long latency period of cancer,e

it may be too early to study cancer 

incidence in GWV. 

6 Mortality Follow-up Study of 

Persian Gulf Veterans 

Mortality Ongoing Yes (interim)d Analysis only included GWV who have 

died of cancer. Other GWV who have not 

died, but have been diagnosed with 

cancer, were not included. 

7 Longitudinal Health Study of Gulf 

War Veterans 

General health Ongoing No GWV self-reported data may be subject 

to overreporting of poor health status. 

Results may not be supported by 

objective data or documentation. 

Sources: VA, DOD, and published manuscripts. 

Note: GAO analysis of VA data, DOD data, and published manuscripts. 

a

G. C. Gray and others, “The Postwar Hospitalization Experience of U.S. Veterans of the Persian Gulf 

War,” New England Journal of Medicine, vol. 335, no. 20 (1996), 1505-13, and G. Gray and others, 

“Are Gulf War Veterans Suffering War-related Illnesses? Federal and Civilian Hospitalizations 

Examined, June 1991 to December 1994,” American Journal of Epidemiology, vol. 151, no. 1 (2000), 

63-71. 

b

U.S. Department of Defense, Combined Analysis of the VA and DOD Gulf War Clinical Evaluation 

Programs: A Study of the Clinical Findings from Systematic Medical Examinations of 100,339 U.S. 

Gulf War Veterans (Washington, D.C.: 2002); T. C. Smith and others, “Ten Years and 100,000 

Participants Later: Occupational and Other Factors Influencing Participation in U.S. Gulf War Health 

Registries,” Journal of Occupational and Environmental Medicine, vol. 44, no. 8 (2002), 758-68; and 

T. C. Smith and others, “The Postwar Hospitalization Experience of Gulf War Veterans Participating 

in U.S. Health Registries,” Journal of Occupational and Environmental Medicine, vol. 46, no. 4 (2004), 

386-97. 

c

H. K. Kang and others, “Illnesses Among United States Veterans of the Gulf War: A PopulationBased Survey of 30,000 Veterans,” Journal of Occupational and Environmental Medicine, vol. 42, no. 

5 (2000), 491-501. 
Page 20 GAO-04-767 Gulf War Illnesses Research Strategy 

d

H. K. Kang and T. A. Bullman, “Mortality among U.S. Veterans of the Persian Gulf War,” New 

England Journal of Medicine, vol. 335, no. 20 (1996), 1498-504; H. K. Kang and T. A. Bullman, 

“Mortality Among U.S. Veterans of the Persian Gulf War: 7–Year Follow-Up,” American Journal of 

Epidemiology, vol. 154, no. 5 (2001), 399-405; and U.S. Department of Veterans Affairs, Mortality 

among U.S. Gulf War Veterans Who Were Potentially Exposed to Nerve Gas at Khamisiyah, Iraq 

(Washington, D.C.: 2002). 

e

Some cancers can take 15 years or more to develop and be detected. 

Overall, the four published research projects found that deployed Gulf War 

veterans did not have demonstrable differences in cancer-related ailments 

compared with nondeployed veterans or the general population. In 

addition, one of the published studies found that rates of hospitalization 

among Gulf War veterans were similar or lower than among nondeployed 

veterans, and another found that cancer-related mortality rates among 

Gulf War veterans were similar or lower than in the general population. 

Research efforts are continuing for one of the two funded research 

projects specifically related to cancer incidence in Gulf War veterans. 

Researchers conducted a pilot project, scheduled to end in September 

2004, which matched the cancer registries of six states and the District of 

Columbia14 with a database of all Gulf War veterans.15 In order to build on 

these efforts, the researchers plan to expand the pilot study to include 

additional states with cancer registries to obtain a more refined estimate 

of cancer incidence in Gulf War veterans. While this approach appears 

promising, the study’s principal investigator said further efforts beyond 

September 2004 would be limited to working with state cancer registries 

that do not charge a fee or do not require on-site use of a registry. 

A number of inherent limitations in research related to cancer incidence in 

Gulf War veterans could adversely affect the reliability of the findings from 

such research. (See table 1.) For example, since some cancers can take 15 

years or more to develop and subsequently be detected, it may be too early 

to determine cancer incidence in Gulf War veterans, as studies 4 and 5 in 

table 1 were designed to do. Hospitalization studies of Gulf War veterans 

are applicable only to those veterans who seek care in specific hospitals 

 14The pilot study included cancer registries from California, Florida, Maryland, New Jersey, 

Texas, Virginia, and the District of Columbia. 

15A cancer registry is an information system designed for the collection, management, and 

analysis of data on individuals with the diagnosis of a cancer, which may include data on 

the occurrence of cancer, the types of cancer that occur, the cancer’s location in the body, 

the extent of disease at time of diagnosis, and the kinds of treatment patients receive. 

Research Related to 

Cancer Incidence in Gulf 

War Veterans Has Several 

Limitations That Could 

Affect Reliability of 

Findings 
Page 21 GAO-04-767 Gulf War Illnesses Research Strategy 

included in the studies; veterans who use other health care systems are 

not included. Mortality studies of Gulf War veterans are limited because 

only veterans who have died of cancer are captured; other veterans who 

have not died, but have been diagnosed with cancer, are not included. 

Additionally, some general health studies of Gulf War veterans may use 

self-reported data only, which may not be accurate unless validated by 

objective physical or laboratory findings. Other research projects, which 

have samples that are not representative of all Gulf War veterans, such as 

studies 1 and 5 in table 1, may not reliably assess the possibility of 

elevated levels of cancer incidence or related ailments in Gulf War 

veterans when compared to the general population or nondeployed 

veterans. 

Research related to cancer incidence in Gulf War veterans may also be 

hampered by incomplete federal data on the health characteristics of Gulf 

War veterans. In 1998, we reported that VA and DOD did not have data 

systems providing complete information on the health characteristics of 

Gulf War veterans that could be used to accurately estimate cancer 

incidence.16 For example, data from medical records and files on disability 

claims, treatment, and pensions do not include all Gulf War veterans. 

These data do not account for veterans who are separated from the 

services and receive non-VA health care or disability benefits. 

Furthermore, linking VA and DOD data systems still would not overcome 

these shortcomings. VA officials have also stated that existing data 

systems, such as medical record or pension systems, are not adequate for 

determining cancer incidence and that epidemiological research projects 

are needed. 

 16U.S. General Accounting Office, Gulf War Veterans: Limitations of Available Data for 

Accurately Determining the Incidence of Tumors, GAO/T-NSIAD-98-186 (Washington D.C.: 

May 14, 1998) and Gulf War Veterans: Incidence of Tumors Cannot Be Reliably 

Determined from Available Data, GAO/NSIAD-98-89 (Washington D.C.: Mar. 3, 1998). 
Page 22 GAO-04-767 Gulf War Illnesses Research Strategy 

RAC’s efforts to provide advice and make recommendations on Gulf War 

illnesses research may have been impeded by VA’s limited sharing of 

information on research initiatives and program planning as well as VA’s 

limited collaboration with the committee. However, VA and RAC are 

exploring ways to improve information sharing, including VA’s hiring of a 

senior scientist who would both guide the agency’s Gulf War illnesses 

research and serve as the agency’s liaison to provide routine updates to 

RAC. VA and RAC are also proposing changes to improve collaboration, 

including possible commitments from VA to seek input from RAC when 

developing research program announcements. At the time of our review, 

most of these proposed changes were in the planning stages. 

According to RAC officials, VA senior administrators’ poor information 

sharing and limited collaboration with the committee about Gulf War 

illnesses research initiatives and program planning may have hindered 

RAC’s ability to achieve its mission of providing research advice to the 

Secretary of VA. RAC is required by its charter to provide advice and make 

recommendations to the Secretary of VA on proposed research studies, 

research plans, and research strategies relating to the health consequences 

of service during the Gulf War. (See app. III for RAC’s charter.) RAC’s 

chairman and scientific director said that the recommendations and 

reports that the advisory committee provides to the Secretary of VA are 

based on its review of research projects and published and unpublished 

research findings related to Gulf War illnesses. 

Although RAC and VA established official channels of communication, VA 

did not always provide RAC with important information related to Gulf 

War illnesses research initiatives and program planning. In 2002, VA 

designated a liaison to work with RAC’s liaison in order to facilitate the 

transfer of information to the advisory committee about the agency’s Gulf 

War illnesses research strategies and studies. However, RAC officials 

stated that most communication occurred at their request; that is, the VA 

liaison and other VA staff were generally responsive to requests, but did 

not establish mechanisms to ensure that essential information about 

research program announcements or initiatives was automatically 

provided to the advisory committee. RAC officials cited the following 

instances in which VA did not fully collaborate with the advisory 

committee or provide information that RAC considered important: 

RAC’s Efforts to 

Provide Advice May 

Be Hindered by VA’s 

Limited Information 

Sharing and 

Collaboration, but 

Several Changes to 

Address These Issues 

Have Been Proposed 

RAC Officials Cite VA’s 

Poor Information Sharing 

and Limited Collaboration 

as Impediments in Meeting 

Its Mission 
Page 23 GAO-04-767 Gulf War Illnesses Research Strategy 

• According to RAC’s scientific director, bimonthly teleconferences between 

the advisory committee’s and VA’s liaisons did not result in full disclosure 

of relevant ongoing research activities. For example, despite several 

months of discussions in which RAC’s liaison requested information about 

proposed research program announcements for Gulf War illnesses 

research, VA’s liaison did not inform RAC that VA’s Office of Research and 

Development was preparing a research program announcement until it 

was published in October 2002. Consequently, RAC officials said that they 

did not have an opportunity to carry out the committee’s responsibility of 

providing advice and making recommendations on research strategies and 

plans. 

• RAC officials stated that VA did not notify advisory committee members 

that the Longitudinal Health Study of Gulf War Era Veterans—a study 

designed to address possible long-term health consequences of service in 

the Gulf War—had been developed and that the study’s survey was about 

to be sent to study participants. RAC officials expressed concern that VA 

did not inform the advisory committee about the survey even after the 

plans for it were made available for public comment. Although the survey 

had been finalized, the study’s principal investigator provided additional 

time to allow RAC to recommend additional survey question topics and 

incorporated RAC’s suggested changes into the survey. 

• In May 2004, VA published its annual report that described the results, 

status, and priorities of federally funded Gulf War illnesses research as of 

2002. However, RAC officials said they had not seen a draft of this report 

and had not been asked to review or comment on the document before it 

was published, even though the advisory committee has a responsibility to 

advise the Secretary of VA on the state and direction of Gulf War illnesses 

research. 

According to RAC officials, there were also instances in which information 

relevant to Gulf War illnesses research provided by VA’s liaison or other 

VA officials was unclear or incomplete. Miscommunication about the 

purpose of the October 2002 research program announcement and the 

details of a corresponding VA plan to increase funding up to $20 million 

for research related to hazardous military deployments, which would 

include the Gulf War, led RAC members to believe that VA had committed 

a large portion of this $20 million to Gulf War illnesses research for fiscal 

year 2004. Moreover, RAC officials did not receive routine reports on Gulf 

War illnesses research proposals that had been either received or funded 

by VA under the October 2002 research program announcement. RAC 

officials said that until VA administrators were asked to brief the advisory 

committee in February 2004, advisory committee members were unaware 

that only one new Gulf War illnesses research project had received 
Page 24 GAO-04-767 Gulf War Illnesses Research Strategy 

funding for fiscal year 2004 under this program announcement and that no 

other proposals were under review. 

Information sharing about these types of issues is common practice among 

advisory committees of the National Institutes of Health (NIH), which has 

more federal advisory committees than any other executive branch 

agency.17 A senior official within NIH’s Office of Federal Advisory 

Committee Policy said that it is standard practice for NIH advisory 

committees to participate closely in the development of research program 

announcements. For example, some advisory committees’ members 

review preliminary drafts of announcements, and some discuss program 

announcements during regular committee meetings. Furthermore, this 

official stated that many NIH institutes require advisory committee 

approval before issuing research program announcements. In addition, 

NIH’s advisory committee members are routinely asked to make 

recommendations on both research concepts and priorities for research 

projects, and are kept up-to-date about the course of ongoing research 

projects. This official also stated that NIH advisory committee members 

often review draft reports summarizing research findings or research 

progress prior to their publication. 

Additionally, RAC officials stated that VA’s staffing choices for the liaison 

position and more recent VA staff turnover have hindered the 

development of working relationships and information flow. RAC officials 

stated that the initial VA liaison—a senior official in one of VA’s four 

research services—was not very knowledgeable about current Gulf War 

illnesses research developments. In early 2003, VA’s Chief Research and 

Development Officer (CRADO),18 whom RAC officials said was 

knowledgeable about Gulf War illnesses issues, began to serve as the VA 

liaison to RAC. (See fig. 6 for organizational chart.) However, this 

individual left VA in December 2003, and according to RAC officials, 

further communication with the advisory committee was delegated to 

lower-level VA staff. After the advisory committee’s February 2004 

 17NIH is the largest funder of medical research in the United States and maintains more 

than 140 chartered advisory committees. NIH has four types of advisory committees—for 

the purposes of this report, we refer to practices of two committee types: program advisory 

committees and national advisory councils. 

18The CRADO is responsible for oversight of research programs within the four VA research 

services: the Biomedical Laboratory Research and Development Service, the Clinical 

Science Research and Development Service, the Health Services Research and 

Development Service, and the Rehabilitation Research and Development Service. 
Page 25 GAO-04-767 Gulf War Illnesses Research Strategy 

meeting, the acting CRADO (appointed in December 2003) and the deputy 

CRADO began to communicate regularly with the advisory committee. 

However, the acting CRADO has additional management responsibilities 

that can limit the amount of time available to coordinate with RAC. 

Specifically, in early April 2004, this official was named to temporarily 

head VA’s health care system—the Veterans Health Administration.19 For 

this reason, the deputy CRADO more often has acted as a point of contact 

for the committee. 

Figure 6: Organizational Relationships between VA and RAC, as of April 2004 

 19The Veterans Health Administration is the nation’s largest integrated health care system, 

employing more than 180,000 health care professionals and operating more than 1,300 

health care facilities. In addition to its medical care mission, the veterans health care 

system is the nation’s largest provider of graduate medical education and a major 

contributor to medical and scientific research. 

Secretary of VA

Deputy CRADO

Biomedical

Laboratory

R&D Service

Health Services

R&D Service

Clinical

Sciences

R&D Service

Rehabilitation

R&D Service

RAC

Under Secretary

for Health

Deputy Under

Secretary for

Health

Chief Research

and Development

Officer (CRADO)

Advice and 

recommendations

Point of contact

Point of contact

Research services Research services

The same VA official was serving in each position as of April 2004.

Source: VA.
Page 26 GAO-04-767 Gulf War Illnesses Research Strategy 

In recognition of RAC’s concerns, VA is proposing several actions to 

improve information sharing, including VA’s hiring of a senior scientist to 

guide its Gulf War illnesses research and improving formal channels of 

communication. In addition, VA and RAC are exploring methods to 

improve collaboration. These would include possible commitments from 

VA to seek input from RAC when developing research program 

announcements and to include RAC members in a portion of the selection 

process for funding Gulf War illnesses research projects. As of April 2004, 

most of the proposed changes were in the planning stages. 

Since the February 2004 RAC meeting, VA and RAC officials said they have 

had multiple meetings and phone conversations and have corresponded 

via e-mail in an attempt to improve communication and collaboration. VA 

officials said they have already instituted efforts to hire a senior scientist 

to guide the agency’s Gulf War illnesses research efforts. The official 

assigned to this position will be the RAC liaison and coordinator of VA’s 

research on Gulf War illnesses and health issues related to other 

hazardous deployments. According to VA officials, this official will be 

required to formally contact RAC officials weekly, with informal 

communications on an as needed basis. In addition, this official will be 

responsible for providing periodic information on the latest publications 

or projects related to Gulf War illnesses research. 

To facilitate collaboration with RAC, VA has proposed involving RAC 

members in developing VA program announcements designed to solicit 

research proposals, both specifically for Gulf War illnesses and related 

areas of interest, such as general research into unexplained illnesses. RAC 

officials stated that throughout March and April 2004, VA and RAC 

officials had been jointly developing a new research program 

announcement for Gulf War illnesses. In addition, VA has proposed that 

RAC will be able to recommend scientists for inclusion in the scientific 

merit review panels. VA also plans to involve RAC in reviews of project 

relevancy to Gulf War illnesses research goals and priorities after the 

research projects undergo scientific merit review. This could facilitate 

RAC’s ability to provide recommendations to the CRADO on the projects 

that it has judged to be relevant to the Gulf War illnesses research plan. 

VA and RAC Are Exploring 

Methods to Improve 

Information Sharing and 

Collaboration 
Page 27 GAO-04-767 Gulf War Illnesses Research Strategy 

While more than 80 percent of federally funded Gulf War illnesses 

research projects have been completed, little effort has been made to 

assess progress in answering the 21 key research questions or to identify 

the direction of future research in this area. Additionally, in light of 

decreasing federal funds and expanding federal research priorities, 

research specific to Gulf War illnesses is waning. Without a 

comprehensive reassessment of Gulf War illnesses research, underlying 

questions about the unexplained illnesses suffered by Gulf War veterans 

may remain unanswered. 

Since RAC’s establishment in January 2002, its efforts to provide the 

Secretary of VA with advice and recommendations may have been 

hampered by incomplete disclosure of VA’s Gulf War illnesses research 

activities. By limiting information sharing with RAC, VA has not fully 

realized the assistance that the scientists and veterans’ advocates who 

serve on RAC could provide in developing effective policies and guidance 

for Gulf War illnesses research. VA and RAC are exploring new 

approaches to improve information sharing and collaboration. If these 

approaches are implemented, RAC’s ability to play a pivotal role in helping 

VA reassess the direction of Gulf War illnesses research may be enhanced. 

However, most of these changes had not been formalized at the time of 

our review. 

With respect to the federal Gulf War illnesses research efforts, we 

recommend that the Secretary of Veterans Affairs take the following 

action: 

• conduct a reassessment of the Gulf War illnesses research strategy to 

determine whether the 21 key research questions have been answered, 

whether they remain relevant, and whether there are promising areas for 

future research. 

To facilitate RAC’s ability to provide advice on Gulf War illnesses research, 

we recommend that the Secretary of Veterans Affairs take the following 

additional two actions: 

• ensure that a liaison who is knowledgeable about Gulf War illnesses 

research is appointed to routinely share information with RAC and 

• ensure that VA’s research offices collaborate with RAC on Gulf War 

illnesses research program development activities. 

Conclusions 

Recommendations for 

Executive Action 
Page 28 GAO-04-767 Gulf War Illnesses Research Strategy 

We provided a draft of this report for comment to VA and DOD. In 

commenting on this draft, VA agreed with the report’s conclusions and 

concurred with the report’s recommendations. VA said that it has begun a 

preliminary assessment of the federal Gulf War illnesses research strategy, 

including an evaluation of the 21 key research questions, to ensure the 

research strategy’s continued validity and to identify promising areas for 

future research. The agency also noted that it has undertaken various 

steps, such as coordinating its most recent request for Gulf War research 

applications with RAC, in order to better collaborate with the advisory 

committee. VA’s written comments are in appendix IV. 

DOD informed us that it had no substantive comments on the draft report. 

Both VA and DOD provided technical comments, which we incorporated 

where appropriate. 

We are sending copies of this report to the Secretary of VA, the Secretary 

of Defense, and the Secretary of HHS. We will also provide copies to 

others upon request. In addition, the report will be available at no charge 

on GAO’s Web site at http://www.gao.gov. 

If you or your staff have any questions about this report, please call me at 

(202) 512-7119 or Bonnie Anderson at (404) 679-1900. Karen Doran, John 

Oh, Danielle Organek, and Roseanne Price also made key contributions to 

this report. 

Sincerely yours, 

Janet Heinrich 

Director, Health Care—Public Health Issues 

Agency Comments 

and Our Evaluation 
Appendix I: Scope and Methodology 

Page 29 GAO-04-767 Gulf War Illnesses Research Strategy 

To describe the status of research and investigations on Gulf War illnesses, 

we reviewed reports to congressional committees outlining annually 

awarded and completed research projects and research funding. We 

summarized data from the Department of Veterans Affairs’ (VA) annual 

reports to congressional committees, including numbers of funded 

research projects and total funding by federal agency, in order to 

determine the status of completed research. We interviewed VA’s thenAssistant Chief Research and Development Officer (CRADO) and the 

Department of Defense’s (DOD) Deputy Director of the Deployment 

Health Support Directorate (DHSD) regarding the agencies’ current and 

future Gulf War illnesses research and investigation plans. We also 

interviewed CRADO and DHSD staff and senior managers with DOD’s 

medical research offices, including Defense Research and Engineering and 

the Army’s Medical Research and Materiel Command. We reviewed other 

relevant documents, including interagency coordinating council meeting 

minutes, federal laws, presidential directives, and VA- and DOD-published 

documents on Gulf War illnesses research and DOD investigations. 

To describe efforts made by VA and DOD to monitor cancer incidence 

among Gulf War veterans, we interviewed VA’s then-Assistant CRADO, a 

VA senior research manager, and VA researchers, along with DOD’s 

Deputy Director of DHSD. We reviewed annual reports to congressional 

committees describing federally funded Gulf War illnesses research, 

published articles from peer-reviewed journals reporting research 

findings, and other agency documents describing research projects. 

To evaluate the VA’s Research Advisory Committee on Gulf War Veterans’ 

Illnesses (RAC) efforts to provide advice on Gulf War illnesses research, 

we interviewed RAC’s Chairman and Scientific Director, attended the most 

recent RAC meeting in February 2004, and reviewed RAC reports and 

recommendations to the Secretary of VA. We also interviewed officials 

with the National Institutes of Health’s (NIH) Office of Federal Advisory 

Committee Policy and officials within an NIH advisory committee to 

identify common practices related to information sharing and 

collaboration between NIH and its advisory committees. To determine 

VA’s efforts to improve information sharing and collaboration with RAC, 

we interviewed VA’s deputy CRADO and CRADO staff. 

Appendix I: Scope and Methodology 
Appendix II: Key Gulf War Illnesses Research 

Questions 

Page 30 GAO-04-767 Gulf War Illnesses Research Strategy 

From 1995 through 1996, the Research Working Group (RWG) of the 

interagency Persian Gulf Veterans’ Coordinating Board identified 19 major 

research questions related to illnesses in Gulf War veterans. RWG later 

added 2 more questions to create a set of 21 key research questions to 

serve as a guide for federal research on Gulf War illnesses. (See table 3.) 

Appendix II: Key Gulf War Illnesses Research 

Questions 
Appendix II: Key Gulf War Illnesses Research 

Questions 

Page 31 GAO-04-767 Gulf War Illnesses Research Strategy 

Table 2: Twenty-one Key Gulf War Illnesses Research Questions 

Research 

question number Key research questions 

1 What is the prevalence of symptoms/illnesses in the Persian Gulf veterans population? How does this 

prevalence compare to that in an appropriate control group? 

2 What was the overall exposure 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 veterans’ 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 Muthannna, 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 pyridostigmine bromide use among Persian Gulf troops?a

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 nonspecific 

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? 

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 nonspecific 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 repellent 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 and 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? 

Source: VA. 
Appendix II: Key Gulf War Illnesses Research 

Questions 

Page 32 GAO-04-767 Gulf War Illnesses Research Strategy 

a

Pyridostigmine bromide is a drug that was supplied to troops for use as a pretreatment for potential 

exposure to nerve agents. 
Appendix III: Charter for VA’s Research 

Advisory Committee on Gulf War Veterans’ 

Illnesses 

Page 33 GAO-04-767 Gulf War Illnesses Research Strategy 

Appendix III: Charter for VA’s Research 

Advisory Committee on Gulf War Veterans’ 

Illnesses 
Appendix III: Charter for VA’s Research 

Advisory Committee on Gulf War Veterans’ 

Illnesses 

Page 34 GAO-04-767 Gulf War Illnesses Research Strategy 
Appendix III: Charter for VA’s Research 

Advisory Committee on Gulf War Veterans’ 

Illnesses 

Page 35 GAO-04-767 Gulf War Illnesses Research Strategy 

Source: RAC.
Appendix IV: Comments from the Department 

of Veterans Affairs 

Page 36 GAO-04-767 Gulf War Illnesses Research Strategy 

Appendix IV: Comments from the 

Department of Veterans Affairs 

(290324) 
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